1. Population Health and Its Role in Our Community Virginia A. Caine, MD Director, Marion County Public Health Department vcaine@marionhealth.org 317-221-2301

2. Population Health is: The health outcomes of a group of individuals, including the distribution of such outcomes within the group.

3. Aren’t Population Health and Public Health the Same? Public Health focuses on the critical functions of state and local health departments such as preventing epidemics, containing environmental hazards, and encouraging health behaviors. Population health concerns the determinants of health like health care, education, and income inequality to name a few, which remain outside the traditional public health authority and its responsibility.

4. The Future of the Public’s Health in the 21 st Century Significant movement in “building a new generation of intersectoral partnerships that drawn on the perspectives and resources of diverse communities and actively engage them in health action.”

5. But What About Population Medicine? Considers the specific activities of the medical care system that promote population health beyond the goals of care of the individuals treated Requires the medical care system to collaborate and partner with other organizations Acknowledgement that individual health and clinical outcomes greatly influenced by population factors, such as education

6. Population Health Provides the Best Definitional Framework It focuses on measurable outcomes from multiple sectors – Clinical outcomes – Education levels – Poverty rates – Environmental factors Creating a holistic picture of a community’s health

7. So…How Do We Measure Population Health Outcomes? MCPHD initiated a Community Health Assessment to create a baseline of these factors. Inputs: Health Care Individual Behavior Social Environment Physical Environment Genetics

8. Population Health in the Affordable Care Act Provisions to expand insurance coverage by improving access to the health care delivery system (Medicaid expansions, state insurance exchanges, support for community health centers) Improving the quality of the care delivered (National Strategy for Quality Improvement, CMS Center for Medicare and Medicaid Innovation, and establishment of the Patient-Centered Outcomes Research Institute)

9. Population Health in the Affordable Care Act Promotion and implementation of ACOs to incentivize providers to take responsibility for population health outcomes Expansion of primary health care training, requirements that private health plans and Medicare provide specific services recommended by U.S. Preventive Services Task Force without cost sharing

10. Population Health in the Affordable Care Act Promoting community-and population-based activities The establishment of the National Prevention, Health Promotion and Public Health Council A new Prevention and Public Health Fund (authorized $1 billion in fiscal year 2012) Funding for Community Transformation Grants

11. What is a Community Health Assessment (CHA)? Quantifies prevalent or impactful health issues Detects health trends that merit attention Identifies health inequities Compares Marion County to peer cities and the nation, to provide context

12. Why do a Community Health Assessment?  Increases community awareness of health issues  Prioritizes community health needs  Identifies health disparities  Provides an evidence base for MCPHD’s Community Health Improvement Plan (CHIP) Improves the health status of our community

13. Top Priorities  Unhealthy Weight  Poor Mental Health  Increasing Poverty Rates  Chronic Disease Prevention and Management  Chief contributing factor: SMOKING  Violence

14. Key Data Sources National Sources 2010 Census, American Community Survey Bureau of Labor Statistics County Health Rankings www.countyhealthrankings.orgwww.countyhealthrankings.org Behavioral Risk Factor Surveillance System (BRFSS) Local Sources Birth and Death Certificates Hospital Discharges, ED visit data CHA 2012 Telephone Survey

15. Community Health Assessment 2012 Telephone Survey 5013 total respondents 100 survey questions: health status, behavioral risk factors, family, local resources Survey is a SAMPLE of whole-county population (928,281), randomly selected to represent county as a whole. Called cell phones as well as in-house phones to reach a more diverse group

16. Survey Process 7 workgroups identified priority issues – Workgroups: Ages 0-4, 5-11, 12-17, 18-34, 35-64, 65+, & Environment – Content experts, service providers, & community members – 3 to 5 meetings, reviewed data, discussed issues Steering Committee selected overall priorities – Reviewed workgroup’s output – Synthesized that output into the overall priorities

17. What Did We Learn and What Did We Find?

18. Increasing Poverty Rate

19. County Poverty Rates DOUBLED Between 2000 and 2012: Now 19% 100% Federal Poverty Level (FPL) Definition: Family of 4 with annual household income less than $23,496 (2012) County residents meeting 100% FPL includes: 1 in 5 individuals 1 in 3 households with children (up from 1 in 5, 2007)

