Leveraging Community & Population Health Efforts: Current Community and Population Health Efforts Addressing the Social Determinants of Health

Transcription

1 Leveraging Community & Population Health Efforts: Current Community and Population Health Efforts Addressing the Social Determinants of Health Dr. Jeff Levi Executive Director, TFAH Alliance of Community Health Plans (ACHP) Webinar October 15, 2013

2 Overview About Trust for America s Health Key health challenges require a new way of thinking ACA and health delivery/financing changes compel new partnerships to improve health Public health can be the leader in driving change that addresses social determinants of health

3 About TFAH: Who We Are Trust for America s Health (TFAH) is a non-profit, nonpartisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

4 Status quo is not an option NCD mortality rate (16/17) CD mortality rate (14/17) Last in life expectancy Youth least likely to survive to 50 Highest level of income inequality; poverty; child poverty Third lowest rate of pre-school education and secondary school completion

5 Bradley, et al. BMJ Qual Saf

6 Healthier America 2013 Partnerships across health and non-health sectors to improve health and create health equity Partnerships across the health sector to increase focus on population health in a reforming health system Restructure federal public health programs to reflect new partnerships and new roles in a post-aca implementation world. Provide a federal guarantee for stable funding for state and local foundational public health capabilities

7 Embrace all definitions of population health Population health concept is driving all to think about outcomes, not process Covers everything from a patient panel to an entire geographic community Achieving health outcomes for any definition of population requires partnering with others with a different definition

8 Innovative Approaches to Resilient Communities Collaborative partnerships leverage multi-sector resources to improve community health. Benefits of partnership: Addresses broad range of issues with greater breadth and depth Coordinates services and prevents redundant efforts Increases public support Allows individual organizations to influence community on a larger scale Includes diverse perspectives Strengthens connections between existing resources Provides shared frame of inquiry for community health concerns Faith community Mental health services Alcohol/drug services Medicine Public Health Community Members Health Systems & Healthcare providers Community programs Academic researchers National Health Coalitions Government & Philanthropy Higher education Secondary education Safety-net health services

9 Prevention for a Healthier America: Financial Return on Investment? With a Strategic Investment in Proven Community-Based Prevention Programs to Increase Physical Activity and Good Nutrition and Prevent Smoking and Other Tobacco Use INVESTMENT: $10 per person per year HEATH CARE COST NET SAVINGS: RETURN ON INVESTMENT (ROI): $16 Billion annually within 5 years $5.60 for every $1

10 The Prevention & Public Health Fund Community Transformation Grants (CTG) Racial and Ethnic Approaches to Health (REACH) Tobacco Prevention, Quitlines, National Media Campaign Coordinated core chronic disease funding for state health departments CDC state grants for Nutrition, Physical Activity, and Obesity (NPAO) Chronic Disease Self Management Clinical Preventive Research And much more

11 4 in 10 Americans are reached by Community Transformation Grants (CTGs) Building Community Partnerships to Promote Health Building capacity to implement evidence- and practice-based policy, environmental, programmatic, and infrastructure changes to prevent chronic disease Supporting implementation of interventions across five broad areas: Active Living and Healthy Eating Community-Clinical and Other Preventive Services Social and Emotional Wellness Healthy and Safe Physical Environment Tobacco Free Living

12 CTG Goals CTG National Goals Five year, measurable performance goals: Reduce the rate of obesity through nutrition and physical activity interventions by 5%; Reduce death/disability due to heart disease and stroke by 5%. Reduce death and disability due to tobacco use by 5%;

13 New systems and structures Add population health to new delivery systems: ACOs become Accountable Care Communities Hennepin County linkage of Medicaid population to community (social) services MD Local Health Improvement Coalitions Increase community prevention focus to existing funding mechanisms such as community benefit Global budgets and prevention Medicaid and other third party coverage of nontraditional providers, services, and settings

14 National Prevention Strategy: Goal Strategic Directions Priorities

15 Communities with CTGs and Community Health Plans Minnesota: HealthPartners and Hennepin County Public Health Department CTG California: Kaiser Permanente and Public Health Institute CTG Maine: Martin s Point Health Care and MaineHealth CTG New Mexico: Presbyterian Health Plan and Bernalillo County Office of Environmental Health CTG

