1. Funded by the Centers for Disease Control and Prevention, through the Philadelphia Department of Public Health

2.  Affordable Care Act ◦ Prevention and Public Health Fund (PPHF) ◦ CDC 1422 grant  Opportunity to focus resources on some of Philadelphia’s most serious health issues: hypertension & diabetes, using HIT tools to inform approaches and measure progress  Opportunity to work collaboratively with providers and community organizations to devise strategies that can be tested and refined so that they actually work  Opportunity to document progress at zip level & citywide 2

3. 1422 Health System Strategies (Component 2) 3 EHR adoption & use of HIT to improve performance Institutionalization and monitoring of quality measures Greater engagement of non-physician team staff in hypertension management Increase self-measured blood pressure monitoring tied with clinical support Implement systems to identify prediabetes & undx hypertension Increase engagement of CHWs to promote linkages between health systems and community resources for adults with high blood pressure, prediabetes, or those at high risk Increase engagement of community pharmacists in medication management for high blood pressure Implement systems and increase partnerships to facilitate bi-directional referral between community resources and health systems, including lifestyle change programs

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5. 5 191041913319141 191201913419142 191211913519143 191231913719144 191241913819145 191311913919146 191321914019148 If we wanted to measurably reduce citywide CVD morbidity/mortality over the next 5 years, in which zip codes would interventions be most necessary? *In numerical order, not order of morbidity/mortality: “ Heart-Vulnerable” Zip Codes*

6. 6 Chronic Disease Morbidity & Mortality in Philadelphia, Geographical Portrait 1 1 Map by Health Federation of Philadelphia

7. 7 Age- Adjusted CVD Mortality Rate per 100,000 Residents Age-Adjusted CVD Mortality Rate per 100,000 Residents, Ages 18-64 Hypertension Prevalence Diabetes Prevalence Citywide 1,476.61,094.237.3%15.9% North 1,641.81,274.937.0%18.5% West 1,541.01,379.739.9%14.3% Chronic Disease Morbidity & Mortality in Philadelphia, Geographical Portrait* * Source: Philadelphia Vital Statistics (2007-2011), PHMC Household Health Survey (2012)

8. 8 Chronic Disease Morbidity & Mortality in Philadelphia, Health Disparities Portrait

9. 9 Chronic Disease Morbidity & Mortality in Philadelphia, Health Disparities Portrait 201020112012 Race/EthnicityPopulationMortalityRatePopulationMortalityRatePopulation Mortalit y Rate All Race/Ethnicities 987,1991,070107.81,000,1371,129108.91,006,6061,01397.3 White Non- Hispanic 386,49534286387,63837791.2386,14930073.1 Black Non- Hispanic 400,212646149.9404,264655145406,086600133.1 Asian Non- Hispanic 69,242213571,7762337.173,3592029 Hispanic 114,5375763.3119,3586770.2123,6375353.7 Other/Unknown 16,71343017,101752.717,37440282.5 Premature Cardiovascular Mortality Philadelphia, 2010 - 2012 Source: Philadelphia Vital Statistics and US Census Bureau. The rate has been expressed as per 100,000 population, which has been calculated using yearly Vintage population for Philadelphia as a denominator, except 2010 which used the 2010 Census Enumeration population for Philadelphia as a denominator, which was then adjusted for age using 2000 US Standard Population. "Premature Cardiovascular Mortality" is defined as death due to cardiovascular disease, ages 18-64.

10. 10 Getting at Real Outcomes: It’s Really About the Patients Using HIT to derive the best picture of prevalence & incidence of chronic disease, geographically and with reference to different races/ethnicities Using HIT and other means (assessments) to document what is currently being done while seeking to improve, and documenting the changes made and their effect on patients, workflow, practice Devising processes that can be tested (consideration of already developed best practices) Contributing data to a citywide portrait of chronic disease while figuring out what works in the context of Philadelphia and your community of patients Assisting with the construction of chronic disease networks that help patients by bridging clinic and community supports

11. 11 Exciting Prospects Ahead Thank you for your partnership! Questions?