Copyright © 2013 ACHI – 155 North Wacker Drive, Suite 400, Chicago, IL 60606 | communityhlth@aha.org | 312-422-2193

Joint Webinar Series Thursday, November 14, 2013 1 pm CST / 2 pm EST

Today’s session awards 1.0 contact hours. To successfully complete this activity and earn contact hours, participants must attend the entire session and complete the evaluation.

ACHI does not endorse any commercial products discussed in conjunction with this activity. • Ron Bialek, Shawna Mercer, Jennifer Teller, Deborah Plate and

E. Demond Scott do not have anything to disclose.

The Association for Community Health Improvement is a designated provider (MEP3728) of continuing education by the National Commission for Health Education Credentialing.

Disclosures

Copyright © 2013 ACHI – 155 North Wacker Drive, Suite 400, Chicago, IL 60606 | communityhlth@aha.org | 312-422-2193

Presenter(s)

Ron Bialek, MPP Shawna L. Mercer, M.Sc., Ph.D. President Director, The Guide to Community Preventive Services Public Health Foundation Chief, The Community Guide Branch Centers for Disease Control and Prevention Jennifer L.S. Teller, Ph.D. Deborah S. Plate, DO, FAAFP Head, Chronic Disease Initiatives Clinical Associate Director and Austen BioInnovation Institute in Akron Family Medicine Clerkship Site Director Akron General Center for Family Medicine E. Demond Scott, MD, MPH Executive Director for Health Equity Summa Health System

Application of “The Community Guide” By Two Health Systems to Improve the Health of a Community

PHF Mission: We improve the public’s

health by strengthening the quality and performance of public health practice

www.phf.org

Healthy Practices Healthy People Healthy Places

Public Health Foundation: Helping Communities Achieve Better Results

Performance Management/Quality Improvement (PM/QI)

Turning hard work into better results Developing quality improvement tools Helping people use PM/QI tools and methods Expanding the evidence-base Integrating science into practice

Workforce Development Fostering academic/practice linkages Developing core competencies Delivering, tracking, and evaluating training Developing and tailoring training

Relevant Resources Evidence-based Resources for Improving Community Health • Guide to Community Preventive Services

http://www.thecommunityguide.org/index.html

• Stories and Webinars on uses of the Guide to Community Preventive Services http://www.phf.org/programs/communityguide/Pages/default.aspx

• Partners in Information Access for the Public Health Workforce

http://phpartners.org/

TRAIN – the nation’s premier learning management network for public health • Over 750,000 registered learners • Over 28,000 training programs • Nearly 4,000 providers of training • A FREE resource for public health and healthcare professionals

https://www.train.org/

Learning Resource Center – where public health, healthcare, and allied health professionals find high quality training materials at an affordable price • Comprehensive selection of public health quality improvement publications • Many consumer-oriented health education publications • Search for publications by CDC’s Winnable Battles and many other public health topics

http://bookstore.phf.org/

The Community Guide: Identifying Effective, Evidence-Based Programs, Services, and Policies for Health Improvement

Division of Epidemiology, Analysis, and Library Services Center for Surveillance, Epidemiology, and Laboratory Services

Shawna L. Mercer, MSc, PhD, Chief Community Guide Branch

Division of Epidemiology, Analysis, and Library Services (DEALS) Center for Surveillance, Epidemiology, and Laboratory Services

(CSELS)

Health Improvement Planning Steps

Planning & Assessment What’s the problem?

Setting Objectives What do we want to achieve?

Selecting Interventions What works?

Implementing How do we do it?

Evaluating Did it work? How well?

The Community Guide

• Systematic reviews – Analyze all available evidence on the effectiveness of community-based

programs, services, and policies in public health – Assess the economic benefit of all

effective programs, services, policies – Highlight critical evidence gaps

• Evidence-based findings and recommendations

– About the effectiveness of these programs, services, and policies

– Help inform decision making – Developed by the

Community Preventive Services Task Force (Task Force)

www.thecommunityguide.org

Community Preventive Services Task Force • A non-federal, independent, rotating panel • Internationally renowned experts in public health

research, practice, and policy • Nomination process includes broad input from

throughout public health and healthcare • Members are appointed by CDC Director • Serve without compensation

– CDC provides scientific, technical and administrative support for

the Task Force

Community Preventive Services

• Informational – Education programs when used alone for increasing use of child

safety seats – Mass media campaigns for reducing alcohol impaired driving

• Behavioral, Social

– Behavioral interventions to reduce risky sexual behavior and HIV, other sexually transmitted infections, and pregnancy among youth

– Cognitive behavior therapy in reducing psychological harm among children and adolescents following traumatic events

