Welcome! 2015 MCH Workforce Academy
Leading in a transformative environment to improve population health
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• Good morning & welcome!
• Time as a gift
• Learner-teachers
• Additional resources and slides on amchp.org-Transformation Station
• Today’s events
• Luggage & airport transportation
Housekeeping
Implications of Population Health Initiatives for the MCH
Workforce
Brian Castrucci
Health Equity with Population Health Initiatives
Diane Rowley, MD, MPH
Department of Maternal and Child Health
UNC Gillings School of Global Public Health
Population health perspective:
Considers a broad set of determinants in improving the distribution of health and well-
being outcomes.
MCHB:
“Our vision of a Nation where all children and families are healthy and thriving,
where every child and family have a fair shot at reaching their fullest potential.”
Lu MC, Lauver CB, Dykton C, Kogan MD, Lawler MH, Raskin-Ramos L, Watters K, Wilson LA. Transformation of the title V maternal and
child health services block grant. Matern Child Health J. 2015 May;19(5):927-31.
.
Culture
Capacity
Resources
Resilience
Inputs are the same, but
Outcomes are
unequal
With Equity, inputs may need to be different to achieve equal outcomes
This is EQUITY
How to
Develop an
Equity Plan
Hogan VH, Rowley DL
Outlines the five new domains of action you need to make it
an Equity Plan
R4P
Otherwise, it’s just
“a plan”
• PROVIDE • Culturally and economically feasible health education and medical care are required,
along with the required resources and environmental supports, so that it is the easiest
option for people to choose and sustain health promoting actions
REPAIR RESTRUCTURE
REMOVE REMEDIATE
Repair the damage of the past. Historical risk is embedded in current physiologic, biologic, psychological, behavioral and social structures. Historical trauma sets a population group back in the present.
Societal structures (where we live, work, play…..) can function inequitably and continue to expose new populations and produce risk. Structural changes (changes in social, economic, educational equity, rules, regulations, etc…) are needed to stop new production of risk and permanently remove the stressors and toxic exposures.
Forces that are adverse to health, health maintenance and health seeking are embedded in most societal institutions. Such forces-- like Power imbalances, Racism, SES inequities-- must be directly acknowledged and removed.
While we wait for structural changes to be completed, the social context continues to be a source of adverse exposures. At-risk populations need to be buffered from these exposures to reduce their vulnerability until such time that the negative stressor is completely removed.
R4P Copyright 2010, Hogan and Rowley
What past exposures
produced damage that
impact on current ability
(of population) to access
health care, maintain
health, or practice healthy
behaviors?
REPAIR
REPAIR THE DAMAGE OF THE PAST
• Historical risk is embodied in current physiologic, psychologic, behavioral and social structures
• Actively recognize and discuss historical disadvantages of populations we serve
• Actively undo historical
disadvantages of populations we serve
• What processes/social forces continue to produce risk,
disadvantage and other adverse effects in vulnerable populations?
• How can I revamp the process or structure so that future generations
are no longer exposed?
Restructure
BET questions
Institutional policies and processes need to be restructured so that they stop producing more risks. Assess the structures in organizations that maintain systematic exclusion of disparity populations while simultaneously providing advantage or privilege to others. Interventions that include the restructure component will focus on changing institutions and organizations rather than attempting to change people.
How can we buffer people from the adverse effects
while we wait for structural change?
• While we wait for structural changes the social context continues to product risks.
• It is important to minimize effects until restructuring occurs.
Remediate
R4P Copyright 2010, Hogan and Rowley
Where do racism and
other ‘isms’ operate
here?
The remove component may overlap with repair, restructure, and remediate, but this component requires explicit attention to racism, sexism, and classism that could be overlooked in previous steps.
Remove
R4P Copyright 2010, Hogan and Rowley
Culturally and socioeconomically feasible
interventions (or policies) and ensure that families have the tools and resources to carry
out recommended care PLANS
• Services should be planned and delivered in a way that the resources and environmental supports are easily attainable for disparity populations.
• Not only do we need to define the right EBP, but we also need to focus attention on the way that practice is implemented vis a vis the population factors with respect to race, class, gender, history.
Provide
R4P Copyright 2010, Hogan and Rowley
• •
• When you include these- it becomes an equity plan!
Woo Hoo!
Whenever a need, a problem, or a gap is identified:
Always Do Something!
Practicing Equity requires this!!!
