A Look at the Determinants of Health and Proposed Priorities in the 10 Counties of the Greater Columbia ACH Presentation to the Retreat of the Greater Columbia Accountable Community of Health, 8.20.15

Goal: To Set the Factual Framework for GC ACH’s Priorities over next 2-3 Years Today, participants tasked with arriving at, or re-confirming, priority areas to tackle as part of the ACH. My goal: To assist in understanding of the environment, broadly speaking, and of some “upstream” measures affecting the outcomes the ACH would like to change. Data dive will not take up clinical measures Outside of participating providers & perhaps MCOs, the ACH doesn’t have the means to affect those outcomes. (This might change if the WA Waiver Request succeeds.) But we should have the ability to affect the performance of certain upstream measures.

About the numbers……. Sources – used those that had county-level, or sometimes, local health jurisdiction, data available. Most are surveys. Census (American Community Survey, SAIPE, SAIHE) WA Department of Health’s Local Public Health Indicators (CDC’s BRFSS & WA’s Healthy Youth Survey) University of Wisconsin & Robert Wood Johnson Foundation’s County Health Rankings Presenting the most current data available Often, due to small sample size, years combined to show 5 years No time trends available, such as in the Benton-Franklin & Walla Walla Trends Remember – all these graphs (& numbers) tell a story! So, challenge for those tackling concrete issues in the ACH is first to know the story behind the indicators, then design the strategies to move the indicator needle. Won’t have time today to consider the “why.”

The 80/20 Rule: Clinical Care comprises only 20% of the Key Factors Determining Good Health From County Health Rankings, Robert Wood Johnson Foundation

Key Social Determinants of Health from the Centers for Disease Control Poverty rates Median HH income Population w/ no HS degree HS grad rate Vacant housing rates (will have 2 housing “distress” indicators) Rate of physicians by county

From U.S. Government’s Healthy People 2020: Leading Indicators Healthy People targets 42 topic areas, composed of 1,200 objectives! Leading Health Indicators (LHIs) is “A smaller set of Healthy People 2020 objectives….to communicate high-priority health issues and actions that can be taken to address them.” LHIs = 26 Access to Health Services Clinical Preventive Services Environmental Quality Injury & Violence Maternal, Infant & Child Health Mental Health Nutrition, Physical Activity & Obesity Oral Health Reproductive & Sexual Health Social Determinants Substance Abuse Tobacco Use

GC ACH Vote on Priorities at December 2014 Retreat Reduce the incidence of diabetes Provide greater assistance to those with behavioral health problems Improve care coordination Question: Are they the same today?

Which Upstream Indicators? To help answer this, not all indicators will be covered. Totals: 30 in County Health Rankings 30 in Local Public Health Indicators 26 in Healthy People 2020’s LHIs Chose those that clarified the December ‘14 priorities & that were most heavily weighted in County Health Rankings List here is necessarily incomplete.. But insightful, I hope

Determinants of Health Economic Factors: Median Household Income in 2013 Census: Small Area Income & Poverty Estimates (SAIPE) Red = statistically significant below (at 90% confidence level) WA

Determinants of Health All-Age Poverty Rates in 2013 (%) Census: Small Area Income & Poverty Estimates (SAIPE) Red = statistically significant above (at 90% confidence level) WA

Determinants of Health Unemployment Rate, June 2015 (%)

Determinants of Health Share of Population 25+ w/out a High School Degree (or equivalency): ‘09-13 (%) Census, American Community Survey Table S1501 Red = statistically above (at 90% confidence level) WA; Green = statistically below WA

Determinants of Health Population 18-24 w/out a High School Degree (or equivalency): ‘09-13 (%) Census, American Community Survey Table S1501 Red = statistically significant above (at 90% confidence level) WA; Green = statistically significant below WA

Determinants of Health Public High School 5-Year Graduation Rate in 2014 (%) WA OSPI: http://www.k12.wa.us/DataAdmin/default.aspx#dropoutgrad

Determinants of Health Share of the Households with Severe Housing Problems ‘07-11 (%) Robert Wood Johnson Foundation, County Health Rankings Red = statistically significant above the WA average; Green statistically significant below the WA average

Determinants of Health Share of Households Paying 50% + of Income to Rent ‘09-13 (%) Census: American Community Survey, Table B25070

Determinants of Health Share of All Households with Householder Living Alone: ‘09-13 (%) Census, American Community Survey Table S1101 Red = statistically significant above (at 90% confidence level) WA; Green = statistically significant below WA

Determinants of Health Share of All Families w/ Single Parents w/ Children < 18, ‘09-13 (%) WA = 17% Census, American Community Survey Table S1101

Determinants of Health Property Crime: Rate per 1,000 Residents in 2013 FBI: Uniform Crime Reports

Determinants of Health Violent crime: Rate per 1,000 Residents in 2013 FBI: Uniform Crime Reports

