Sharon Moffatt Association of State and Territorial Health Officials May 2, 2013

 Concept Models  State examples  Systems Approach to Implementing Prevention and Wellness  Summary

How does public health decide it’s future role? What are the models we use to inform our direction and priorities?

5/19/2011 Determinants of Health Determinants of Health and their Contribution to Premature Death, Adapted from McGinnis, et al., 2002

INFRASTRUCTURE-BUILDING SERVICES Needs assessment, evaluation, planning, policy development, coordination, quality assurance, standards development, monitoring, training, applied research, systems of care, and information systems. POPULATION-BASED SERVICES Newborn screening, lead screening, immunization, sudden infant death syndrome counseling, oral health, injury prevention, nutrition, and outreach/public education. ENABLING SERVICES Transportation, translations, outreach, respite care, health education, family support services, purchase of health insurance, case management coordination with Medicaid, WIC, and Education. DIRECT HEALTH CARE SERVICES (gap filling) Basic health services and health services for Children with Special Health Care Needs (CSHCN) Maternal and Child Health Pyramid of Health Services

Better CareQuality of Care Cost Benefit

5/19/2011 System Approach to Health Transformation Medical Home, School, Worksite, Faith-Based

What can we learn from our colleagues in public health?

ACTIONResults Massachusetts 2006 health reform mandated tobacco cessation coverage for Medicaid By October 1, 2010 states are required to cover comprehensive tobacco cessation services for pregnant women in Medicaid (§ 4107) State health departments have experience developing and promoting comprehensive tobacco use prevention and cessation strategies Comparison of pre-benefit coverage to post-benefit coverage demonstrated a 26% decline in smoking rates

ACTIONRESULTS  Used HHS Viral Hepatitis Action Plan as an opportunity to reframe public health program  Health department ◦ developed guiding principles for integration with HIV services ◦ Engages health providers with the greatest expertise and in areas of high need  The program integration generated savings  Funds for demonstration project with Harborview Medical Center  Fund for expansion of the telemedicine Project ECHO to the urban, underserved setting.  Expansion has served 429 new patients an no increased costs

ACTIONRESULT  State and Local Health Agencies worked with local hospitals, obstetrical providers and families to increase awareness of delivery to full term  Partnered with Medicaid  Legislation to eliminate Medicaid payment for elective inductions/C- sections <39 weeks  Health department received 4.1 M for statewide Healthy Babies  Pre Term birth rate has dropped from to 12.5 in 1 year

Is public health at the table? Is it too late for public health?

The Community Preventative Services Guide Over 200 National evidence-based recommendations  communities  worksites  schools  health care systems

 By statute, the CHNAs must take into account input from “persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health.”  Collaboration between hospitals and governmental public health departments and public health experts to facilitate effective and cost-efficient hospital CHNAs  These assessments and strategies create an important opportunity to improve the health of people in a community by ensuring that hospitals have the information they need to provide community benefits that meet the needs of the community  They also provide an opportunity to improve coordination of hospital community benefits with other efforts to improve community health

 2011: Small business grants to establish wellness programs. $200M authorized over 5 years. (FY11- 15)  2012: National survey on worksite health policies and programs  2013: Congressional report on the effectiveness and impact of wellness programs  2014: Employers can offer incentives (e.g., premium discounts, rebates or cost-sharing waivers) up to 30% of the cost of participating in a wellness program

25-30% of companies’ annual costs are spent on employees with excess health risks Annual obesity-related costs range from $400 - $2,000 per employee Companies can:  Save $3-15 for every $1 spent on health and wellness within months  Reduce absenteeism from injury or illness  Affordable Care Act: 3590 Sec. 2717(b)  By 2012 – establish wellness and health promotion activities for enrollees

Do we have a clearly defined role? Are we getting funded for this role?

