1. Building Healthy Communities: Understanding Outcomes One, Two and Three Joel Diringer, JD, MPH Michael Cousineau, DrPH Dana Hughes, DrPH Long Beach, December 3, 2009

2. Building Healthy Communities: Guiding principles Shift in thinking toward addressing root causes of poor health and policies that prioritize prevention. This will involve changes in the way things are currently done – “systems change” Through advocacy and strategic communications, local experiences will influence and shape policy at the regional, state and national level.

3. Building Healthy Communities: Goals 10-year strategic plan designed to improve health systems and the physical, social, economic and service structures that support healthy living and healthy behaviors in California. Four goals guide The Endowment’s work: Health systems prioritize prevention; Schools promote healthy behaviors and are a gateway for resources and services; Human services systems prioritize prevention and promote opportunities for children and their families; Physical, social and economic environments in local communities support health.

4. Building Healthy Communities: “Big Results” The Four Big Results Big Result #1: Provide a health home for all children Big Result #2: Reverse the childhood obesity epidemic Big Result #3: Increase school attendance Big Result #4: Reduce youth violence

5. Building Healthy Communities: Outcomes The 10 Outcomes of Success 1.All children have health coverage. 2.Families have improved access to a “health home” that supports healthy behaviors. 3.Health and family-focused human services shift resources toward prevention. 4.Residents live in communities with health-promoting land use, transportation and community development. 5.Children and their families are safe from violence in their homes and neighborhoods. 6.Communities support healthy youth development. 7.Neighborhood and school environments support improved health and healthy behaviors. 8.Community health improvements are linked to economic development. 9.Health gaps for young men and boys of color are narrowed. 10.California has a shared vision of community health.

6. Outcome 1 – All Kids Have Coverage

7. Outcome 1 – All Children Have Health Coverage Roadmap to coverage 1.Expand health coverage to all children in California 2.Improve systems and policies to ensure that children get enrolled and stay enrolled 3.Increase points of access for children by using coverage to provide preventive health care and health promotion services (inclusive of physical, dental, mental, and vision) 4.Reduce the burden of chronic health conditions through coverage of prevention strategies

8. 1.Expand health coverage to all children – Children’s Health Initiatives (CHIs) local efforts to both enroll and retain in existing programs and provide coverage to ineligible populations Enroll in Medi-Cal, Healthy Families, Kaiser Child Health Plan (where available), CalKids (where available) Create new local plan called Healthy Kids for ineligible children with benefits similar to Healthy Families Inclusive coverage: physical, oral, mental and vision Outcome 1 – All Kids Have Coverage

9. 1.Expand health coverage to all children (continued) – Alternatives/augmentation of Children’s Health Initiatives Ensure access to care for uninsured through partnerships with safety net providers Enroll in “stopgap” programs such as CHDP Gateway Outcome 1 – All Kids Have Coverage

10. 2. Improve systems and policies to ensure that children get enrolled and stay enrolled. – Outreach, Enrollment, Retention and Utilization (OERU) Maximize enrollment in existing programs funded by state and federal governments (Medi-Cal, Healthy Families) – think beyond health programs Keep children enrolled and reduce churning Help families to appropriately utilize coverage Community based application assistors (CAAs) Outcome 1 – All Kids Have Coverage

11. 3. Increase points of access for children by using coverage to provide preventive health care and health promotion services – Expand sources of care by having coverage – Assist families to access early primary and preventive services – Integrate referrals for physical, dental, mental and vision services Outcome 1 – All Kids Have Coverage

12. 4. Reduce the burden of chronic health conditions through coverage of prevention strategies – Ensure that health plans cover prevention services – Reduce obstacles to prevention services created by removing financial and other barriers Outcome 1 – All Kids Have Coverage

13. Examples of systems change approaches Current systemsSystems change Pay providers for direct services using local funds Develop resources to get kids on federal- state funded coverage programs; develop coverage for uninsured for short term and advocate for children’s coverage Pay for dental care for those who have medical coverage Advocate for state adoption of CHIPRA option for “dental wrap-around benefits in Healthy Families Have families enroll for different programs at different places Work in community coalitions of providers, enrollers, schools, advocates, social services, health plans, etc. Develop “no wrong door” approach to accepting applications One-e-App enrollment software Express Lane Enrollment Outcome 1 – All Kids Have Coverage

14. Outcome 2 – “Health Home” A “Health Home” is a primary care provider who: Coordinates and integrates care across the health care system (e.g., subspecialty care, hospitals, home health agencies) and the patient’s community (e.g., family, public, and private community- based services). Considers a patient’s cultural traditions, personal preferences and values, family situations, and lifestyles. Puts responsibility for self-care and monitoring in patients’ hands— but provides the tools and support needed to carry out that responsibility. Focuses on promoting good health through ensuring that transitions among providers, departments, and healthcare settings are respectful, coordinated, and efficient. Emphasizes preventing disease and poor health by using health care providers other than physicians.

