Saving Lives. Protecting People. “Population Health Readiness” Wayne H. Giles, MD, MS January 10, 2015 Hello everyone I am glad to participate in this webinar. For my section I will focus on the State Innovation Models or SIM awards. Centers for Disease Control and Prevention Division of Population Health

CDC Strategic Directions Improve health security at home and around the world Better prevent the leading causes of illness, injury, disability, and death Strengthen public health/ health care collaboration

What are the Drivers? Actual Causes of Death† Leading Causes of Death† United States, 2000 Leading Causes of Death† United States, 2008 Percentage (of all deaths) Heart Disease Cancer Chronic lower respiratory diseases Unintentional Injuries Diabetes Alzheimer’s disease Pneumonia/influenza Kidney Disease Stroke Tobacco Poor diet/ Physical inactivity Alcohol consumption Microbial agents Toxic agents Motor vehicles And, of course, the reason we need to focus on the lower rungs of the pyramid -- changing environments, systems and policies -- is that this approach is where we can have the greatest impact – an impact that begins to approach the scale of the problem and the roots of so many or our chronic diseases. You are all familiar, of course, with the national data on chronic disease deaths and related behavioral risk factors. Chronic disease continues to represent the leading causes of death in the United States – with deaths from heart disease and cancer dwarfing other conditions. The figure on the right hand side of the slide shows the “Actual causes of death” – or deaths expressed by behavioral causes - which were first documented in a landmark study by Drs. McGinnis and Foege that was published in 1993. That work was subsequently updated in 2000. The findings did not change much between 1993 and 2000 - the major risk factors behind the leading causes of death in our nation continue to be tobacco use, poor diet, lack of physical inactivity and excessive alcohol consumption. Moreover, researchers found that about half of all deaths in the US, nearly 47%, could be attributed to a limited number of largely preventable behaviors and exposures. Addressing these modifiable risk factors is, of course, one of the lynch-pins to preventing chronic disease. JAMA. 1993 Nov 10;270(18):2207-12. Actual causes of death in the United States. McGinnis JM, Foege WH. US Department of Health and Human Services, Washington, DC 20201. To update this data, go to http://www.cdc.gov/nchs/fastats/lcod.htm Firearms Sexual behavior Illicit drug use 5 10 15 20 Percentage (of all deaths) * Minino AM, Murphy SL, Xu J, Kochanek KD. Deaths: Final data for 2008. National vital statistics reports; vol 59 no 10. Hyattsville, MD: National Center for Health Statistics. 2011. † Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-1246.

OPTIONAL

County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years: United States 2009 OPTIONAL Age-adjusted percent 0 - 6.3 6.4 - 7.5 7.6 - 8.8 8.9 - 10.5 > 10.6 www.cdc.gov/diabetes

Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) 1990 2000 2010 OPTION 1 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Hospitals in Georgia

Map: Obesity (Georgia) Graphs are state- and indicator-specific. State vs. US comparison, and racial/ethnic and education disparities depicted. Some estimates suppressed due to small sample sizes.

Map: Blood Pressure (Georgia) Map for GA that depicts county-level estimates for persons taking medication for high blood pressure.

Map: Cholesterol (Georgia)

Map: Diabetes (Georgia) For each of the SIM states we have created a map that shows at the county level the distribution of the measure. This helps states to identify where they may want to target interventions. Portable Network Graphics (.PNG) file format. One graphic file per mapped measure for each state. Total of 12 or 15 maps per state.

Map: Smoking Prevalence (Georgia)

Definition of Population Health Kindig et al (adapted) Population health includes factors that influence health outcomes of individuals, including the distribution and equity of such outcomes across various segments of society (Kindig et a. Am J Public Health. 2003;93:380-383).

Expanded Chronic Care Model The Expanded Chronic Care Model provides a graphical depiction of the core functions of state and community-based public health and the health care system. It also can provide clues to help solve some rather significant challenges and offer thoughts about the intersections that exist between public health and the health care system.

Federal Resources Resources from CMS (innovation Center), CDC, ACL and HRSA—not a complete list.

What is State Innovation Model (SIM)? Testing the ability of state government to use their regulatory and policy levers to accelerate health transformation Improve population health Transform healthcare payment & delivery systems Decrease total per capita health care spending Public and private collaboration with multi-payer and multi-stakeholder engagement Cooperative agreement between awardee and the Innovation Center Provides technical and financial assistance to provide better care and better health at lower cost through quality improvement to the state population

SIM Round 2 Awardees OR AR MN ME MA VT CA UT IA IL MI OH TN PA NH RI MD DE CT HI ID MT WA NV AZ NM CO OK WI NY VA KY WV NJ Round 1 Model Test States Round 2 Model Test Awardees Round 2 Model Design Awardees Note: The following R2 Model Design Awardees are NOT captured in this graphic: Puerto Rico, American Samoa, the Commonwealth of the Northern Mariana Islands and the District of Columbia

Health Care Innovation Award (HCIA) Priority Areas: High Value Targets of Change Hypertension and Cardiovascular Disease, Diabetes, COPD, Asthma, HIV/AIDS Fall prevention in older adults Behaviors that reduce the risk for chronic disease Adherence and self management skills Broader models that link clinical care with community-based interventions Note to Peter---No need to put into slide but can you please give an example of what is meant by “broader” models.

