1. Intentionally Designing Health and Well-Being in Virginia
Marissa J. Levine, MD, MPH, FAAFP
Virginia State Health Commissioner
The Virginia Department of Health

2. Objectives Define factors that affect health
Describe Virginia’s health status
Outline an Approach to Population Health Improvement
Identify the Virginia State Health Improvement Plan Framework (Virginia Plan for Well-Being)
Discuss opportunities for intentional and aligned health improvement efforts

3. AMONG ALL STATES, Virginia RaNKS 21ST IN HEALTH STATUS
Data Source: America’s Health Rankings, United Health Foundation Scorecard-2015 3

4. Think alignment

5. Relative Contribution of Factors that Affect Health
Genetics
Clinical
Care
Social and
Economic
Factors
Environment
Health
Behaviors
Source: McGinnis et al, The Case for More active Policy Attention to Health Promotion, Health Affairs, 21, no. 2 (2002): 78-93

6. County Health Rankings

7. Health Factor Rankings for Virginia Counties (2016)
Health factors are the four big categories:
Social and economic factors
Health Behaviors
Clinical factors
Physical environment

8. Health Outcome Rankings for Virginia Counties (2016)
Outcomes are quality and length of life (morbidity and mortality)

9. Annual Cost of Chronic Diseases in Virginia
Total cost estimate of these conditions $41 billion
Data Source: CDC Cost Calculator for Virginia Includes costs only for diseases that are selected and have cost values available. The projections: 1) are medical costs only, including nursing home costs but excluding absenteeism costs; 2) are based on default inputs; 3) are reported in 2010 $ and do not project inflation; and 4) assume no changes in policy or technology and exclude changes due to the Affordable Care Act. 9

10. Years of Potential Life Lost Before Age 65
Virginia, 2013
Data Source: National Center for Health Statistics Vital Statistics System for Virginia Data includes all races, both sexes, all deaths 10

11. Years of Potential Life Lost Before Age 65
Virginia, 2014
Data Source: National Center for Health Statistics Vital Statistics System for Virginia Data includes all races, both sexes, all deaths 11

12. Number of ED Visits for Heroin Overdose among Virginia Residents by Month, 2015-2016

13. Number of ED Visits for Heroin Overdose among Virginia Residents by Month and Age (Years), Previous 12 Months
*0-8 year olds excluded from graph because no visits

14. Number of ED Visits for Heroin Overdose among Virginia Residents by Month and Sex, Previous 12 Months

15. Rate of ED Visits for Heroin Overdose among Virginia Residents by Month and Health Region, Previous 12 Months

16. Cancer Death Rate
Data Source: Virginia Department of Health , Office of Information Management, Division of Health Statistics, 2012: Cancer Deaths 16

17. Heart Disease Death Rate
Data Source: Virginia Health Information, Office of Information Management, Division of Health Statistics: Heart Disease Deaths, 2012 17

18. Question: What would it take for Virginia to be the healthiest state?

19. Health Opportunity Index
Educational Attainment
Population Density
Spatial Segregation
Material Deprivation
Population Churning
Job Participation
Income Diversity
Affordability of Housing and Transportation
EPA Environmental Hazards
Food Access
Walkability
Access to Care
Employment Access
HOI
What is the HOI?.....is a tool for identifying some key SDOH - socioeconomic, demographic, and environmental processes that explain how race, class, and geography influence health outcomes.
In effect the HOI helps answer important questions. For instance it answers the question “how do race and poverty act to influence life expectancy and which policies are needed?”
And as a result, identifies key policy areas for health equity promoting policy intervention.
Life expectancy, Disability adjusted Life Expectancy, and Infant Mortality were chosen as the health outcome of interest to evaluate the HOI for several reasons:
It provides a generally accepted global indication of health across a population and across the life span.
It summarizes the overall health of a population in an easily understood manner. It answers the question, “How long a life can I expect to live if I am typical member of my local community?”
It provides a general measure of health without reference to the specific cause of a condition such as stroke or health disease. Therefore inaccuracies in determining causes of death are controlled for.
It is consistent with research suggesting that SES and other SDOH are fundamental causes of disease, such that low income, limited social support, etc. are associated with multiple causes of death regardless of their associated risk factors.