16 Questions? Thank you.

17 Leveraging Community & Population Health Efforts: A Close Look at Colorado s Collaborative Efforts to Identify and Target Prevention Efforts and Interventions Matthew F. Daley, MD Arthur J. Davidson, MD, MSPH John F. Steiner, MD, MPH Kaiser Permanente Colorado (MFD, JFS) Denver Public Health, Denver Health (AJD) Alliance of Community Health Plans (ACHP) Trust for America s Health (TFAH) Tuesday, October 15, 2013, 1:00 pm ET 17

18 Disclosures The authors report no relevant financial interests and no conflicts of interest regarding the work presented in this talk. 18

19 Outline Problem: limited health disparities monitoring capacity Setting: innovative community health laboratory Method: Colorado Health Observation Regional Data Service (CHORDS) Early results: BMI monitoring project Lessons for integrated delivery systems and public health agencies Next steps 19

20 Geographic Context 20

21 Why Monitor for Health Disparities? Social determinants (i.e., income and education) highly associated with poorer health outcomes (smoking, cardiovascular disease, obesity) Ability to use place-based knowledge to identify specific population subgroups and inform interventions 21

22 Education Income

23 Who lives in Denver County? 23

24 Who Lives in Denver County? Total population 600,158 Hispanic/Latino (any race) 32% White 69% Black 10% Asian 3% Native American/Alaskan 1% Other 12% Mixed 4% 24

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26 Who lives in Denver County? 26

27 Percent of BRFSS respondents who visited a provider in the past 12 months, by income level, Denver, 2011 FPL = Federal Poverty Level Guidelines % FPL % FPL % FPL > 300% FPL 27

28 Multi-institutional Collaboration Clinical Delivery Systems with EHR Data and Research/Methods Skills Denver Health Kaiser Permanente Colorado (KPCO) Colorado Children s Hospital National Jewish Health University of Colorado Anschutz Medical Campus Colorado Health Outcomes Program Colorado Clinical Translational Sciences Institute 28

29 Denver s Natural Resources for Collaboration Large enough Small enough Long-standing clinical/research partnerships Public health/community funder partnerships Informatics expertise to foster federated data sharing 29

30 Linking Clinical, Social and Environmental Data Across Delivery Systems Aggregated data can provide larger N, broader representation, allow focus on vulnerable subpopulations Geocoding/mapping of patients with specific risk factors or health conditions can identify hot spots with high prevalence Linkage with other big data sources can identify contributory social/environmental factors Can target place-based interventions (social marketing, community resource development) 30

31 Rationale for KPCO involvement Non-profit health plan with community benefit mission and requirements Long experience in multi-institutional research requiring data sharing Prior collaborations in public health surveillance (bioterrorism, influenza) Largest EHR-enabled clinical provider in Denver Metro counties ( 20% of the total population) 31

32 Data Linkages for Research the KPCO Experience KPCO engaged in multi-institutional research networks (HMO Research Network and others) since late 1990 s Developed substantial infrastructure Common data model (virtual data warehouse) Software to facilitate data queries (PopMedNet) Governance structures, policies, processes Approaches to data privacy and safety issues, human subjects considerations One model a distributed research network 32

33 Requestor 1 Insert DRN diagram from SPAN here 2 Distributed Querying Portal Data Partner Institutional Firewall / Policies 5 Review and Run Query Review and Return Results 3 4 Local Datasets Common Data Model 1. Query submitted by requestor to distributed querying portal 2. Data partners retrieve the query on the distributed querying portal 3. Data partners review and run query 4. Data partners review results (aggregate data, or limited data set) 5. Data partners return results to distributed querying portal for review by requestor 10/18/ Ref: Adapted from Brown J, Hertz D: Technical Guide, FDA Mini-sentinel; 2010.