• I’m tough enough
• Acknowledge
the risk of
failure… and be
at peace with
the
consequences
Effectively Advancing Population Health Priorities:
What, How and Who
Agenda
Context setting
The What
The How
The Who
Getting started Getting Better
23
Facilitators Sharron Corle, Amy Mullenix, Sarah Beth McClellan, Steve Orton, Oscar Fleming
Objectives
• Demonstrate the use of active implementation concepts to inform the design, preparation, delivery and sustainability of population health strategies
• Apply population health planning tool to move participants from theory to appropriate action
Methodology
• Form Small Groups
– All state representatives together
– Pairs and Individuals will be joined with others
• Activity Blocks
– Content Review, Applied Example, Group dialogue & action planning
• Reflect, Discuss, Capture
PopHealth Connections
Evidence base
Implementation Effectiveness
System Performance
Population Health Outcomes
• NPMs represent population health outcomes
• The Title V program creates the collective action platform & plans
ESMs NPMs NOMs
SPMs
Evidence-based
strategies / practices
Improved performance
leads to improved outcomes
Title V Measurement Framework
STATE PRIORITIES
Block Grant Guidance
NPMs and SPMs drive improved
MCH population outcomes (i.e. NOMs).
ESMs: • Measure evidenced-based/informed
practices that will impact population-based NPMs.
• State-specific and actionable,
• Track Title V program’s strategies and activities
• Provide accountability for improving quality and performance
Evidence-based Practices - Selected Sources • AMCHP Innovation Station: Best,
promising, and emerging practices from MCH programs
• NACCHO Model Practices Database: programs, resources and tools from local health departments
• The Community Guide: effective program and policy interventions
• National Center for Education in MCH: Evidence Briefs by domain and national performance measure
• Child Trends’ What Works/LINKS database: over 650 programs with at least 1 randomized, intent-to-treat evaluation to assess child or youth
• Strengthen The Evidence Base For MCH Programs: Resources from Johns Hopkins University, HRSA, Welch Medical Library at JHU, and AMCHP
• What Works in Health: information to help select and implement evidence-informed policies, programs, and system changes
System: Policy and Infrastructure
Organizational Leadership
Site Leadership
Providers
Constituents
External Su
pp
orts
Systems Complexity Funding
Policy
Culture
History Economy
Definition
• Implementation:
A specified set of activities designed to put into practice an activity or program of known dimensions1
1 National Implementation Research Network (NIRN). Implementation defined. NIRN Web site. http://nirn.fpg.unc.edu/learn-implementation/implementation-defined. Accessed November 13, 2014.
Why it Matters
Women, children and families
do not benefit from interventions they do not receive.
• Developing and identifying evidence-based/informed programs and practices has improved significantly…
• The science and practice of Implementing these programs with fidelity, in real-world settings, has lagged behind…
…but the science is emerging rapidly
ACTIVE Implementation
Moving from Letting it happen (Diffusion ) & Helping it happen (dissemination) to…
Making it happen
All too often…
Effective Interventions
Effective Implementation
Enabling Contexts
Significant Outcomes
Implementation Equation
Active Implementation Frameworks
Frameworks
The “What”
• Neither “Rigorous evidence” for evidence-based/informed interventions nor promising results from emerging practice is enough…
• Well-defined interventions must be teachable, learnable, doable, assessable, and repeatable in practice
Effective Interventions
The “What”
3. Operational Definitions
1. Clear Description
4. Performance Assessment
2. Essential Functions
1. Clear Description of the program Philosophy, values, principles
Inclusion – exclusion criteria
2. Identified Core Components (aka, active ingredients, essential functions)
3. Operational Definitions of core intervention components (what practitioners do, say)
4. Practical Performance/Fidelity Assessment
Effective Interventions
Title V & Interventions
• NPM: “Medical home”
• Selected Strategy: Care Coordination for CYSHCN
• Potential Interventions:
Care Coordination
Services Family
Engagement
Medicaid Partnerships
Applied Example:
Usable Interventions
Effective Interventions
Pulse Check
For each state or territory, select ONE intervention linked to a population health strategy
• Reflect on the Usable intervention criteria
• Discuss – How well defined is the population health
intervention you selected?
– What is needed to further define the intervention?
• Capture your action ideas
Interlude
The “How”
• Implementation Stages: Describe and guide how the work unfolds over time.
• Implementation Drivers: Identify the capacity and infrastructure linked to effective intervention delivery across the stages.
