Intentionally Designing Health and Well-Being in Virginia Marissa J. Levine, MD, MPH, FAAFP Virginia State Health Commissioner The Virginia Department of Health

Objectives Define factors that affect health Describe Virginia’s health status Outline an Approach to Population Health Improvement Identify the Virginia State Health Improvement Plan Framework (Virginia Plan for Well-Being) Discuss opportunities for intentional and aligned health improvement efforts

AMONG ALL STATES, Virginia RaNKS 21ST IN HEALTH STATUS Data Source: America’s Health Rankings, United Health Foundation Scorecard-2015 3

Think alignment

Relative Contribution of Factors that Affect Health Genetics Clinical Care Social and Economic Factors Environment Health Behaviors Source: McGinnis et al, The Case for More active Policy Attention to Health Promotion, Health Affairs, 21, no. 2 (2002): 78-93

County Health Rankings

Health Factor Rankings for Virginia Counties (2016) Health factors are the four big categories: Social and economic factors Health Behaviors Clinical factors Physical environment

Health Outcome Rankings for Virginia Counties (2016) Outcomes are quality and length of life (morbidity and mortality)

Annual Cost of Chronic Diseases in Virginia Total cost estimate of these conditions $41 billion Data Source: CDC Cost Calculator for Virginia 2015. Includes costs only for diseases that are selected and have cost values available. The projections: 1) are medical costs only, including nursing home costs but excluding absenteeism costs; 2) are based on default inputs; 3) are reported in 2010 $ and do not project inflation; and 4) assume no changes in policy or technology and exclude changes due to the Affordable Care Act. 9

Years of Potential Life Lost Before Age 65 Virginia, 2013 Data Source: National Center for Health Statistics Vital Statistics System for Virginia 2013. Data includes all races, both sexes, all deaths 10

Years of Potential Life Lost Before Age 65 Virginia, 2014 Data Source: National Center for Health Statistics Vital Statistics System for Virginia 2014. Data includes all races, both sexes, all deaths 11

Number of ED Visits for Heroin Overdose among Virginia Residents by Month, 2015-2016

Number of ED Visits for Heroin Overdose among Virginia Residents by Month and Age (Years), Previous 12 Months *0-8 year olds excluded from graph because no visits

Number of ED Visits for Heroin Overdose among Virginia Residents by Month and Sex, Previous 12 Months

Rate of ED Visits for Heroin Overdose among Virginia Residents by Month and Health Region, Previous 12 Months

Cancer Death Rate Data Source: Virginia Department of Health , Office of Information Management, Division of Health Statistics, 2012: Cancer Deaths 16

Heart Disease Death Rate Data Source: Virginia Health Information, Office of Information Management, Division of Health Statistics: Heart Disease Deaths, 2012 17

Question: What would it take for Virginia to be the healthiest state?

Health Opportunity Index Educational Attainment Population Density Spatial Segregation Material Deprivation Population Churning Job Participation Income Diversity Affordability of Housing and Transportation EPA Environmental Hazards Food Access Walkability Access to Care Employment Access HOI What is the HOI?.....is a tool for identifying some key SDOH - socioeconomic, demographic, and environmental processes that explain how race, class, and geography influence health outcomes. In effect the HOI helps answer important questions. For instance it answers the question “how do race and poverty act to influence life expectancy and which policies are needed?” And as a result, identifies key policy areas for health equity promoting policy intervention. Life expectancy, Disability adjusted Life Expectancy, and Infant Mortality were chosen as the health outcome of interest to evaluate the HOI for several reasons: It provides a generally accepted global indication of health across a population and across the life span. It summarizes the overall health of a population in an easily understood manner. It answers the question, “How long a life can I expect to live if I am typical member of my local community?” It provides a general measure of health without reference to the specific cause of a condition such as stroke or health disease. Therefore inaccuracies in determining causes of death are controlled for. It is consistent with research suggesting that SES and other SDOH are fundamental causes of disease, such that low income, limited social support, etc. are associated with multiple causes of death regardless of their associated risk factors.

