Primary Care – Public Health Integration and the Role of Data and Epidemiology J. Lloyd Michener, MD Professor and Chair Department of Community and Family Medicine Director, Duke Center for Community Research Duke University Health System Council of State and Territorial Epidemiologists Annual Conference Nashville, Tennessee June 23, 2014

Released: March 28, 2012

What Do We Mean By Integration? “The linkage of programs and activities to promote overall efficiency and effectiveness and achieve gains in population health.” Degrees of Integration :

Why integrate now? Call to Action IOM Report Affordable Care Act New Funding Opportunities Changes in Health Care Rise in Health Care Costs Disturbing Health Trends Increase in Health Research and Data Impact of Social Determinants of Health Drive to PCMHs and ACOs Availability of Electronic Health Records

Principles for Successful Integration Shared goal of population health improvement Community engagement in defining and addressing population health needs Aligned leadership Sustainability Shared data and analysis

System Overview

CalPERS Excess Medical Spending attributable to selected preventable conditions by county (2008) THE URBAN INSTITUTE

CalPERS Excess Medical Spending per person per year (2008) Condition Annual Excess Expenditure Per Person Short run conditions Diabetes only $2,863 Hypertension only $1,595 Diabetes and Hypertension only $3,920 Medium run conditions Diabetes with Heart, Cerebrovascular or Renal Disease $21,181 Hypertension with H, C, or R $14,576 Diabetes and Hypertension with H, C, or R $24,215 H, C, or R without Diabetes or Hypertension $10,743 THE URBAN INSTITUTE

Emergency Department Utilization for Primary Care in Charlotte, NC Neighborhoods Matter

Note: density plots depict ACTUAL patients and respective blood pressures in Durham County Source: DSR data from 1/1/06-5/1/09; patients seen at DUHS Neighborhoods Matter People with Hypertension in Durham

DM patients seen at Duke ,345 unique patients 8.7% of all patients >20 yo 14.3% of all patients >40 yo Durham County Stats (per CDC): 2008 ~ 10% of adults diagnosed with diabetes North Carolina (CDC): 2008 ~ 9% of adults diagnosed with diabetes By Race: 8.4% White 15.6% AA 12.4% NA 4.5% Hispanic 4.3% Other

HbA1C >9 HbA1C >9, AA 40-60, 60+

Just For Us Integrated Intervention – Durham, NC

Just For Us

DHI teams are connecting community partners and working with neighborhood residents to ensure: Healthy schools and neighborhoods Safe places to exercise Access to healthy foods Access to health information Building Neighborhood Capacity in Durham, NC

Percent Difference Between Medicaid Recipients Enrolled in CCNC and Those Not Enrolled in CCNC, for Rates of Asthma-Related Emergency Department Visits and Inpatient Admissions, 2008–2012 Note. CCNC, Community Care of North Carolina. NCMJ September/October 2013, Volume 74, Number 5

The Practical Playbook A cornerstone of the next transformation of health, in which primary care and public health groups work collaboratively to achieve population health improvement.

Target Audience Public Health Professionals Primary Care Teams Additional Stakeholders –Hospitals –Health Care Investors –Academic Institutions –Community Organizations

Steering Committee Duke Community and Family Medicine –Lloyd Michener de Beaumont Foundation –Brian Castrucci –Jim Sprague Centers for Disease Control and Prevention –Denise Koo

National Advisory Committee

Practical Playbook Overview

Maryland Prevents One Million Heart Attacks and Strokes The Maryland Million Hearts Initiative is part of a national campaign to prevent one million heart attacks and strokes by 2017.Maryland Million Hearts Initiative The statewide initiative is a partnership between the Department of Health and Mental Hygiene and local communities, health systems, nonprofit organizations, federal agencies and private-sector businesses. The program has seen a 27 percent increase in blood pressure control at participating centers.

MASSACHUSETTS IMPROVES QUALITY OF LIFE FOR CHILDREN WITH ASTHMA The Community Asthma Initiative works to improve the health and quality of life for children with asthma.Community Asthma Initiative Boston Children’s Hospital designed the program to focus on medical interventions rather than environmental influences. Since its establishment, the program has worked in tandem with partners at every level, including the individual, family, and larger community. CAI helped reduce the number of asthma-related hospitalizations by 80 percent. Massachusetts Improves Quality of Life for Children with Asthma

Playbook Google analytics Visitors: 14,131 - Returning visitors: 31.7% - New visitors: 68.3% Page views: 59,348 March 5 - June 18, 2014 (3 ½ months) 6

KEY ELEMENTS : Aggregated data from healthcare and public health Hot spotting for avoidable illness Coordinated community interventions IT as key infrastructure

Introducing PCORnet: The National Patient-Centered Clinical Research Network

PCORnet embodies a “community of research” by uniting systems, patients & clinicians Clinical Data Research Networks (CDRNs) 18 Patient- Powered Research Networks (PPRNs) PCORnet: A national infrastructure for patient-centered clinical research

29 CDRN and PPRN awards were approved on December 17 th by PCORI’s Board of Governors 32 This map depicts the number of PCORI-funded Patient-Powered or Clinical Data Research Networks that have coverage in each state.

PCORnet organizational structure 33

Other related activities Improving Population Health by working with communities Draft report available at Community Health Improvement Technical Package

-Roundtable on Population Health Improvement -Building Capacity for Population Intervention Research in Primary Care -Opportunity Knocks: Population Health in State Innovation Models -Paying for Population Health: A View of the Opportunity and Challenges in Health Care June 2014 Report to the Congress: Measuring population-based outcomes

What this means to Epidemiologists: More activity with and across health systems 16 Epidemiologists in Duke Department of Community of Family Medicine (8 with PhD in Epidemiology) Collaboration and Competition