Effective Implementation
Exploration Installation Initial
Implementation Full
Implementation
2-4 Years
Implementation Stages
Effective Implementation
Performance Assessment (Fidelity)
Coaching
Training
Selection
Systems Intervention
Facilitative Administration
Decision Support Data System
Adaptive Technical
Leadership Drivers
Consistent Uses of Innovations
Reliable Benefits
Integrated & Compensatory
Effective Implementation
Competency: Build provider confidence and competence to deliver intervention with fidelity
Organizational: Align organizational and system resources to support high fidelity delivery
Leadership: Provide sustained vision, motivation & support for the change process; Responds appropriately to adaptive and technical challenges
Integrated & Compensatory: The divers reinforce each other and gaps in one driver can be compensated by another
Effective Implementation
Implementation Drivers
Exploration Installation Initial
Implementation Full
Implementation
• Assess needs • Examine
intervention components
• Consider Implementation Drivers
• Assess fit
• Acquire Resources • Prepare
Organization
• Prepare Implementation Drivers
• Prepare staff
• Activate Data Systems
• Manage change
• Strengthen Implementation Drivers
• Initiate Improvement Cycles
• Achieve and improve Fidelity and Outcomes
• Monitor & manage Implementation Drivers
Drivers and Stages Together
Effective Implementation
2-4 Years
Applied Exploration
Accessed on 8/21/2105 at http://implementation.fpg.unc.edu/sites/implementation.fpg.unc.edu/files/resources/NIRN-TheHexagonTool_0.pdf
Applied Example:
Implementation Drivers &
Stages
Effective Implementation
Pulse Check
In your groups Reflect, Discuss and Capture
• Which Implementation Stage are you in with the selected intervention? Briefly justify your response.
• How are the Implementation Drivers being addressed? Which need more attention?
Interlude
The “Who”
Implementation Teams: Integrate the use
of implementation stages, drivers and
improvement cycles to support the
implementation, sustainability, and scale-
up of usable interventions
Teams “MAKE IT HAPPEN”
Effective Implementation
Site Implementation
Team
Regional Implementation
Team
State Implementation
Team
Implementation Teams have…
- Competencies • Know the Intervention
• Know and apply Implementation Science
(e.g. Active Implementation
Frameworks)
• Know and facilitate Organization and
Systems Change
– Minimum of three people • four or more preferred
Effective Implementation
Exploration: - Evaluate and recommend
potential interventions to address your priorities
Installation:
- Develop communication protocols for program stakeholders (e.g. parents and leaders)
Effective Implementation
What Implementation Teams do: Implementation Teams are involved in all stages.
Initial Implementation: - Regularly review performance
data related to strategies
Full Implementation: - Formalize technical assistance
plans for ongoing program support and resources;
Applied Example:
Implementation Teams
Effective Implementation
Pulse Check
In your groups…
• Who can be engaged in an Implementation Team to support the effective delivery of the intervention?
• What’s your role?
Interlude
• Sustained Attention – Keeping the goals in focus, energizing the effort
• Stable Resources – Ensuring human, financial and material supports aligned with goals
• Support for Learning - Getting Started, Getting Better; Fail forward
Enabling Contexts
Leadership
Quality Improvement
“Getting Started, Getting Better”
• Rapid Cycle Improvement
• Usability Testing
• Practice Policy Feedback Loops
Enabling Contexts
Form Supports Function
Policy
Practice
Do Exte
rnal
Imp
lem
en
tati
on
Su
pp
ort
Policy
Practice
Structure
Procedure Stu
dy
Act
Pra
ctic
e In
form
s P
olic
y
Po
licy Enab
les P
ractice
Plan
Practice Policy Feedback Loops
Enabling Contexts
All organizations are designed, intentionally or unwittingly, to achieve precisely the results they get.
R. Spencer Darling, Leadership Institute, Inc.
The reality is that any social system is the way it is because the people in that system want it that way.
Heifetz, Grashow, & Linsky (2009, p.17)
Systems trump programs. Patrick McCarthy, Annie E. Casey Foundation
System Wisdom
Enabling Contexts
Discussion
Oscar Fleming [email protected]
http://nirn.fpg.unc.edu/
www.globalimplementation.org
http://implementation.fpg.unc.edu/
Additional Resources
Website: http://mchwdc.unc.edu/
Website: http://www.amchp.org
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. (2005). Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231).
Implementation Research:
A Synthesis of the Literature
• Health Resources and Services Administration (Maternal and Child Health Workforce Development Center)
• Annie E. Casey Foundation (EBPs and Cultural Competence)
• William T. Grant Foundation (Implementation Literature Review)
• Substance Abuse and Mental Health Services Administration (Implementation Strategies Grants; National Implementation Awards)
• Centers for Disease Control & Prevention (Implementation Research)
• National Institute of Mental Health (Research And Training Grants)
• Juvenile Justice and Delinquency Prevention (Program Development And Evaluation Grants)
• Office of Special Education Programs (Scaling up and Capacity Development Center)
• Administration for Children and Families (Child Welfare Leadership; Capacity Development Center)
• The Duke Endowment (Child Welfare Reform)
Recognition
©Copyright Oscar Fleming, Dean Fixsen and Karen Blase
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Lunch Panel with: Mallory Cry
Owen Erquiaga Eileen Forlenza
Moderated by: Anita Farel