Health Enterprise Zones and Infant Mortality in Maryland April 9, 2014 Carlessia A. Hussein, RN, DrPH Director Office of Minority Health and Health Disparities Maryland Department of Health and Mental Hygiene 1

Maryland is One of the Most Racial/Ethnic Diverse States 45% minority 4 jurisdictions >50% minority 6 jurisdictions >40% minority 9 jurisdictions >33% minority Out of 24 jurisdictions 2

Disparities by Race/Ethnic Group Selected Racial and Ethnic Health Disparities in Maryland (Shows how many times higher the minority rate is compared to the White rate) 3

Unadjusted ED Visit Rates per 100,000 for Diabetes, by County, Black vs. White, Maryland 2011 Both Place and Race Matter to this rate

Hospital Admission Rate Disparities Black vs. White For Ambulatory Care Sensitive Conditions (or AHRQ Prevention Quality Indicators) for Maryland: Kid’s Asthma: Black rate is 3.1 times higher Adult Asthma: Black rate is 2.7 times higher Adult Hypertension: 4.5 times higher Adult Congest Heart Fail 2.6 times higher Various Diabetes metrics 2.6x to 4.6 x higher (data from AHRQ State Snapshots as presented in the MHQCC Health Disparities Workgroup Report) 5

Cost of Disparities in Maryland Minority Health Disparities cost Maryland between 1 and 2 Billion Dollars per year of direct medical costs. Excess charges from Black/White hospitalization disparities alone were $814 Million in – These are just the hospital charges, NOT including physician fees for hospital care, emergency department charges, or any outpatient costs. 6

Maryland Health Disparities Workgroup Convened by Maryland Health Quality and Cost Council in 2011 (Council chaired by Lt. Gov Brown and Sec Sharfstein) Workgroup Chaired by Dean Reece of U of MD School of Medicine, included diverse experts on minority health Maryland Office of Minority Health and Health Disparities staffed workgroup and co-drafted Final Report in 2012 Report Recommendations: Health Enterprise Zones (HEZs) Maryland Health Innovation Prize Racial and Ethnic tracking of health care delivery performance 7

Report Implementation Legislature passed Maryland Health Improvement and Disparities Reduction Act of 2012 based on the Report Administration funded HEZ program with $ 4 million per year for four years beginning in 2013 State Health Department and the Community Health Resources Commission oversee implementation Five HEZs were designated in January

Maryland Health Improvement & Disparities Reduction Act of 2012 Health Enterprise Zones Racial / ethnic data from insurers (MHCC) Racial / ethnic data for incentive programs: Hospital incentives (HSCRC) Patient-Centered Medical Homes (MHCC) Hospitals report efforts to reduce Disparities Health education institutions report efforts Cultural competency workgroup of Health Quality and Cost Council 9

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Health Enterprise Zones: Definition and Eligibility A Health Enterprise Zone was defined in law as – A contiguous area of one or more zip codes – Experiencing documented poor health outcomes and health disparities – Experiencing documented economic disadvantage Operationalized eligibility as – Bottom 50% on one of two poverty metrics, AND – Bottom 50% on one of two poor health metrics 11

Health Enterprise Zones: Provider Incentives HEZ enabling legislation provides various statutory incentives for providers in the Zones: – State income tax credits – Hiring tax credits – Grants for equipment purchase or lease – Loan repayment assistance programs These are contingent on – Participating in cultural competency training – Accepting Medicaid and uninsured patients – Participating with the Coordinating Organization 12

Health Enterprise Zones: Community Intervention HEZ enabling legislation provides grants for community-level public health interventions: – Deploying community health workers – Increasing availability of fresh fruits and vegetables – Improving access to safe physical activity – Transportation assistance programs – Mobile crisis teams for mental health – Providing cultural competency training – Supporting community coalitions 13

Health Enterprise Zones: Principles for Proposals HEZ call for proposals contained 13 principles that doubled as proposal review criteria. Several key principles were: – Cultural, linguistic, and health literacy competency – Workforce diversity – Outreach and targeting of minority populations – Racial, ethnic & language data collection/reporting – Addressing social determinants of health – Balance between provider and community focus 14

Health Enterprise Zones: Progress and Future Five HEZs designated in January of 2013 To date, 43 new health providers of various types hired in the zones Cultural competency training assistance Programmatic technical assistance Quarterly reporting on productivity and quality External evaluation contract to be established 15

Infant Mortality in Maryland: DEMO Programs MHHD is currently funding 3 pilot Minority Health Disparities Reduction Demonstration Grant (DEMO) sites for minority infant mortality in FY 2014 DEMO Programs utilize: – Minority Perinatal Navigators, CHWs, and health promoters; – Community coalitions and taskforces; – Increased community outreach and education; – Enhancement of clinical services; – Infrastructure for Program Sustainability; – Inter-county collaboration. 16

Infant Mortality in Maryland: General Background Racial and Ethnic Breakdown of births and infant deaths, Maryland * Infant deaths per 1000 live births, the Infant Mortality Rate **American Indian rate varies greatly year to year due to small numbers

Infant Mortality Reduction in Maryland Black White 18

Racial/Ethnic Population in Delaware 33.7% minority 2 jurisdictions >33% minority Out of 3 jurisdictions 19 Racial or Ethnic Minority Population, by Jurisdiction, Delaware, 2010 % Minority New Castle37.5% Kent33.4% Sussex23.5% Delaware33.7%

Infant Mortality in Delaware: General Background Racial and Ethnic Breakdown of births and infant deaths, Delaware 5-Year Average, * Infant deaths per 1000 live births, the Infant Mortality Rate

Infant Mortality Reduction in Delaware 21 White Black

Disparities Reduction Principles HEZsDEMO Program Community coalitionsCommunity coalitions and taskforces Community health workers and workforce diversity Minority Perinatal Navigators, CHWs, and health promoters Outreach and targeting of minority populations Increased community outreach and education Addressing social determinants of healthLinkage to community resources Provider Incentives (tax credits, loan repayment) Enhancement of clinical services Evaluation and SustainabilityInfrastructure for Program Sustainability Chronic Disease UtilizationChronic Disease and Infant Mortality 22

Linkages to Maryland HEZs DEMO PROGRAMS Shared logic model and common operational design features HEZs Low Birth Weight is used in designation of HEZs & HEZs may choose to target Infant Mortality INFANT MORTALITY Programs develop locally-targeted strategies for reducing infant mortality within a community 23

Recommendations 24 Use HEZ/DEMO model to target infant mortality in clusters of zip codes Identify specific small population groups by geographic areas where infant mortality rates and numbers are higher than the state average Where small groups of individuals with infant mortality that is higher than acceptable, target communication in a culturally competent manner Distribute infant mortality data trends information (rates and numbers) by small areas within counties Activate a coalition of diverse interest groups ( health, citizens, elected officials, faith-based, etc.) to focus on reducing infant mortality as a community Engage in innovative communication: movie theater ads, Man/Boys support groups, sports and entertainment personalities, grandma/senior citizen groups, etc.

Important Links Health Disparities Plan Health Disparities Workgroup Final Report Cultural Competency Workgroup Report pdf Maryland Chartbook of Minority Health and Minority Health Disparities Data 25

Contact Information Office of Minority Health and Health Disparities Maryland Department of Health and Mental Hygiene 201 West Preston Street, Room 500 Baltimore, Maryland Phone: Fax: Website: Facebook: