Brianna Gass, MPH November 17, 2014 Local Needs, Local Data

2  Understand local data integration efforts  Highlight potential application of integrated and mapped data  Identify ways integrated data can assist in targeting health improvement activities Objectives

Census data CountyNation Total population161,000313,874,000 % Population over age % Population below poverty level % Bachelors degree or higher % Hispanic or Latino % Self report health status as fair or poor* About the County

4  Key informant interviews  Data catalog  Dashboards and Key user sessions  Community case studies  Focus groups with stakeholders  Network analysis Methods

5 Key informant interviews Facilitators of integration:  Visionary organizational leadership  Committed community members  Necessity created by shrinking resources  Experience with benefits of integrated data Barriers to data integration:  Regulatory complexity  Technical challenges of integrating data on different platforms  Lack of consistent variable definitions, analytic methods Results

6 Key informant interviews Desire for data and service integration:  Utilization data – Behavioral health – Substance abuse treatment – Medicare & Medicaid  Health care quality indicators  Disease prevalence Results

7 Key informant interviews Use of integrated data  Describe service utilization patterns  Measure success of social programs  Plan for integration of services for individuals  Create efficiencies, maximize resources Results

8 Data Catalog  Medicare beneficiaries – Age (including beneficiaries under 65) – Admissions/30-day readmissions – Payment per beneficiary for inpatient stays, ED visits, observation stays, SNF admissions  Population variables – Poverty status – Education – Age – Households with no vehicle – Housing Choice Vouchers  FQHC locations  Medicaid Expenditures Results

9 Key user sessions and Dashboards  Tableau dashboards displayed interactive maps and graphs – Medicare utilization data – Demographic data – Elements based on key informant interviews  Key user chosen for access to and familiarity with local data sources, demonstrated leadership with integration efforts  Key user additions or modifications to the dashboards – Percent of Civilian Non-institutionalized Populations With No Health Insurance Coverage, – ZIP Code level live births to mothers <=18 (Teenage pregnancy rates), – various county health rankings, – metrics around community needs assessment and surveying efforts, and – Senior housing locations and program outcomes. Results

10 Focus groups Community characteristics:  High poverty; poor health outcomes  Many organizations provide social services  Limited resources drive desire to create efficiencies  Existing and active community collaboratives  Leaders are well connected and used to working together Results

11 Data elements desired by participants Results- Network Analysis

12 County priorities  Access to poverty and income data  Micro-target census tracts identified as areas of need – Target services under circumstances of limited resources  Engage residents in process to identify local needs  Leverage existing collaboratives to break down silos and share information  Integrate data from diverse sources to inform program interventions Many participants expressed desire for raw data Discussion

13 Limitations  Platform license structure created limitations  Stakeholder competing agendas  Reluctance to share  Lack of community resources – Limited resources available to invest in integration – Few stakeholders have skills necessary, key user cannot act alone Above factors limited key users’ ability to incorporate dashboard into workflow and take full advantage of functionality Discussion

14 Recommendations  Align funding cycles for initiatives that target similar populations  Identify common measures for health improvement  Improve local agency access to federal data sources  Develop maps that show utilization, demographics, prevalence of conditions, and social determinants of health at the census tract level Discussion

15 Acknowledgements  This material was prepared under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Sequence #: 11SOW-QINNCC /10 For more information:  Jane Brock, MD, MPH –  Brianna Gass, MPH – More information