1. John Auerbach Commissioner Department of Public Health Workplan Integration of Chronic Disease Programs CDC’s Negotiated Agreement

2. MDPH September 2008 2 Chronic Disease Program Integration in Massachusetts Goal: To improve health outcomes for Massachusetts residents across the life span through chronic disease program integration Two levels directing activities: 1)Macro-level operations & policy-setting groups; a)MASS Goals & EHS Goals at the Gubernatorial and Secretariat levels b)Health Care Reform c)HealthyMass Compact Initiatives d)Health Care Quality & Cost Council 2)State Health Department program-specific activities a)Public Health Council b)DPH priorities c)DPH program integration and collaboration

3. MDPH September 2008 3 DPH Priorities Support health care reform Eliminate disparities Promote wellness Manage chronic disease Support regionalization Maintain core public health functions Context Driving Massachusetts’ Integration Demonstration Project HealthCare Reform Increase access to health insurance Strengthen public health infrastructure HealthyMass Compact Ensure access Advance health care quality Contain cost Promote wellness Promote healthy Communities Healthcare Quality & Cost Council Improve chronic & preventive care Mitigate Disease impact Asthma BRFSS Comprehensive Cancer Diabetes Heart Disease & Stroke Prevention Healthy Aging & Disability Injury and Violence Prevention Primary Care Oral Health Tobacco School Health Substance Abuse Prevention and Treatment Community Wellness Nutrition, Physical Activity and Obesity WHN/MHP-Care Coordination Pilot Worksite Wellness External Partnerships Diabetes Task Force Obesity Task Force Chronic Disease Blueprint Macro Level ( system-wide) Operations & Policy Framework Department Level Program Specific Activities MASS Goals & EHS Goals Dashboard Regulatory Authority Public Health Council

4. MDPH September 2008 4 Macro Level: Health Care Reform Goal: increase access to health insurance and strengthen public health infrastructure Provide health insurance to all residents Outcome: 439,000 formerly uninsured residents are insured Increase in coverage provides  Increased opportunity for prevention, earlier detection and treatment  More data regarding the “health” of our residents

5. MDPH September 2008 5 Macro Level Activities – Involving Governor, Legislature and Secretary of HHS Goal: Quality, Affordable Health Care for All HealthyMass Compact: A Multi-Agency Wellness and Quality of Health Care Initiative with 5 Goals  Ensure access to care  Advance health care quality  Contain health care costs  Promote individual wellness  Promote healthy communities

6. MDPH September 2008 6 Macro Level: HealthyMass Compact Activities include 1. Establish five state-wide task forces – including the Chronic Disease Management and Wellness Task Force 2. Develop and implement a state-wide Action Plan for Preventing and Managing Diabetes 3. Create a blueprint for a statewide system of care to prevent and control chronic disease Goal: Establish unified health priorities for the administration targeting healthcare access, quality and costs; promoting individual wellness and healthy communities

7. MDPH September 2008 7 Macro Level: Health Care Quality & Cost Council Activities include 1. Analyze utilization, quality and cost data 2. Develop a blueprint for implementing a statewide model system of care that improves the health status of people with, or at risk for chronic conditions (Assigned to HealthyMass Task Force) 3. Ensure that all programs include targeted strategies to reduce racial and ethnic disparities 4. Establish policy as needed Goal: Establish a council comprised of state leaders that reports to the legislature and is charged with implementing polices that maximize quality, minimize costs and reduce racial and ethnic disparities

8. MDPH September 2008 8 Macro-Level – Other Activities 1.Establish Governor-level and Secretary-level quantitative goal-setting [Mass Goals and EHS Goals respectively] resulting in a transparent dashboard to measure outcomes 2.Strengthen the public health infrastructure using new funding for childhood immunizations, tobacco control, violence prevention, substance abuse & family services 3.Expand the regulatory authority of the Public Health Council Goal: Strengthen pubic health through data, programs and policy