20. Virginia Health Opportunity Index
A composite measure comprised of 13 indices that reflect a
broad array of social determinants of health
Air Quality ● Population Density ● Population Churning ● Walkability ● Affordability ● Education ● Food Access ● Material Deprivation ● Employment ● Income Inequality ● Job Participation ● Segregation ● Access to Health Care

21. Health Outcome Rankings for Virginia Counties (2016)
Outcomes are quality and length of life (morbidity and mortality)

22. Intentional Design: A Population Health Approach
A population is a collection of individuals 22

23. Key Points/Assumptions
Health and well-being matter to all people in Virginia
Dealing with the burden of disease and breaking the cycle of debilitating disease must be addressed simultaneously
Community-led, data-driven, focused solutions are the ideal
Leadership efforts should intentionally facilitate the development and/or maintenance of these community efforts and be aligned for efficiency and impact

24. Strong Start for All Children
Health Status Assessment
Data-driven decision making and feedback
Create a System of Healthcare
Build Prevention Everywhere
Redefine Health
Strong Start for All Children
Define
Decode
Design
HEALTHY CONNECTED COMMUNITY

25. http://www.virginiawellbeing.com RWJF
Good health flourishes across geographic, demographic and social sectors.
Attaining the best health possible is valued by our entire society.
Individuals and families have the means and the opportunity to make choices that lead to the healthiest lives possible.
Business, government, individuals, and organizations work together to build healthy communities and lifestyles.
Everyone has access to affordable, quality health care because it is essential to maintain, or reclaim, health.
No one is excluded.
Health care is efficient and equitable.
The economy is less burdened by excessive and unwarranted health care spending.
Keeping everyone as healthy as possible guides public and private decision-making.
Americans understand that we are all in this together.

26. Virginia’s Plan for Well Being Metrics
Percent of Adults Who Report Positive Well-Being
HEALTHY, CONNECTED COMMUNITIES
H.S. Grads Enrolled in Higher Ed
Cost-Burdened Households
Consumer Opportunity Index
Economic Opportunity Index
Districts with Collaborative Improvement Processes
PREVENTIVE ACTIONS
Adults Not Participating In Physical Activity
Adults Who Are Overweight or Obese
Households That Are Food Insecure
Adults Using Tobacco
Adults Vaccinated Against Influenza
Adolescents Vaccinated Against HPV
Adults Screened for Colorectal Cancer
Percent of Adults With Adverse Childhood Experiences
Disability-free Life Expectancy
STRONG START FOR CHILDREN
Teen Pregnancy Rate
Kindergarteners Not Meeting PALS-K Benchmark
Third Graders Passing Reading SOL
Infant Mortality Rate by Race
SYSTEM OF HEALTH CARE
Adults With A Regular Health-care Provider
Avoidable Cardiovascular Disease Deaths
Mental Health and Substance Abuse Hospitalizations
Avoidable Hospital Stays
Adults Whose Poor Health Kept Them from Usual Activities
Providers With Electronic Health Records
Health Districts With EHRs
Entities Connected to the Health Information Exchange
Hospitals Meeting State Goal for Prevention of C. difficile Infections

27. Population Health Data Framework
State
Data
Virginia’s Plan
for Well-Being
Regional Data
Regional Data
Regional Data
Regional Data
Community Health Assessment in Every District
Local Data
Local Data
Local Data
Local Data
Local Data
Local Data
Local Data
Local Data
Drivers
Drivers
Drivers
Drivers

28. Aim 1: Healthy, Connected Communities

29. Community Health Services
Network of Health Districts & Local Health Departments
Data Source: Virginia Department of Health, Health Planning Districts. 29

