1. Improving health and healthcare at the population level
SCHA Data Knowledge Academy
Keynote Presentation
October 13, 2016

2. The most important number for determining health status?
Genetic Code
BMI
Age
Zip Code

3. The Neighborhood and The Need
Update with focus on education and health. Need education data. Pg 19 health data can be included here, selectively
The 5.6 square mile area of CPN is marked by under-education, teenage pregnancy, poor healthcare, violent crime, unemployment, and intergenerational poverty.
We aim to break that cycle.
Note: Federal Poverty Line for a family of 4 (200% FPL) = $48,500
4/17/2018

4. population health big picture
The overall health of people and populations is determined by a continuous interplay of social, environmental, economic and clinical factors/drivers.
Certain populations are more adversely impacted by these factors resulting in inequitable differences in healthcare access and health outcomes.
Effective solutions to the greatest health challenges at a community/population level will require collective actions that address both the major drivers of health and healthcare for the population overall and the equity gaps for those subpopulations most at risk

5. Population Health
"the health outcomes of a group of individuals, including the distribution of such outcomes within the group"
Source Pop Health Diagram:
Source: Population Health Definition:

6. Population Health Management
The actions through which care providers can improve clinical and financial outcomes for a defined population
The aggregation of data to provide a comprehensive clinical and financial picture at the patient and population level
Built around an integrated clinical delivery network and intensive care management for high risk patients within the defined population

7. Source: http://www. healthpolicyohio

8. Key Triple Aim Measurement Principles
The need for a defined population- measures of population health require a population denominator
The need for data over time- to distinguish between common and special cause variation, and to better understand the relationship between cause and effect and impact of specific interventions
The need to distinguish between outcome and process measures, and between population and project-based measures
The value of benchmark or comparison data

9. social determinants of health
conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks

10. Understanding Health Equity

11. the health equity challenge
Health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.”
Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment.

12. Location and Built Environment
Health Equity Triad
Race and Ethnicity
Education Level
Income and Assets
Location and Built Environment
Living in poverty- amplified in early childhood
Lack of access to high quality education & jobs
Unstable/unhealthy housing options
Unfavorable work or neighborhood conditions
Exposure to neighborhood violence

13. Disparities in Mortality Rates for Three Health Status Indicators: Black and White Americans (1990 and 2005)
Source: Orsi JM, Margellos-Anast H, Whitman S. Black-white health disparities in the United States and Chicago: A 15-year progress analysis. American Journal of Public Health. 2010;100(2):

14. Relative Risk of All-Cause Mortality by US Annual Household Income Level
Sources: McDonough P, Duncan GJ, Williams D, House J. Income dynamics and adult mortality in the United States, 1972 through American Journal of Public Health. 1997;87(9):
Williams D. “Race, Racism, and Racial Inequalities in Health.” Presentation to Harvard Kennedy School Multidisciplinary Program in Inequality and Social Policy. February 8,

16. South Carolina’s Health
People in 41 other states have better health than people in South Carolina
…people who live in low-income neighborhoods or rural areas, and people of color have even worse outcomes
…our children are the first generation projected to live shorter lives than their parents
Hundreds of people and organizations in our state are doing great work,
..but we have not been as coordinated and aligned as we should be.
We are 42 in America’s Health Rankings: New Update will be available on December 10, 2015
For the first time in our state’s history. We are working together to change this.

17. The Alliance for a Healthier South Carolina
Mission:
Coordinating action on shared goals to improve the health of ALL people in South Carolina.

18. Alignment of goals and actions: our primary way of impacting health in SC
Graph by Bill Barberg - Insightvision

20. Our Common Agenda for Health Improvement

21. Key Alliance metrics
Metrics for overall improvement and disparity reduction:
Infant mortality and low-birthweight
Reading at grade level and well-child visits
Primary-care-preventable utilization of acute care hospitals by people with and without behavioral health conditions
Appropriate management of asthma, diabetes, hypertension, and depression
Self-rated mental health status

22. Recent South Carolina Wins (2014 data)
Healthy Babies 58
12%
338 5%
Fewer baby deaths
Reduction in Infant Mortality Rate.
Met 2020 Alliance Goal.
Fewer babies born with Low-Birthweight
Reduction in Low-Birthweight Rate
Healthy Children 17
7.1%
2,372
Position improvement in America’s Health Rankings for Childhood Immunizations
Improvement in Asthma Medication Ratio
Fewer Pediatric ED visits due to Primary Care Preventable Conditions.