Health Care Innovation Award HCIA

Increase access to healthy foods, physical activity CDC State Program Funding for Diabetes, Tobacco, and Obesity Prevention Tobacco: Prevent tobacco use, eliminate secondhand exposure, promote quitting Diabetes: Increase A1C reporting, awareness of prediabetes, and participation in self management education All 50 state health departments are funded to work on diabetes, tobacco, and obesity prevention and control Diabetes: Part of the State Public Health Actions (GA is Basic Plus only at $635,818 total); Basic strategies are 1) Promote reporting of blood pressure and A1C measures; 2) Promote awareness of prediabetes among people at high risk for type 2 diabetes; 3) Promote participation in the Diabetes Self Management Education programs Tobacco: States are funded to eliminate secondhand smoke exposure, promote quitting, prevent initiation, and identify and eliminate disparities. Obesity: Part of the State Public Health Actions (GA is Basic Plus only at $635,818 total); Basic strategies are 1) Promote the adoption of food service guidelines/nutrition standards, which includes sodium; 2) Promote the adoption of PE/PA in schools; 3) Promote adoption of PA in early care and education (ECE) and worksites Obesity: Increase access to healthy foods, physical activity

Chronic Disease Self-Management Program Low-cost, community-based class for people with chronic diseases developed at Stanford University A CDC meta-analysis of CDSMP showed improvements in fatigue, depression, health distress, etc. CDC’s Arthritis Program funds 12 state arthritis programs that can offer CDSMP as a proven intervention • CDSMP is a low-cost, community-based, 6-week series of classes for people with chronic diseases that was developed at Stanford University. The program specifically addresses arthritis, diabetes, lung and heart disease, but teaches skills useful for managing a variety of chronic diseases. Subjects covered include: 1) techniques to deal with problems such as frustration, fatigue, pain and isolation, 2) appropriate exercise for maintaining and improving strength, flexibility, and endurance, 3) appropriate use of medications, 4) communicating effectively with family, friends, and health professionals, 5) nutrition, and, 6) how to evaluate new treatments. A CDC meta-analysis of CDSMP showed that it produces small to moderate improvements in fatigue, depression, health distress, and that it fosters healthy behaviors such as exercise and mental stress management techniques. (Executive summary is available at http://www.cdc.gov/arthritis/docs/ASMP-executive-summary.pdf.) More information at http://patienteducation.stanford.edu/programs/cdsmp.html

Administration on Aging: Chronic Disease Self-Management Education (CDSME) programs State of Georgia: CDSME Document: Purpose and Background Chronic Disease Self-Management Education (CDSME) programs provide older adults and adults with disabilities with education and tools to help them better manage chronic conditions such as diabetes, heart disease, arthritis, HIV/AIDS and depression. The U.S. Administration on Aging (AoA) has been supporting the dissemination of CDSME programs through grants to states since 2003. State governments use these funds to develop an infrastructure (state and community partners, workforce, sites, enrollment system) to deliver these programs in their communities. AoA’s most recent grant program, the Empowering Older Adults and Adults with Disabilities through Chronic Disease Self-Management Education Programs, began in September, 2012. The first year grants were financed through the 2012 Affordable Care Act Prevention and Public Health Fund (PPHF), second year continuation grants are being financed through 2013 PPHF funds, and the third year grants are financed solely through 2014 PPHF funds. The PPHF CDSME cooperative agreements are designed to achieve two major goals: Goal 1: Significantly increase the number of older and/or disabled adults who complete evidence-based CDSME programs to maintain or improve their health status. Goal 2: Strengthen and expand integrated, sustainable service systems within States to provide evidence-based CDSME programs. Funding In 2012, AoA awarded 22 states over $8.58 million in cooperative agreements. In 2013, AoA awarded the same 22 states $6.043 million in continuation grants. In 2014, the 22 states are receiving $6.579 million in continuation grants. The three-year project period ends August 31, 2015.

Administration for Community Living Chronic Disease Self-Management Education Funding The PPHF CDSME cooperative agreements are designed to achieve two major goals: Goal 1: Significantly increase the number of older and/or disabled adults who complete evidence-based CDSME programs to maintain or improve their health status. Goal 2: Strengthen and expand integrated, sustainable service systems within States to provide evidence-based CDSME programs. The 22 current grantees are providing: Chronic Disease Self-Management Program (CDSMP) (English version of CDSMP) Tomando Control de su Salud (Spanish version of CDSMP) Diabetes Self-Management Program (DSMP) Tomando Control de su Diabetes (Spanish Diabetes Self-Management Program) Arthritis Self-Management Program Positive Self-Management Program for HIV Chronic Pain Self-Management Program Better Choices, Better Health (online version of CDSMP) Better Choices, Better Health for Diabetes (online version of DSMP) Current grantees, through August 2015

Health Resources and Services Administration Community Health Workers Evidence-based Model Toolbox HRSA: The Community-Based Division (CBD) programs provide funding to increase access to care in rural communities. Through eight grant programs and multiple contracts, over 300 grants have been awarded. The Community Based Division staff are focused on peer-peer learning and coordinated technical assistance. Technical Assistance Workshops Every year, CBD conducts several Grants Technical Assistance Workshops in partnership with the State Offices of Rural Health. These workshops are designed to educate rural health providers and advocates about upcoming community-based grant funding opportunities from HRSA, encourage community organizations to apply, and increase organizations' capacities in obtaining future grant funds

Million Hearts: Prevent 1M Heart Attacks and Strokes Over 5 Years

Indicators – Status of the ABCS Aspirin People at increased risk of cardiovascular events who are taking aspirin 47% Blood pressure People with hypertension who have adequately controlled blood pressure 46% Cholesterol People with high cholesterol who are effectively managed 33% Smoking People trying to quit smoking who get help 23% MMWR. 2011;60:1248-51

Saving Lives. Protecting People. Contact Information: Wayne H. Giles, MD, MS 770 488 5269 hgiles@cdc.gov Office of the Director Division of Population Health