31. Strong Start for Children
Aim 2:
Strong Start for Children

32. Life Course Theory HEALTH OUTCOMES
The Life Course Theory states that a complex interplay of biological, behavioral, psychological, and social protective and risk factors contribute to health outcomes across the span of a person’s life. It states that trajectories that impact health are built or diminished over the lifespan.
Exposure to multiple protective factors increases the chance that an individual will follow a “high trajectory” and have positive health outcomes. Exposure to multiple risk factors increases the chance that an individual will follow a “low trajectory” and have poor health outcomes.
Trajectories are paths of change in developmental processes and mark the long view of the life course.
Protective factors, like a planned pregnancy, healthy home, early reading, social capital, and physical activity, contribute to healthy development while risk factors, like prematurity, poverty, violence, school failure, and tobacco use, make it more difficult to reach full developmental potential.
Early experiences, like whether or not you have access to quality pre-school or graduate from high school and college, can lay the foundation for health or create vulnerabilities.
There are also critical periods of development during pregnancy, in early childhood, and during adolescence.
Additionally, while individual episodes of stress may not impact a positive trajectory, cumulative stresses over time may have a profound impact on health. (This is called “weathering” or “allostatic load”)
Patterns can be predicted for populations based on social, economic and environmental exposures and experiences. An individual’s health status, however, results from the interaction throughout life of genes, experiences, exposures and individual choices.
Understanding population trends strengthens our ability to promote both individual and community interventions that can increase protective factors and reduce risk factors.
PGY= Pregnancy
Source: William Hollinshead, Trajectories and MCH Checkpoints, 2007

35. Quintiles
Page 35

36. Aim 3:
Preventive Actions

37. Due to the methodology change, BRFSS data collected in 2011 or later should not be trended to data collected in 2010 or prior.

38. Aim 4: System of Health Care

40. Patients With Undiagnosed Hypertension: Hiding in Plain Sight
JAMA November 19, 2014 Volume 312, No 19

41. Figure in “The Plan” has incorrect data. Needs to be noted.

42. * Per 100,000 Population ages 18 years and older

43. * Per 100,000 Population ages 18 years and older

44. Health Impact Assessment (HIA)
A systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those effects within the population. HIA provides recommendations on monitoring and managing those effects.
National Research Council, Improving Health in the United States: The Role of Health Impact Assessment, 2011.
A HIA is…
HIA is a practical approach that can inform and influence decision makers about how a proposal (or variations) would impact on people’s health
It provides information to stakeholders and the public.
Also, it provides the decision maker with recommendations to mitigate or negate possible risks to health, and opportunities to improve people’s health.
The overarching aim of HIA is to create conditions that encourage and support the protection and improvement of people’s health and wellbeing
The CDC has found that the HIA holds promise for incorporating aspects of health into decision-making and improving the Health in the U.S.

45. HIA Answers the Question...
“How would this new development/project affect people’s health?’.
An HIA seeks to answer the question... ‘How would this new development affect people’s health?’
HIA Toolkit Available at:

46. Different Types of HIAs
Desk Based
Rapid
Intermediate
Comprehensive
2-4 Weeks
6-12 Weeks
12 Weeks to six Month
6-12 Months for one person full time
Provides broad overview of potential health impacts
Provides more detailed overview of potential health impacts
Provides a more thorough assessment of potential health impacts, and more detail on specific predicted impacts
Provides a comprehensive assessment of potential health impacts.
HIA serves as an umbrella that encompasses different approaches: rapid health impact assessment, health impact analysis, and health impact review.
These approaches are differentiated by the availability of time and resources.
The approach can take a couple weeks to up to months.
It can cost from a few thousand to exceeding 100K depending upon the depth and breadth of the analysis.
So now let’s take a look at the actual steps involved in conducting an HIA!
Rapid Health Impact Appraisal is a systematic assessment of the health impact of a policy, program, or project by a number of experts, decision-makers and representatives of those potentially affected by the proposed policy. This appraisal occurs without a great deal of resources and rather quickly. Note: A rapid HIA while faster than a full, environmental impact assessment-style HIA, still takes some time
Health Impact Review is aimed at creating a convincing summary estimation of a policy, program, or project’s most significant impacts on health, without necessarily trying to disentangle the precise impact of the various parts of the policy, program, and project. It is based largely on a review of earlier published analyses of similar policies. As in the rapid health impact analysis, expert panels and other methods of reviewing the available informed assessments of the policy proposal are used.
Health Impact Analysis involves an in-depth examination of a policy, program, or project in regard to its potential impact on health. Opportunities for adjusting the policy, program, or project to ensure a more positive impact on health are considered. The resources and time needed for implementation are necessarily greater than those for a rapid appraisal and impact review.