23. Recent South Carolina Wins (2014 data)
Healthy Minds
People with existing behavioral health conditions spent
We consolidated in a public, online map, all statewide drop-boxes for prescription drugs.
4,272
fewer days hospitalized due to
primary care preventable conditions.
Healthy Bodies
12%
136,624
4,276
Reduction in proportion of people who needed a doctor but couldn’t see one due to cost.
Met 2020 Alliance Goal.
Fewer uninsured
Fewer hospitalizations due to Primary Care Preventable Conditions.

24. SC Call to Action for Health Equity

25. Alliance equity metrics
Remind everyone that we have a set of 20 metrics to track progress. Most of the metrics that track overall progress in SC are in yellow.
But most of our equity metrics are in red.
WE ARE MAKING IMPROVEMENTS, BUT LEAVING OUR MOST VULNERABLE POPULATIONS BEHIND. THAT’S NOT SUSTAINABLE IMPROVEMENT.
This is why the Alliance has a Health Equity Team

26. Equity Call to Action- Obesity
1: Stratify data to identify what populations to target.
2: Maximize the potential of diversity in your organization to develop culturally sensitive solutions WITH the community.

27. The health equity ripple effect
Obesity/Chronic Disease of the mom prior to conception is a risk-factor for Low-birthweight.
Low-birthweight is a risk factor for Infant Mortality and for difficulty to learn.
Difficulty to learn is a risk factor for high-school graduation.
High-school graduation is a major socioeconomic determinant of health.

28. Guide to Preventing Readmissions among Racially & Ethnically Diverse Medicare Beneficiaries
Prepared for CMS OMH by the Disparities Solutions Center at Massachusetts General Hospital in collaboration with the National Opinion Research Center at the University of Chicago
This presentation will:
Explain the importance and value of the Guide in assisting CMS OMH and hospital leaders in preventing avoidable readmissions for diverse populations
Provide an overview of goals, intended audience, and content
Present a summary of high-level recommendations for hospitals to prevent avoidable readmissions contained in the Guide
Discuss next steps for dissemination and use of the Guide

29. key differentiating factors between hospital systems with lower and higher Medicare readmission rates
Higher minority population
Higher unmarried population
Lower education level
Higher proportion not in labor force
Lower total financial assets
Lower household income
Lower supplemental health insurance
Higher depression scores
Lower cognition scores
Worse self rated health
Higher difficulty with ADLs
Patient Characteristics and Differences in Hospital Readmission rates.
Barnett, Hsu, Wiliams
JAMA Intern. Med. 2015; 175(11):

30. All Payor Readmission Rates by Diagnosis
Based on The Revenue and Fiscal Affairs data, South Carolina all payer acute care hospital data base. We have seen an improvement in all diagnosis except all cause/ and pneumonia from the baseline data of 2011 and 2015.

31. Racial Readmission Disparity Gap

32. 1. Stratify the data
This is an example of the report each hospital received from SCHA.
Grey Sloan Memorial Health System numbers are really South Carolina numbers

33. 2. Maximize the potential of diversity in your organization to develop culturally humble solutions WITH the community.
Grey Sloan Memorial Health System numbers are really South Carolina numbers
And you would move your Overall Readmission Rate from Orange to Yellow in the comparative dashboard

34. Centering Pregnancy Results

35. Achieving population health equity- key collective upstream solutions
Collect and analyze all health data through an equity lens
Build a culture of diversity and inclusiveness that reduces the negative impact of implicit bias
Adopt a life course perspective to education and early childhood development (from cradle to career)
Deliver culturally and linguistically tailored health and social programs for specific at risk populations
Target urban planning and community development to healthy food access, safe spaces for physical activity, safe and affordable housing, public transportation and safety
Invest in community-based programs and resources

36. HealthierSC.org