Virginia Health Opportunity Index A composite measure comprised of 13 indices that reflect a broad array of social determinants of health Air Quality ● Population Density ● Population Churning ● Walkability ● Affordability ● Education ● Food Access ● Material Deprivation ● Employment ● Income Inequality ● Job Participation ● Segregation ● Access to Health Care

Health Outcome Rankings for Virginia Counties (2016) Outcomes are quality and length of life (morbidity and mortality)

Intentional Design: A Population Health Approach A population is a collection of individuals 22

Key Points/Assumptions Health and well-being matter to all people in Virginia Dealing with the burden of disease and breaking the cycle of debilitating disease must be addressed simultaneously Community-led, data-driven, focused solutions are the ideal Leadership efforts should intentionally facilitate the development and/or maintenance of these community efforts and be aligned for efficiency and impact

Strong Start for All Children Health Status Assessment Data-driven decision making and feedback Create a System of Healthcare Build Prevention Everywhere Redefine Health Strong Start for All Children Define Decode Design HEALTHY CONNECTED COMMUNITY

http://www.virginiawellbeing.com RWJF Good health flourishes across geographic, demographic and social sectors. Attaining the best health possible is valued by our entire society. Individuals and families have the means and the opportunity to make choices that lead to the healthiest lives possible. Business, government, individuals, and organizations work together to build healthy communities and lifestyles. Everyone has access to affordable, quality health care because it is essential to maintain, or reclaim, health. No one is excluded. Health care is efficient and equitable. The economy is less burdened by excessive and unwarranted health care spending. Keeping everyone as healthy as possible guides public and private decision-making. Americans understand that we are all in this together. http://www.virginiawellbeing.com

Virginia’s Plan for Well Being Metrics Percent of Adults Who Report Positive Well-Being HEALTHY, CONNECTED COMMUNITIES H.S. Grads Enrolled in Higher Ed Cost-Burdened Households Consumer Opportunity Index Economic Opportunity Index Districts with Collaborative Improvement Processes PREVENTIVE ACTIONS Adults Not Participating In Physical Activity Adults Who Are Overweight or Obese Households That Are Food Insecure Adults Using Tobacco Adults Vaccinated Against Influenza Adolescents Vaccinated Against HPV Adults Screened for Colorectal Cancer Percent of Adults With Adverse Childhood Experiences Disability-free Life Expectancy STRONG START FOR CHILDREN Teen Pregnancy Rate Kindergarteners Not Meeting PALS-K Benchmark Third Graders Passing Reading SOL Infant Mortality Rate by Race SYSTEM OF HEALTH CARE Adults With A Regular Health-care Provider Avoidable Cardiovascular Disease Deaths Mental Health and Substance Abuse Hospitalizations Avoidable Hospital Stays Adults Whose Poor Health Kept Them from Usual Activities Providers With Electronic Health Records Health Districts With EHRs Entities Connected to the Health Information Exchange Hospitals Meeting State Goal for Prevention of C. difficile Infections

Population Health Data Framework State Data Virginia’s Plan for Well-Being Regional Data Regional Data Regional Data Regional Data Community Health Assessment in Every District Local Data Local Data Local Data Local Data Local Data Local Data Local Data Local Data Drivers Drivers Drivers Drivers

Aim 1: Healthy, Connected Communities

Community Health Services Network of Health Districts & Local Health Departments Data Source: Virginia Department of Health, Health Planning Districts. 29