47. Virginia HIA Examples
Proposed poultry litter-to-energy facility in the Shenandoah Valley of Virginia.
Building a new transit center along Richmond Highway Corridor in Northern Virginia
HIA is an emerging process that is being used to address decisions impacting health from a broader perspective.
I included links to two HIAs conducted in Virginia.
HIA of a Poultry Litter-Fired Power Plant
Authors: Virginia Commonwealth University Center on Human Needs Organization , Benjamin F. Evans, MHSA, Steven H. Woolf, MD, MPH
Location: Richmond, Virginia, United States
An HIA to inform the zoning and permitting decisions associated with a proposal to build a poultry litter-fired power plant as part of Virginia's federally-mandated plan to reduce water pollution in the Chesapeake Bay watershed.
Completion Date: March 2013
HIA Report: The Potential Health Impact of a Poultry Litter-to-Energy Facility in the Shenandoah Valley, Virginia
Richmond Highway Transit Center Project - Which you will have the pleasure of hearing about from our next presenters!

48. Model Process for Developing Public Health Policy
Proposal – Define The Issue In Collaboration With Stakeholders And Appropriate Data
Stage 1- Foundation
Stage 2- Action
Assumptions
Not A Linear Process
No Fixed Time Table
DATA
Analyze Existing Data
Including ROI
Key Principles
Data Driven
Stakeholder Engagement
Thorough Vetting
Broad Based Benefit
LAW & Legislative Activity
Analyze Existing Laws,
Prior Legislative Activity
Bills & Fiscal Impact Statements
Stage 3- Consolidation & Decisions
Stage 4- Evaluate
STAKEHOLDER
Analyze & Identify Existing and Future Stakeholders
Consolidate All Analyses & Input
Develop Proposal, Alternative or Stop
Resulting Policy Changes Evaluated For Effectiveness
This slide illustrates the Model Process that our team has developed with input from stakeholders
The key principles, and assumptions, on which the process is based on listed in the upper right corner [READ].
There are 4 stages to the Model : Foundation, Action , Consolidation & Decisions and Evaluation.
[CLICK FOR FOUNDATION STAGE]
The Foundation stage is all about recognizing and appreciating that there are various different types of information that need to be utilized and considered Public Health Data, Law and Legislative Activity, Stakeholders, Evaluations & Analyses, and Best Practices
[CLICK FOR ACTION STAGE]
The Action stage involves reviewing, analyzing and understanding those different types and sources of information.
The first two stages are integral to defining the issue into a specific proposal that can be evaluated. Again, this is not a linear process. Different steps can be happening simultaneously.
[CLICK FOR STAGE 3]
Stage 3 is focused on decision making. A possible outcome of this process is a decision not to proceed with the proposed policy change.
[CLICK FOR STAGE 4]
Stage 4 is focused on evaluation
We can certainly point to examples in Virginia of where this type of approach has been followed. It represents common sense and good government. But acting in haste, it can be rather easy to leave out one or more of these steps. The bottom line is you have to do your homework.
Now, there are certainly issues with how best to follow and implement such a process.
[CLICK FOR IMPLEMENTATION CHALLENGES]
Some challenges to the implementation of this Model Process are stated in the lower right hand corner.
This process does assume the ready and convenient availability of various types of data and information, which leads into the next slide…
Evaluations & Analyses
Review articles, studies and reports
Implementation Challenges
Political Will
Emotional Constituents
How Much is Enough?
Best Practices

50. References Virginia’s Plan for Well-Being
Virginia Health Opportunity Index
Health in All Policies - NCSL
Page 50

51. Summary and Thank You Together, we will make Virginia the healthiest state in the nation
P4WB is a
framework for action
reporting platform for high level population health metrics for VA
Your awareness, engagement leadership and support and perhaps most importantly reflection will make the difference