15. Outcome 2 – Health Home Promising Strategies and Practices 1.Integrated, Coordinated, and Comprehensive Care 2.Patient- and Family-Centered Care 3.Culturally Competent Care 4.High-quality Care

16. Outcome 2 – Health Home 1. Integrated, Coordinated, and Comprehensive Care Seamlessly combines the range of clinical care, services, and providers needed by patients and their families Explicitly focuses on preventing the development of a disease, and improving the health of an entire community Joins together all health providers, including oral, mental, and vision health providers. Uses health information technology that ensures availability of patient information at the point of care, and gives patients health care tools Works with community-based programs such as schools, law enforcement, family resource centers, child welfare organizations, parks and recreation, faith-based organizations, parent organizations, etc.

17. Outcome 2 – Health Home 2. Patient- and Family-Centered Care Includes the perspective of individuals, families and communities in the design of care Is respectful of, and responsive to individuals, families and communities preferences, needs, and values to ensure that these values guide all clinical decisions Encourages and educates patients, families and communities to expand their role in health care decision-making through self-management and other strategies. Makes health homes accessible through expanded hours, e-consults, and other on-line services Encourages the support of personal health records that includes all health history and information, and their use by patients and families.

18. Outcome 2 – Health Home 3. Culturally Competent Care Delivery of care that is culturally competent and linguistically accessible Culturally and linguistically appropriate services (CLAS) services to improve access to care and the quality of care, and to diminish current health disparities. Culture is defined broadly and includes race, ethnicity, national origin, primary language, age, sexual orientation, physical and mental ability, spirituality, and religion Ability to use collect and use data to identify any disparities in the care received by individuals, families and communities.

19. Outcome 2 – Health Home 4. High Quality Care Providing the right care at the right time as established by the available evidence Strategies include clinical decision-support tools or clinical guidelines, medication management systems, and disease registries Customized checklist for each patient visit, indicating what services are due, document diagnoses and problems, and record actions taken

20. Outcome 2 – Health Home Current SystemHealth home After several days of waiting, eight-year- old Sam and his mother get in to see his pediatrician. Sam has been missing school lately because of a combination of colds and an ongoing asthmatic condition. When they arrive at the busy doctor’s office, they spend time updating their information in a crowded waiting room. After meeting with the physician for ten minutes, they receive an adjustment to Sam’s medication with verbal instructions on how to monitor his asthma. While Sam’s cold resolves, his asthma symptoms worsen to the point that Sam's mother thinks she needs to take him to the emergency room one night. Pediatrician responds to an e-mail from Sam’s mother regarding his school absences, and sets up appointment. When they arrive for the appointment, they verify that all the information from Sam’s electronic medical record (EMR) is correct and his immunizations are current. Following the meeting with the pediatrician to discuss Sam’s symptoms, they meet with the practice's nurse, who performs an asthma assessment and discusses family issues that have been aggravating his condition. Together, they draw up a written plan to help Sam manage his asthma. Nurse refers Sam to a local group of children with similar asthmatic conditions at the recreation department. The Pediatrician’s office provides Sam’s information to the health center at his school. Nurse follows up a week later to check on Sam’s progress.

21. Outcome 3 – Services shift to prevention Support systems for families include – Social supports – Financial resources – Human services Resource poor families living in isolated neighborhoods are more reliant on public health and human services systems than those in more affluent communities Current focus is more on intervention of those with problems Need to shift focus to prevention when it comes to health, family security, and social services Links to other outcomes on youth, economic and community development

22. Outcome 3 – Prevention Strategies to create seamless, coordinated, culturally competent and accessible “quilt” of health and human services that: 1.Support health and human services systems to become more preventive in their approaches 2.Coordinate services to strengthen families and promote children’s health development 3.Strengthen family’s economic security

23. Outcome 3 – Prevention 1. Health and human services support systems become more preventive – Get ahead of the serious crises by investing in community-based approaches – Invest in prevention of child maltreatment by strengthening protective factors such as parental resilience, concrete support and education – Shift juvenile justice resources toward early intervention and prevention – Create infrastructure of integrated community services with families to maintain preventive approaches

24. Outcome 3 – Prevention 2. Services are coordinated to strengthen families and promote children’s health development – Weave together health care, early care and education, with family support services Family resource centers such as Magnolia Place which combine parenting supports, early care and education, school readiness, health care and economic development programs – Acknowledge parents’ roles – Support relationships and infrastructure that are critical to success – Commit to services for all children, while having strategies for families that are most likely to be left behind – Use qualitative and quantitative data to maintain accountability and demonstrate success

25. Outcome 3 – Prevention 3. Systems strengthen family’s economic security – Link families to needed support and benefits Create “one-stop shopping” for health, nutrition and economic programs, e.g. Ohio Benefit Bank, or One-e-App potential – Develop employment opportunities for youth and families through education, job creation and connecting residents to jobs Link to Outcome 8 – workforce development

26. Outcome 3– Prevention Current SystemPrevention oriented systems Reactive – you need to “fail” to receive services Fragmented and uncoordinated Not effective at engaging consumers Focus on strengthening health of individual, family and community Coordinated, culturally competent and accessible Engages clients and consumers in improving service delivery

27. Concluding remarks The outcomes are inter-related and should be viewed as a package Focus on changing the current systems to be more responsive to and inclusive of families and community Try to get ahead of the curve by emphasizing prevention at the policy, community, family and individual level

28. Questions? Thank you!