Strong Start for Children Aim 2: Strong Start for Children

Life Course Theory HEALTH OUTCOMES The Life Course Theory states that a complex interplay of biological, behavioral, psychological, and social protective and risk factors contribute to health outcomes across the span of a person’s life. It states that trajectories that impact health are built or diminished over the lifespan. Exposure to multiple protective factors increases the chance that an individual will follow a “high trajectory” and have positive health outcomes. Exposure to multiple risk factors increases the chance that an individual will follow a “low trajectory” and have poor health outcomes. Trajectories are paths of change in developmental processes and mark the long view of the life course.   Protective factors, like a planned pregnancy, healthy home, early reading, social capital, and physical activity, contribute to healthy development while risk factors, like prematurity, poverty, violence, school failure, and tobacco use, make it more difficult to reach full developmental potential. Early experiences, like whether or not you have access to quality pre-school or graduate from high school and college, can lay the foundation for health or create vulnerabilities. There are also critical periods of development during pregnancy, in early childhood, and during adolescence. Additionally, while individual episodes of stress may not impact a positive trajectory, cumulative stresses over time may have a profound impact on health. (This is called “weathering” or “allostatic load”) Patterns can be predicted for populations based on social, economic and environmental exposures and experiences. An individual’s health status, however, results from the interaction throughout life of genes, experiences, exposures and individual choices. Understanding population trends strengthens our ability to promote both individual and community interventions that can increase protective factors and reduce risk factors. PGY= Pregnancy Source: William Hollinshead, Trajectories and MCH Checkpoints, 2007

Quintiles Page 35

Aim 3: Preventive Actions

Due to the methodology change, BRFSS data collected in 2011 or later should not be trended to data collected in 2010 or prior.

Aim 4: System of Health Care

Patients With Undiagnosed Hypertension: Hiding in Plain Sight JAMA November 19, 2014 Volume 312, No 19

Figure in “The Plan” has incorrect data. Needs to be noted.

* Per 100,000 Population ages 18 years and older

* Per 100,000 Population ages 18 years and older

Health Impact Assessment (HIA) A systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA provides recommendations on monitoring and managing those effects. National Research Council, Improving Health in the United States: The Role of Health Impact Assessment, 2011. A HIA is… HIA is a practical approach that can inform and influence decision makers about how a proposal (or variations) would impact on people’s health It provides information to stakeholders and the public. Also, it provides the decision maker with recommendations to mitigate or negate possible risks to health, and opportunities to improve people’s health. The overarching aim of HIA is to create conditions that encourage and support the protection and improvement of people’s health and wellbeing The CDC has found that the HIA holds promise for incorporating aspects of health into decision-making and improving the Health in the U.S.

HIA Answers the Question... “How would this new development/project affect people’s health?’. An HIA seeks to answer the question... ‘How would this new development affect people’s health?’ HIA Toolkit Available at: http://www.vdh.virginia.gov/healthpolicy/healthequity/hia/index.htm

Different Types of HIAs Desk Based Rapid Intermediate Comprehensive 2-4 Weeks 6-12 Weeks 12 Weeks to six Month 6-12 Months for one person full time Provides broad overview of potential health impacts Provides more detailed overview of potential health impacts Provides a more thorough assessment of potential health impacts, and more detail on specific predicted impacts Provides a comprehensive assessment of potential health impacts. HIA serves as an umbrella that encompasses different approaches: rapid health impact assessment, health impact analysis, and health impact review. These approaches are differentiated by the availability of time and resources. The approach can take a couple weeks to up to 12-18 months. It can cost from a few thousand to exceeding 100K depending upon the depth and breadth of the analysis. So now let’s take a look at the actual steps involved in conducting an HIA! Rapid Health Impact Appraisal is a systematic assessment of the health impact of a policy, program, or project by a number of experts, decision-makers and representatives of those potentially affected by the proposed policy. This appraisal occurs without a great deal of resources and rather quickly. Note: A rapid HIA while faster than a full, environmental impact assessment-style HIA, still takes some time Health Impact Review is aimed at creating a convincing summary estimation of a policy, program, or project’s most significant impacts on health, without necessarily trying to disentangle the precise impact of the various parts of the policy, program, and project. It is based largely on a review of earlier published analyses of similar policies. As in the rapid health impact analysis, expert panels and other methods of reviewing the available informed assessments of the policy proposal are used. Health Impact Analysis involves an in-depth examination of a policy, program, or project in regard to its potential impact on health. Opportunities for adjusting the policy, program, or project to ensure a more positive impact on health are considered. The resources and time needed for implementation are necessarily greater than those for a rapid appraisal and impact review.