 The estimated US costs of preventable adverse events is $17 Billion  Medication related to preventable errors are estimated at $2 billion for inpatient care  For every dollar spent on ambulatory medications another dollar is spent to treat new health problems caused by the medication

 At least 44,000 Americans dies each year as a result of medical errors. ◦ This is more than: ◦ Motor vehicle accidents (43,458) ◦ Breast Cancer (42,297) ◦ AIDS ( 16,516)  What is our public health role?  What are our prevention solutions? “To Err is Human, Building A Safer Health System”, Institute of Medicine, 2000

 Requires hospitals to report hospital associated infections and serious reportable events to the public health department (with transparent web site)  Prohibits health care facilities from charging for services provided as the result of the occurrence of serious reportable event/medical error – decisions based on public health dept. 21

How do we Improve? Health Outcomes Quality of Care Cost Burden

Cost of Chronic Conditions is both Personal and Financial Care for people with chronic conditions accounts for ◦ 78% of health care spending ◦ 76% of hospital admissions ◦ 72% of all physician visits ◦ 88% of all prescriptions filled

 1 in every 10 Americans have major limitations due to chronic conditions  Arthritis is the number one cause of disability affecting 1 in every 3 adults  Stroke has left 1 Million Americans with disabilities  Asthma causes 500,000 hospitalizations, 14 million missed school days

Self Management Healthy Living Workshops Individual Self Management Healthy Living Workshops  Stanford Patient Education Research Center - Self Management Program  Evidence based research to affect individual health  Empowers individual and families in requesting more of health care “Effects of a Self Management Program on Patients with Chronic Disease”, Lorig, K. et al, Effective Clinical Practice Nov/Dec 2001, Vol 4.

Community Care Teams  Supports individual and health care provider for improved health care  Connects individual with community resources  Replaces or enhances disease management programs

Evidence Based:  Prompts to use stairs  Smoke free worksites  Access to places for physical activity

 Health Impact Assessments  Community Needs Assessments

 Plan policy levers  Include Public Health on state and local advisory boards ◦ Health Reform ◦ Patient Quality ◦ Health Info Organizations ◦ Accountable Care Organizations

 How do we prioritize our work? ◦ Direct Services: Are we getting funded to provide these services? Is there another provider who can do these services?  What is our unique Public Health Expertise? ◦ Data gathering, analysis and communication ◦ Population Health and Health System Perspective ◦ Patient Protection  How do we demonstrate our value? ◦ Are we measuring our impact? ◦ Are we communicating our value?

Sharon Moffatt Chief of Health Promotion and Disease Prevention Association of State and Territorial Health Officials 2231 Crystal Drive, Suite 450 Arlington, VA

 Patient Protection and Affordable Care Act, March Patient Protection and Affordable Care Act, March  Congressional Research Service (CRS) Congressional Research Service (CRS)  Healthreform.gov Healthreform.gov  Community Preventative Services Guide:  Astho.org 

Resources/References  The Chronic Care Model: Improving chronic illness care a national program of The Robert Wood Johnson Foundation,  Wagner, E.H. Chronic Disease Management: What will it take to improve care for chronic illness? Effective Clinical Practice 1998;  National Estimated Cost of Obesity, CDC, BRFSS ).

 The Model for Improvement by the Institute for Health Improvement  The Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine 2003, 348:26.

 Agency for Healthcare Research and Quality  Institute for Clinical Systems Integration  American Diabetes Association  American Heart Association

Resources/References  Crossing the Quality Chasm: A New Health System for the 21 st Century, Institute of Medicine, National Academy of Sciences,  To Err is Human: Building a Safer Health System, Institute of Medicine, National Academy of Sciences, 2000.Institute of Medicine  Effects of a Self Management Program on Patients with Chronic Disease, Lorig, K. et al, Effective Clinical Practice Nov/Dec 2001, Vol 4.

 Blueprint for a Healthier America, Trust for America’s Health, Oct 2008  Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings, Stronger Communities, Trust for America’s Health, July 2008