9. MDPH September 2008 9 Programmatic & Departmental Activities Current Programs focused on integration Activity ASTHMA Inputs Asthma program staff MA Asthma Advocacy Partnership Integrative Aspects Chronic Disease Blueprint Guidelines for Diagnosis and Management of Asthma Funding 6 Care Centers to implement evidence-based interventions Current Outcomes Coordination of chronic disease management Increase provider adherence to asthma guidelines Activity BRFSS Inputs Health Survey Staff MDPH programs CDC Integrative Aspects MDPH programs Collaborate in publications Provide data directly to programs Current Outcomes Developed a population data base Disseminate findings via reports Activity Community Health Worker Inputs DPH Staff CHW -Advisory Council CHEC Training Integrative Aspects Diabetes Program & TF WHN & CHC collaboration Current Outcomes CHW assigned cohorts w/ CD CHW –Self Mgmt of CD Activity Comprehensive Cancer Inputs Cancer program staff Cancer Control Coalition Colorectal Cancer QI projects Patient Navigation surveys Informed decision- making initiative Integrative Aspects WHN/MHP Care Coordination Centers Current Outcomes Increase access Improved outcomes for Black/Hispanic cancer patients Activity Diabetes Inputs Diabetes program staff MA Diabetes Coalition Healthy Mass Diabetes Task Force MA Health Disparities Collaborative Integrative Aspects WNH/MHP Care Centers Current Outcomes Improved care coordination Eliminate health disparities Improved health outcomes for people at risk for or with diabetes

10. MDPH September 2008 10 Programmatic & Departmental Activities Current Programs Targeting Integration Activity Heart Disease and Stroke Prevention Inputs Heart Disease and Stroke program staff Relationship with emergency medical dispatchers and technicians Coverdell licensed stroke centers collaborative Guidelines for management of hypertension and hyperlipidemia Partnership for Heart Healthy, Stroke-Free Massachusetts Integrative Aspects Coverdell hospitals WHN/MHP care centers Current Outcomes Increase adherence to guidelines at WHN/MHP Care Centers Activity Healthy Aging & Disability Inputs, e.g. Healthy Aging and Disability staff AHRQ National Council on Aging Integrative Aspects Chronic Disease Self- Management Program at WHN/MHP care centers and their communities -Executive Office of Elder Affairs Disability access at WHNMHP Care Centers Current Outcomes Documented integration of Chronic Disease Self Management into systems of care Activity Obesity Inputs DPH Leadership Partnerships Obesity Grant Integrative Aspects Obesity health risks linked to chronic conditions- Broad-based policies Data collections Current Outcomes Coordinate w/ HealthyMass Link to MPHW & NECON action plans Share resources Activity Oral Health Inputs -Oral Health Director -DPH Staff -Educational Resources Integrative Aspects School Health programs Diabetes programs Tobacco Use/Cancer Cardiovascular Disease Nutrition Current Outcomes Integration of oral health info into chronic disease education resources

11. MDPH September 2008 11 Activity School Health Inputs UMass Medical Sch MA Academy of Peds Blue Cross Integrative Aspects Asthma Coalition PTA Boston College School of Nursing Collaborating with MDPH Current Outcomes Increase awareness to 2100 sch nurses re: substance abuse, asthma Implemented CE for school health personnel with Northeastern University School Health Initiative Activity WHN/MHP Inputs WHN/MHP staff WHN/MHP Contractors Advisory Committee UMass Medical School Health Education Network (AHEC) Integrative Aspects Integrative person- centered care coordination model AHEC training statewide for Community Health Workers and Patient Navigators MA Tobacco Control Program collaboration Current Outcomes Increaser access to and use of preventive services Elimination of health disparities Activity Worksite Wellness Inputs DPH Leadership DPH Staff HealthyMass Compact Integrative Aspects Training Evaluation Models Current Outcomes Developed community worksite & school collaborative Innovative model that increases health and decreases costs Programmatic & Departmental Activities Activity Women of Reproductive Age Inputs Bureau Family Health Bureau of Substance Abuse HealthyMass Compact Integrative Aspects Work with at risk patients for CD {what is this?} Diabetes Task Force Current Outcomes Secured medical home for at risk patients Improved perinatal outcome Current Programs Targeting Integration

12. MDPH September 2008 12 Baseline Data Outcome Indicators CDC Chronic Disease health indicators  WHN/MHP Care Coordination Pilot intake data  Statewide surveillance systems (BRFSS, YRBS, YHS) Economic impact  Quality & Cost Council and other health care reform mechanism yield new data collection & analysis  DPH program budget information  WHN/MHP Care Centers budget information Integration process  STAR Review ( February 2008)  Care Center process data ( patient satisfaction, site satisfaction )