Virginia HIA Examples Proposed poultry litter-to-energy facility in the Shenandoah Valley of Virginia. http://societyhealth.vcu.edu/work/the-projects/health-impact-assessment-poultry-litter-to-energy-facility-in-the-shenandoah-va.html Building a new transit center along Richmond Highway Corridor in Northern Virginia http://www.naccho.org/topics/environmental/health-impact-assessment/project-locations/va.cfm HIA is an emerging process that is being used to address decisions impacting health from a broader perspective. I included links to two HIAs conducted in Virginia. HIA of a Poultry Litter-Fired Power Plant Authors: Virginia Commonwealth University Center on Human Needs Organization , Benjamin F. Evans, MHSA, Steven H. Woolf, MD, MPH Location: Richmond, Virginia, United States An HIA to inform the zoning and permitting decisions associated with a proposal to build a poultry litter-fired power plant as part of Virginia's federally-mandated plan to reduce water pollution in the Chesapeake Bay watershed. Completion Date: March 2013 HIA Report: The Potential Health Impact of a Poultry Litter-to-Energy Facility in the Shenandoah Valley, Virginia Richmond Highway Transit Center Project - Which you will have the pleasure of hearing about from our next presenters!

Model Process for Developing Public Health Policy Proposal – Define The Issue In Collaboration With Stakeholders And Appropriate Data Stage 1- Foundation Stage 2- Action Assumptions Not A Linear Process No Fixed Time Table DATA Analyze Existing Data Including ROI Key Principles Data Driven Stakeholder Engagement Thorough Vetting Broad Based Benefit LAW & Legislative Activity Analyze Existing Laws, Prior Legislative Activity Bills & Fiscal Impact Statements Stage 3- Consolidation & Decisions Stage 4- Evaluate STAKEHOLDER Analyze & Identify Existing and Future Stakeholders Consolidate All Analyses & Input Develop Proposal, Alternative or Stop Resulting Policy Changes Evaluated For Effectiveness This slide illustrates the Model Process that our team has developed with input from stakeholders The key principles, and assumptions, on which the process is based on listed in the upper right corner [READ]. There are 4 stages to the Model : Foundation, Action , Consolidation & Decisions and Evaluation. [CLICK FOR FOUNDATION STAGE] The Foundation stage is all about recognizing and appreciating that there are various different types of information that need to be utilized and considered Public Health Data, Law and Legislative Activity, Stakeholders, Evaluations & Analyses, and Best Practices [CLICK FOR ACTION STAGE] The Action stage involves reviewing, analyzing and understanding those different types and sources of information. The first two stages are integral to defining the issue into a specific proposal that can be evaluated. Again, this is not a linear process. Different steps can be happening simultaneously. [CLICK FOR STAGE 3] Stage 3 is focused on decision making. A possible outcome of this process is a decision not to proceed with the proposed policy change. [CLICK FOR STAGE 4] Stage 4 is focused on evaluation We can certainly point to examples in Virginia of where this type of approach has been followed. It represents common sense and good government. But acting in haste, it can be rather easy to leave out one or more of these steps. The bottom line is you have to do your homework. Now, there are certainly issues with how best to follow and implement such a process. [CLICK FOR IMPLEMENTATION CHALLENGES] Some challenges to the implementation of this Model Process are stated in the lower right hand corner. This process does assume the ready and convenient availability of various types of data and information, which leads into the next slide… Evaluations & Analyses Review articles, studies and reports Implementation Challenges Political Will Emotional Constituents How Much is Enough? Best Practices

References Virginia’s Plan for Well-Being http://virginiawellbeing.com/ Virginia Health Opportunity Index https://www.vdh.virginia.gov/omhhe/hoi/ Health in All Policies - NCSL http://www.ncsl.org/research/environment-and-natural-resources/health-in-all-policies.aspx Page 50

Summary and Thank You Together, we will make Virginia the healthiest state in the nation P4WB is a framework for action reporting platform for high level population health metrics for VA Your awareness, engagement leadership and support and perhaps most importantly reflection will make the difference