Community Preventive Services

• Environmental, Policy – Street scale urban design (lighting, improved safety, ease of

walking) in increasing physical activity – Smoking bans and restrictions in reducing exposure to

environmental tobacco smoke

• Health System – Disease management programs for diabetes control – Client reminder and recall systems in increasing vaccination

coverage

All: Guide to Community Preventive Services

~ 225 Task Force Findings The Environment

Health Equity/Social Environment

Settings States Worksites Healthcare system Communities Schools Organizations

Risk Behaviors Specific Conditions

Tobacco Use Alcohol Abuse/Misuse Other Substance Abuse Poor Nutrition Inadequate Physical Activity Unhealthy Sexual Behaviors Current reviews

Vaccine-Preventable Disease Pregnancy Outcomes Violence Motor Vehicle Injuries Depression/Mental Health Cancer Diabetes Oral Health Obesity Asthma Cardiovascular disease

Community Guide: How is it Used?

• To inform decision making around:

– Practice

– Policy making

– Research

– Funding for research and programs

• It provides menus of options

User Involvement in The Community Guide

• Official Liaisons – 30+ federal agency and organizational

NIH, AHRQ, VA, all US Armed Forces, etc. Organizations supporting state and local public health agencies Physician, nurse, public health, other organizations

– Roles Provide input into prioritization of topics, reviews, Task Force

findings and recommendations Serve on, recommend participants for review teams Participate in dissemination and translation of Task Force

findings, especially to their constituents

• Participants on individual systematic reviews

The Task Force Seeks to Answer Key Questions about Interventions

• Do they work? • How well? • For whom? • Under what circumstance are they appropriate (applicability)? • What do they cost? • Do they provide value? • Are there barriers to their use? • Are there any harms? • Are there any unanticipated outcomes?

Findings of the Task Force

• Recommend – Strong Evidence – Sufficient Evidence

• Recommend against – Strong Evidence – Sufficient Evidence

• Insufficient evidence to recommend for or against

www.thecommunityguide.org

Thank you!

Shawna Mercer, MSc, PhD smercer@cdc.gov

Application of

The Community Guide to Improve the Health of a Community

∗ Jennifer L.S. Teller, PhD Austen BioInnovation Institute in Akron

∗ Deborah S. Plate, DO, FAAFP Akron General Center for Family Medicine

∗ E. Demond Scott, MD, MPH Summa Health System

Presenters

∗ By the end of this Webinar, participants will be able to: • Understand how The Community Guide can inform

program decisions • Describe a framework for involving multidisciplinary

team members in a multi-site project • Identify how community partners can implement

evidence-based community health interventions

Learning Objectives

Accountable Care Community (ACC)

∗ Vision ∗ To improve the health of the community

∗ Mission ∗ To design, develop, implement, and serve as a national framework for

improving the overall health of an entire community through a collaborative, integrated, multi-institutional approach that emphasizes shared responsibility for the health of the community

∗ Metrics ∗ The ACC results in job creation, a spin-out business entity, and improved

health via higher quality, cost effectiveness and cost saving, and an improved patient experience in health promotion and disease prevention, access to care and services, and health care delivery

ACC

http://www.abiakron.org/acc-white-paper

∗ ACC is not dependent upon providers adopting Medicare infrastructure

∗ ACC encompasses medical care systems plus grassroots community stakeholders and community organizations

∗ ACC focuses on health outcomes of the entire population in a geographic region

ACC vs. ACO

ACC Coalition

Collaborative partnerships leverage multi-sector resources to improve community health. Benefits of partnership:

• Addresses broad range of issues with greater breadth and depth

• Coordinates services and prevents redundant efforts

• Increases public support • Allows individual

organizations to influence community on a larger scale

• Includes diverse perspectives • Strengthens connections

between existing resources • Provides shared frame of

inquiry for community health concerns

Community Members

Medicine

Public Health

Government & Philanthropy

Higher education

Secondary education

Safety-net health services

National Health Coalitions

Academic researchers

Health Systems & Healthcare

providers

Alcohol/drug services

Mental health services

Faith community

Community programs

The Problem: Diabetes

Currently, $245 billion spent annually in the United States for care of individuals with diabetes.

By 2050, the estimate is 33%.

10% of Ohio population is diagnosed with diabetes.

8% of Akron population are diagnosed with diabetes.

Diabetes has a significant impact on health, economics, and quality of life.

