COMMUNITY-CLINICAL LINKAGES STRATEGIC DIRECTION 3

 Reduce death and disability due to tobacco use by 5% in the implementation area.  Reduce the rate of growth of obesity through nutrition and physical activity interventions by 5% in the implementation area.  Reduce death and disability due to heart disease and stroke by 5% in the implementation area. COMMUNITY TRANSFORMATION GRANT LONG TERM OBJECTIVES

 Goals:  Increase control of high blood pressure and high cholesterol  Increase access to and demand for high impact quality preventive services. INCREASED USE OF HIGH IMPACT QUALITY CLINICAL PREVENTIVE SERVICES STRATEGIC DIRECTION 3

AGE-ADJUSTED HEART DISEASE MORTALITY IN CALIFORNIA ( ); US ( )

AGE-ADJUSTED HEART DISEASE MORBIDITY IN CALIFORNIA, OVERALL AND BY GENDER ( )

AGE-ADJUSTED STROKE MORBIDITY IN CALIFORNIA, OVERALL AND BY GENDER ( )

HIGH BLOOD PRESSURE Years Percent

 National initiative to prevent 1 million heart attacks and strokes over five years.  Million Hearts™ aims to prevent heart disease and stroke by:  Improving access to effective care.  Improving the quality of care for the ABCS.  Focusing clinical attention on the prevention of heart attack and stroke.  Activating the public to lead a heart-healthy lifestyle.  Improving the prescription and adherence to appropriate medications for the ABCS. MILLION HEARTS CAMPAIGN

Productive Interactions and Relationships Population Health Outcomes / Functional and Clinical Outcomes Self Management /Develop Personal Skills Information Systems Delivery System Design/ Re-orient Health Services Strengthen Community Action Create Supportive Environments Build Health Public Policy Decision Support Health System Community IInformed Activated Patient Activated Community Prepared Proactive Practice Team Prepared Proactive Community Partners EXPANDED CHRONIC CARE MODEL: INTEGRATING POPULATION HEALTH PROMOTION Created by: Victoria Barr, Sylvia Robinson, Brenda Marin-Link, Lisa Underhill, Anita Dotts, & Darlene Ravensdale (2002). Adapted from Glasgow,R., Orleans, C., Wagner, E., Curry, S., Solberg, L. (2001). “Does the Chronic Care Model also serve as a template for improving prevention?” The Milbank Quarterly, 79(4), and World Health Organization, Health and Welfare Canada and Canadian Public Health Association. (1986). Ottawa Charter of Health Association.

 Strengthen Community Health Worker infrastructure to facilitate better control of cardiovascular disease  Improve linkages between clinical providers, community- based organizations and interventions  Support and reinforce healthier behaviors by creating health care delivery systems change WHAT ARE WE TRYING TO DO? CAUTION: Changes Ahead

 State Project Period Objective (was) …50% of low-income individuals living in 42 California counties will have access to clinics that are linking PCPs, CHWs, community based organizations, and coalitions…. PROJECT PERIOD OBJECTIVES State Project Period Objective (is) …will increase from 0 to 35 the number of health care delivery teams engaging Community Health Workers who link with community-based resources to promote self-management, wellness, and environmental change among…

 County Annual Objective #1 …will increase from X to X the number of health care delivery teams engaging Community Health Workers who link with community based resources to promote self-management…  County Annual Objective #2 …will increase civic engagement of community health workers focused on environmental change by 10%.

WHAT IS A LINKAGE? Health Care Delivery Team + Community Health Worker + Community Based Organizations (CDSMP) = LINKAGE

 Measured by:  Counting the number of linkages  Population impact  Assumptions  1 physician team = 1 linkage  Physician: Patient ratio = 1:2,000  Baseline linkages = 0  5-year Goal = 35 linkages  Calculation  35 linkages x 2,000 patients = 70,000 total reach  70,000 / 5 years = 14,000 patients/year  Rural Counties (7/12) = 60%; Non-rural (5/12)= 40%  Rural Disparate Population Reach = 14,000 x 60% = 8,400  Non-rural Disparate Population Reach = 14,000 x 40% = 5,600 HOW IS IT MEASURED?

 CHWs understand how environmental change supports overall community health Measured by:  Number of CHWs who self report membership in an environmental change coalition CHW membership in coalition Total number of CHWs WHAT IS CIVIC ENGAGEMENT AND HOW IS IT MEASURED?