34 Distributed Research Network the Essentials Data partners (DH, KPCO, CCH to start) Common data model (using HMORN VDW) Strategy for communication/approval of data queries (using the PopMedNet platform, used for other prior DRNs) Local control of data behind institutional firewalls Audit/approval of data requests Protection of patient/member confidentiality Protection of proprietary information 34

35 Distributed Research Network the Essentials Common secure infrastructure for data aggregation Public health purposes (e.g., through public health departments) different regulatory requirement for prior approval for disclosure Research (e.g., through analysis site) has HIPAA regulatory requirements and federally mandated investigational review processes Data sets range from de-identified data to full PHI, depending on purpose 35

36 Alternatives to Distributed Research Networks (DRNs) Centralized data marts (e.g. all-payer claims databases) bring the question to the data (vs. bring data to the question in DRN) Regional Health Information Organizations (RHIOs) are currently focused on clinical information exchange, one patient at a time, for use at point of care Others? 36

37 Evolution: Colorado Health Observation Regional Data Service (CHORDS) Long-standing CHCO, DH, KPCO, UCD partnerships UCD Clinical Translational Science Award (NIH, 2008) initiated development of regional informatics infrastructure for research, Cancer Center informatics expertise SPAN grant (AHRQ, 2010) allowed initiation of virtual data warehouse (VDW) at DH, development of local expertise Evaluation of the Mini-sentinel PopMedNet model for FDA post-marketing surveillance 37

38 Evolution: Colorado Health Observation Regional Data Service (CHORDS) Additional project support BMI monitoring project (KPCO, The Colorado Health Foundation, ) Cardiovascular risk reduction (Community Transformation Grant, CDC, ) Tobacco use and cessation (Colorado Department of Public Health and Environment, ) Depression (AHRQ, ) 38

39 Types and Sources of Geo-coded Social and Environmental Data for Mapping Source Data type Grocery stores Reference USA Points, aggregated into census tracts Restaurants Reference USA Points, aggregated into census tracts Food Deserts (USDA definition) Walkability (based on number of street intersections per unit area) Green space/parks Poverty USDA Economic Research Council Streetmap USA/ ESRI web distribution From wide variety of sources American Community 39 Survey At census tract level Points, aggregated into census tracts Polygons (areas), with points of park entrance Polygons (areas), aggregated into census tracts

40 Pulling it All Together the BMI Monitoring Project Current state of the art BRFSS self-reported demographic, weight data 12,000 surveys/year/state = 700/year/Denver Allows county-level estimates only BMI project Clinically measured height, weight, BMI Demographic data, location of residence > 250,000 individuals in geographically concentrated area (7 urban Front Range, 1 rural county in CO) 40

41 Data Flow: Not a Distributed Research Network (yet) University of Colorado Denver Mapping Analysis Geocode & BMI Children s Hospital Colorado Address & BMI Colorado Department of Public Health & Environment Geocode & Basic Data Clean Geocode & BMI Kaiser Permanente Colorado Address & BMI Geocode & BMI Colorado Associated Community Health Information Exchange Denver Public Health Address & BMI Geocode & BMI High Plains Community Health Center Denver Health

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43 With Combined Multi-site BMI Data With a valid BMI in Denver County All ages: Adults: 119,075 (26%) Children: 64,606 (51%) 184,644 (31% of Denver population) Census tract coverage varies widely; higher than 50% for some targeted communities With a valid BMI in Prowers County All ages: 6,260 (50%) Adults: 4,585 (50%) Children: 1,671 (48%) 43

44 What next? Expand range of stakeholders and use cases Public health entities (surveillance, community interventions) Researchers (clinical interventions, care delivery interventions, community interventions, studies of social and environmental influences on health) Community organizations (advocacy groups and foundations) Delivery systems (integrated environmental information into decisions) point of care reports Potential new domains: asthma, alcohol/substance dependency, injuries 44

45 Sustainability strategy Create condition agnostic distributed research network Facilitate incorporation of new social/environmental data (barriers and assets) Standardize approach to geocoding, data reporting to a range of stakeholders Target outreach and community-based interventions to those who need them, not only those who seek them Reduce health disparities Develop cadre of researchers and methods 45