∗ Austen BioInnovation Institute in Akron • The two adult hospital systems in Summit County

(Akron General and Summa Health Systems) • One academic nursing center (The University of Akron)

The Team

∗ Use The Community Guide to inform program parameters ∗ Tailor the National Diabetes Prevention Project and Road

to Health Program to the Summit County (Ohio) population

∗ Evaluate the practices on adherence to National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS)

∗ Inclusion of different patient populations, different sites, and variety of professionals

The Strategy

∗ Personalized Educational and Experiential Modules for Diabetes Self-Management, 12-2 hour sessions over six months

∗ Educational information on diabetes, working with your doctor, and self-management techniques

∗ Experiential information on nutrition, exercise, self-efficacy, and social-emotional wellness

∗ Measurement through pre- and post-program chart review and questionnaires, pre- and post-session surveys , and periodic biometric measurements

The Program

∗ “Interventions should be coordinated with the patient’s clinical care provider” ∗ Recommends “diabetes self-management education interventions be

implemented in community gathering places” ∗ In alignment with NCQA HEDIS measures, “recommends diabetes disease

management on the basis of strong evidence of effectiveness in improving glycemic control; provider monitoring of glycated hemoglobin; screening for diabetic retinopathy”

∗ “Sufficient evidence is also available of its effectiveness in improving provider screening of the lower extremities for neuropathy and vascular changes; urine screening for protein; monitoring of lipid concentrations”

∗ “Recommends implementing efforts made in community settings to provide social support for increasing physical activity based on strong evidence of their effectiveness in increasing physical activity and improving physical fitness among adults”

The Community Guide Recommendations as of 2011

∗ “Reducing out-of-pocket costs for cardiovascular disease preventive services for patients with high blood pressure and high cholesterol” through nutrition counseling and community-based weight management program (2012)

∗ “Recommendations for health behavior changes to discuss with patients such as quitting smoking, increasing physical activity, and reducing excessive salt intake” (2013)

The Community Guide Releases 2012 and 2013

∗ 62% African-American ∗ 62% Female ∗ Majority were “baby boomers” ∗ Most attended at least 1 year of college ∗ Average days since diagnosis was 425 ∗ Insurance status

• 38% Private • 31% Public • 31% No insurance

First Wave Demographics (n = 26)

∗ Medical Chart Review ∗ HbA1c decreased .386 + .994 (range -5.4 to 0.6) ∗ LDL cholesterol decreased 11.60 + 37.53 (range -68 to 49)

∗ Weight ∗ 54% participants lost 115.1 pounds and 22.8 kg/m2 BMI ∗ Average reduction in BMI .333 + 1.943 kg/m2

∗ Waist

∗ 62% participants lost 25.26 inches from their waists

First Wave Participant Outcomes

∗ Participant Attendance • 77% attended 8 or more sessions • 35% had perfect attendance

∗ Self-report

• Increase in exercise • Increase in healthy eating and 5-6 small meals per day • Increase in knowledge about diabetes

First Wave Participant Outcomes

∗ Older participants were more likely to decrease BMI

∗ Age and limitations had independent effects

∗ MCQA HEDIS measures

First Wave Participant Outcomes

Per Person Annual Health Care Savings of Decreasing HbA1c

Per Person Annual Savings of Decreasing % of Body Weight

2012 USD Medical Absenteeism

10% to 9% $ 570 5% $ 60 $ 30

9% to 8% $ 415 10% $140 $ 50

8% to 7% $ 285 15% $210 $ 80

10% to 9% w/ complications

$1,955 20% $280 $110

Recognized Benefits of Diabetes Interventions

Estimated Program Savings = $3,185/year Average Pre-Program HbA1c = 8.20% Average Post-Program HbA1c = 7.74%

Estimated Program Savings = $580/year Average Weight Decrease = 2%

ED Visits per 1,000 People with Diabetes in Same Condition

Results: Total Number of ED Visits

Years HbA1c < 8% ED Visit Rate HbA1c < 8% HbA1c > 8%

0 years under 8% 276.3 6 Months Prior 6 9 1 year under 8% 230.6 During Program 3 7

2 years under 8% 200.0 3 years under 8% 127.1 4 years under 8% 115.9

Recognized Benefits of Diabetes Interventions

∗ 8/31/11: Pat began to walk indoors on carpet, because it was easier on her feet (neuropathy).

∗ 9/7/11: Pat was able to walk for 2 blocks outdoors and increased her baseline number of steps from 400 to 900 in just one week.

∗ 7/11/12: Rick’s parents are diabetic, and he had been diagnosed for 1.5 years prior to joining the study. At the 6-month reunion (from the last session in December) , Rick lost ~60 pounds from his weight a year ago. His departing statement was “Thanks for giving me my life back.”