California Community Transformation Initiative SD 3: Creating Community-Clinical Linkages to Improve Community Wellness PHI Staff CDPH Staff Consultants Stakeholders County Health Department Staff County health care providers Environmental Scan Key Informant Interviews Community Wellness Summits CDSMP and WWE Leader trainings PHI and CDPH Technical Assistance and County-wide trainings 12-county CHW Assessment/ Survey CDSMP Workshop and WWE Program Schedule Community- wide Media Plan developed Community Action Plans Developed CHW Environmental Change Trainings Conducted CHW Chronic Disease and Risk Factor Trainings Conducted Increased awareness of the role of CHWs in Community Increased access to community resources Increased knowledge working with CHWs among health care delivery team CHWs understand how environmental change supports overall community health CHWs report increased confidence supporting people with chronic disease More people are aware of risks of uncontrolled blood pressure and cholesterol Improved health related quality of life outcomes Increased participation in self management and physical activity interventions Increased number of CHWs integrated into healthcare delivery team More people taking action to control high blood pressure and high cholesterol Increased civic engagement of CHWs IMPACT: Reduced High Blood Pressure and High Cholesterol Reduced health disparities Improved Community Wellness INPUTS ACTIVITIES Short Term (1-2 years) OUTPUTS Medium Term (2-3 years) Long Term (5+ years) OUTCOMES Annual Objective 1 Annual Objective 2

Continuum of Health Care Screening & Preventive Care Primary Care (Routine) Secondary Care (Specialist) Tertiary Care (Hospitals, etc) CHW ROLES AND LINKAGES Proactive Roles: Health Education Eligibility & Enrollment Patient-PCP Engagement ER Intervention to lower level of care Reactive Roles: CoachingAdherence Linkage Follow-up Community Resources: CDSMP Adapted from: Community Health Worker

Performance Partnership Model COMMUNITY WELLNESS SUMMITS

 Stakeholders  Logistics  Framework: Performance Partnership Model CONVENING A COMMUNITY WELLNESS SUMMIT

Engage key stakeholders  Who cares most about the result?  Who can bring resources to the table?  Who can work collaboratively?  Look beyond traditional partners  Look for partners who will keep going  Look for a mix of resources to help that happen– funds, leadership and administrative support, and worker bees CONVENING A COMMUNITY WELLNESS SUMMIT

ELEMENTS OF SUMMIT: LOGISTICS  Size matters  Location matters  Timing matters  Place matters

A PERFORMANCE PARTNERSHIP  Draws from all sectors  De-emphasizes programs and emphasizes cross-sector initiatives  Focuses on better use of existing resources  e.g. people, money, time  Is organized around a specific, measurable result  Employs multiple strategies to achieve result  Allows partners to “agree to disagree” on the strategy as long as they agree on the result

PERFORMANCE PARTNERSHIP MODEL  Model requires assembling a group of partners all interested in addressing the same issue  Model asks four questions 1.Where are we now? (baseline) 2.Where do we want to be? (target) 3.How will we get there? (multiple strategies) 4.How will we know we are getting there? (measures) Source: Smoking Cessation Leadership Center

WHERE ARE WE NOW? SETTING THE BASELINE  A jumping-off point against which to measure progress  Statistical baselines are good  Use data as a tool for motivation and management

WHERE DO WE WANT TO BE? SETTING A TARGET  Provides the focus for the partnership  Single measurable outcome  Require complete agreement  Agreement on the what rather than the how

HOW WILL WE GET THERE? MULTIPLE STRATEGIES  Allows a wide array of strategies  Even competing strategies– to be used by the various partners  No one party owns the answer to “How will we get there?”  Avoids hierarchy and turf

 Devise a measurement strategy with measurable results tied to the target  Both process and outcome measures are needed  Measures keep partners on track  Publicize progress to keep partners involved How Will We Know We Are Getting There? Setting Measures

Community Action Plan  What does a “linkage” look like in your Community?  How does a “linkage” function in your Community?  Immediately solidify and start implementing  Always a work in progress and can be continually updated  Keep communication going: frequent and early  Watch for breakdowns and step in to try to help  Partners may sign-up for various strategies during and after the summit  Allow self‐organization; each group can do it differently  Celebrate and publicize successes COMMUNITY WELLNESS SUMMIT OUTCOMES

KNOWLEDGE  Understanding of how actions by multiple community sectors can improve community health  Understand chronic disease burden  Aware of chronic disease self-management resources ACTION  Confident in their organization’s ability to implement COMMUNITY WELLNESS SUMMIT OUTCOMES

HEALTHIER LIVING: CHRONIC DISEASE SELF-MANAGEMENT PROGRAM (CDSMP)

Partner Characteristics:  Healthier Living/CDSMP fits with organization’s mission, vision, and goals  Serves individuals likely to have chronic health conditions  Has organizational support to ensure program longevity/sustainability  Has credibility in the community and outreach capacity  Supports data collection Working with Partners:  Promote and deliver Healthier Living/CDSMP  Identify personnel/staff as leaders  Actively recruit participants for Healthier Living/CDSMP  Speak with other organizations about recommending the program  Provide financial or in-kind support IMPLEMENTING HEALTHIER LIVING

Leader Characteristics:  Exhibits enthusiasm, passion, and commitment  Feels comfortable facilitating group discussion and brainstorming  Possesses good communication and interpersonal skills  Able to sharing and role-model  Is dependable, consistent, and organized  Creates a non-threatening, non-judgmental environment  Understands the importance and purpose of fidelity Leader Responsibilities:  Consider drafting a Leader Agreement IMPLEMENTING HEALTHIER LIVING

Lily Chaput, MD, MPH California Heart Disease and Stroke Program Pam Ford-Keach, MS California Heart Disease and Stroke Prevention Program California Arthritis Partnership Program Jackie Tompkins, MPH, CHES California Arthritis Partnership Program CONTACT INFORMATION