20. High Poverty Concentration in 6 Central Marion County Zip Codes  These zip codes have over 25% of their populations living at or below 100%FPL  They exceed County rates of…. Poverty 7 times Unemployment rate3 times Violent Crime rate 5 times Zip Codes % FPL 4620136.9 46204 33.6 46218 33.4 46225 32.5 46202 29.8 46208 28.8

23. More Than 1 in 4 Young Adults (18-34) Met 100% Federal Poverty Guidelines

24. Chronic Disease Prevention and Management

25. County Children: High Prevalence of Chronic Disease * Twice the national rate

26. County Adult Chronic Disease, 2012 (%) compared to U.S.

27. Smoking Marion County Adults – 2005 & 2012 95% CI: 2005 (24.4%-29.6%); 2012 (26.5% - 30.7%)

28. Prevalence of Smoking by Race Adults Over 18 Years Old Marion County – 2005 & 2012

29. Unhealthy Weight

30. 50% of County Youth 5-17 Were Above Normal Weight

31. Overweight and Obesity Continue to Increase in Marion County Obese Children – 2005: 2 out of 10 – 2012: 3 out of 10 Obese Adults – 2005: 3 out of 12 – 2012: 4 out of 12 Adult OutcomesMarion County 1 US 2 Diabetes14.0%9.5% CHD/Stroke7.7%7.0% 1 2012 CHA Telephone Survey 2 2011 BRFSS

32. Obesity Related Health Outcomes AdultsMarion County 1 US 2 Diabetes14.0%9.5% CHD/Stroke7.7%7.0% 1 2012 CHA Telephone Survey 2 2011 BRFSS

33. Poor Mental Health

34. Major Depressive Disorder is the Leading Cause of U.S. Disability, Ages 15-44 Depression is prevalent in all County age groups, including: 1 in 5 Adults U.S.17.5% (2011) 1 in 10 Children (5-17) U.S.3.9% (2007)

35. Depression in Young Adults Young Adults: A high prevalence of depression and poor mental health days. High rates of abuse of prescription painkillers. 47% of Marion County 18- to 25-year-olds reported having 14+ days in the past month of poor mental health – four times the U.S. rate. (CDC 2011 BRFSS Survey)

36. Diagnosed Depression in County Adolescents County adolescents are diagnosed with depression (12.8%) and their suicide risk is high 8.3% U.S. major depressive episode(2010-11) 2 2011 Indiana Teens: Youth Risk Behavior Study 4 25% had been bullied at school 18.9% seriously considered suicide 11% had one or more attempts at suicide

37. Suicide: A Leading Cause of Deaths Among the 5 leading causes for ages 12-64 (Nationally, the second leading cause for ages 12-17) Third leading cause for ages 15-24 (30% higher than U.S.) Fifth leading cause for ages 10-14

38. Increasing Dementia in Senior Adults 6-10% of persons over 65 develop dementia Alzheimer’s makes up 75% of dementia cases 8 in 10 dementia cases are never clinically diagnosed In past decade, Alzheimer’s Disease was the only leading cause of death to increase among seniors (up 20%)

39. Violent Deaths and Prevention

40. Homicide Deaths Deaths per 100,000 AgeRank*MC (2008-2010)US (2010) 10-143 rd 20.9 15-241 st 3110.9 33-445 th 166 45-549 th 134.4 * among all causes of death in Marion County

41. Community Health Assessment & Health Improvement Plan (2015) Identify short–term, evidence based intervention strategies, and action steps Find committed partners to take substantial roles for each issue Assure process and outcome monitoring occurs for each specific action area to document change. Where Do We Go from Here?: The Next Steps

42. Community Health Improvement Plan A community health improvement plan is a long-term, systematic effort to address public health problems on the basis of the results of community health assessment activities and the community health improvement process. This plan is used by health and other governmental education and human service agencies, in collaboration with community partners, to set priorities and coordinate and target resources. A community health improvement plan is critical for developing policies and defining actions to target efforts that promote health. It should define the vision for the health of the community through a collaborative process and should address the gamut of strengths, weaknesses, challenges, and opportunities that exist in the community to improve the health status of that community. Source: NACCHO, http://www.naccho.org/topics/infrastructure/CHAIP/upload/CHIP-Basics.pdf

44. Source: Population Health in the Affordable Care Act Era. Academy Health. Michael A. Stoto, Ph.D., February 13, 2013.

45. Questions?