GC ACH Health Indicators: A Recap Economic conditions: nearly all ACH counties perform below WA average Worst off: Yakima, Franklin Best off: Benton Note: Kittitas & Whitman are special cases, due to large student populations Low education: nearly all GC ACH counties show high shares Most pronounced for counties w/large ag labor force: Franklin & Yakima Troubling trend for the youngest age group, especially in those counties Kittitas & Whitman continue to be outliers Healthy People 2020 features On-time High School Graduation Rate as its leading social determinant of health Also weighted high by County Health Rankings

GC ACH Health Indicators: A Recap, cont’d Housing Majority of the ACH counties face less housing stress than in WA State, on average. Two largest ag work force counties appear to be the most stressed. Kittitas & Whitman seem to be driven by student housing issues. Social Support Majority of the ACH counties have lower rates of people living alone than WA average. However, two large ag counties, Franklin & Yakima, have far higher rates of single parents with children than WA. Crime Majority of ACH counties have lower, sometimes far lower property crime rates than WA average. Same characterization for violent crime.

Reduce the incidence of diabetes GC ACH Preliminary Priorities: A Look at the Outcomes with 1-2 Upstream Measures Reduce the incidence of diabetes Provide greater assistance to those with behavioral health problems Improve care coordination

Proposed Priority: Reduce incidence of diabetes Age-adjusted Incidence of Diabetes in Adults in 2012

Proposed Priority: Reduce Incidence of Diabetes Behavioral Factor of Adult Exercise WA Department of Health: Local Public Health Indicators Red = statistically significant below (at 90% confidence level) WA; Green = statistically above WA

Proposed Priority: Improve behavioral health outcomes Share of Adults Who Report 14+ Days of Poor Mental Health in the Past Month in ‘11-12 (%) WA Department of Health: Local Public Health Indicators Green = statistically significant below WA

Proposed Priority: Improve behavioral health outcomes Factor: Share of Adults Reporting Binge Drinking (5 drinks for men; 4 drinks for women) on at Least 1 Occasion in Last 30 Days WA = 18% WA Department of Health: Local Public Health Indicators Green = statistically significant below WA

Proposed Priority: Improve Behavioral Health Outcomes Factor: Ratio of Population to Mental Health Providers in 2014 Robert Wood Johnson Foundation, County Health Rankings

Propose Priority: Improve Care Coordination Share of Adults with a Personal Healthcare Provider (%) WA = 75% WA Department of Health: Local Public Health Indicators Red = statistically significant below (at 90% confidence level) WA; Green = statistically significant above WA

Proposed Priority: Improve Care Coordination Rate of the Uninsured of Ages < 65 in 2013 (%) Census: Small Area Health Insurance Estimates (SAHIE) Red = statistically significant above (at 90% confidence level) WA

Proposed Priority: Improve Care Coordination Dental Care WA Department of Health: Local Public Health Indicators Red = statistically significant below (at 90% confidence level) WA

Recap of Preliminary Priorities Diabetes Higher in 5 of the ACH counties than WA average, although only 2 statistically higher. Adult Exercise in most ACH counties show considerably lower rates than WA average, with 3 statistically lower. Kittitas & Whitman Counties are outliers due to large student population USDA index of proximity of low income residents to grocery stores – not shown -- does not show any ACH county with great distances to stores, except for Garfield County Further thoughts?

Recap of Preliminary Priorities Behavioral Health Generally, ACH counties perform better for adult mental health than WA average, although only one statistically better. Youth analog not available due to no reports from Benton, Franklin, Columbia & Walla Walla Counties Binge drinking by adults considerably lower than state average Youth drinking data are incomplete and not shown For those that reported, however, three (Asotin, Garfield, Yakima) were statistically higher than WA average However, access to mental health professionals considerably below WA average in all ACH counties. Further thoughts?

Recap of Preliminary Priorities Care Coordination Difficult to measure, so must rely on proxies Assume that if care coordination is taking place, then then proxy measures will improve Share of Adults with a Healthcare Provider ACH counties much like WA; Yakima statistically lower but Asotin statistically better Share of Adults seeing a Dentist within the past year ACH counties not statistically different than WA Average, with the exception of Yakima (lower) Share of Population up to Age 65 without Health Insurance Half of ACH counties (& majority of the population) had uninsured rates > WA average Question: how much different 2014 will be? Further thoughts?

Sources Healthy People 2020: http://www.healthypeople.gov/ Washington State County Health Rankings: http://www.countyhealthrankings.org/app/washington/2015/overview Washington State Local Public Health Indicators: https://fortress.wa.gov/doh/lphi/Indicator.mvc/IndicatorList American Community Survey: http://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml Small Area Health Insurance Estimates: http://www.census.gov/did/www/sahie/ Small Area Income & Poverty Estimates: http://www.census.gov/did/www/saipe/data/index.html Benton-Franklin Trends: http://www.bentonfranklintrends.ewu.edu/ Walla Walla Trends: http://www.wallawallatrends.ewu.edu/

Thank You! D. Patrick Jones, Ph.D. Executive Director Institute for Public Policy & Economic Analysis 509.828.1246 dpjones@ewu.edu