Quality of Life Reflections

∗ Maintenance and/or improvement ∗ 82% lost 113.6 pounds in one year ∗ 82% reduced BMI 18.8 kg/m2

∗ 73% reduced waist 23.5 inches ∗ Self-reported continuance of healthy behaviors

First Wave Reunion (6 months after last session n = 11)

Patient Update 2013

Second Wave Also Informed by The Community Guide

∗ 67% African-American ∗ 69% Female ∗ 26% high school education or greater ∗ 58% disabled or not able to work ∗ 8% employed part-time ∗ Only 35% had health insurance during the past year

Second Wave Demographics (n = 51)

∗ 56.5% of participants who continued at least two months lost 141 pounds and 22.18 kg/m2 BMI

∗ 69.6% of participants who continued at least two months lost 59.75 inches from waist

∗ Self-reported increased healthy behaviors ∗ Average attendance was almost 10 sessions, with

43.1% attending all sessions

Second Wave Outcomes

Per Person Annual Savings of Decreasing % of Body Weight

5% $ 60

10% $140

15% $210

20% $280

Medical Cost Savings

Estimated cost savings from weight reduction: $845 per year

∗ Multidisciplinary team ∗ From different sites and systems ∗ National program tailored to our community ∗ Informed by The Community Guide ∗ Incorporating education, nutrition, exercise, disease

self-management, self-efficacy, and social-emotional wellness

∗ Partnering to positively affect the health of our community

Evidence-Based Programming

Ackermann RT, Finch EA, Brizendine E, Zhou H, Marrero DG. Translating the diabetes prevention program into the community: The deploy Pilot Study. American Journal of Preventive Medicine, 2008 Oct; 35(4):357-63. Adams PF, Barnes PM, Vickerie JL. Summary health statistics for the U.S. population: National Health Interview Survey, 2007. National Center for Health Statistics. Vital Health Stat 10(238). 2008. Available at http://www.cdc.gov/nchs/data/series/sr_10/sr10_238.pdf. Accessed June 6, 2011. Cantor, J., L. Mikkelsen, B. Simons, and R. Water, How Can We Pay for a Healthy Population? Innovative New Ways to Redirect Funds to Community Prevention. 2013, The Prevention Institute: Oakland, California. Centers for Disease Control and Prevention (CDC). 2010 Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. Centers for Disease Control and Prevention, Road to Health Training Guide. 2010, U.S. Department of Health and Human Services: Atlanta, Georgia. Centers for Disease Control and Prevention. National Diabetes Fact Sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2011 [August 11, 2011]; Available from: http://www.cdc.gov/diabetes/pubs/factsheet11.htm. Cohen JT, Neumann PJ, Weinstein MC. Perspective- Does Preventive Care Save Money? Health Economics and the Presidential Candidates. 2008. http://www.nejm.org/doi/pdf/10.1056/NEJMp0708558. Accessed June 6, 2011. Commonwealth Fund State Scorecard, 2009. http://www.commonwealthfund.org/Maps-and-Data/State-Data-Center/Child-Health/DataByState/State.aspx?state=OH. Community Preventive Services Task Force. The Community Guide. 2012 May 23, 2012; Available from: http://www.thecommunityguide.org/index.html. DeVol R, Bedroussian A, Charuworn A, Chatterjee A, Kim I, Kim S, Klowden K. An Unhealthy America: The Economic Burden of Chronic Disease. Santa Monica, Calif.: Milken Institute. 2007. Gallup-Healthways Wellbeing Index. State of Wellbeing: State, City and Congressional District Wellbeing Report for Ohio, 2011. Gilmer TP, O'Connor PJ, Manning WG, Rush WA. The Cost to Health Plans of Poor Glycemic Control. Diabetes Care. 1997 December 1, 1997;20(12):1847-53. Levi, J., L.M. Segal, R. St. Laurent, and A. Lang, A Healthier America 2013: Strategies To Move From Sick Care To Health Care In The Next Four Years. 2013, Trust for America's Health: Washington, D.C.

References

47

Moffat, D. and R. Duffy, The Burden of Diabetes in Ohio. 2008 September, Chronic Disease and Behavioral Epidemiology, Ohio Department of Health: Columbus, Ohio.

National Diabetes Information Clearinghouse, Diabetes Prevention Program (DPP). 2008, U.S. Department of Health and Human Services, National Institutes of Health.

Ohio Behavioral Risk Factor Surveillance System. Chronic Disease and Behavioral Epidemiology Section, Ohio Department of Health, 2010. http://dwhouse.odh.ohio.gov/datawarehousev2.htm

Ohio Department of Health. Ohio Diabetes Prevention and Control Program. 2012 http://www.odh.ohio.gov/sitecore/content/HealthyOhio/default/diabetes/odpcp.aspx

Ohio Family Health Survey. Health Profile of Summit County, February 2010.

Organisation for Economic Cooperation and Development. 2012. Obesity and the economics of prevention: Fit not fat. http://www.oecd.org/health/prevention; http://www.oecd.org/health/health-systems/obesityandtheeconomicsof preventionfitnotfat.htm.

Partnership for Prevention and U.S. Chamber of Commerce. Leading by Example. Washington, D.C.: Partnership for Prevention. 2007.

Summit 2020. Summit 2020 Priority Indicators Disparity Report, 2011. January 2012.

Trogdon J, Finkelstein EA, Reyes M, Dietz WH. A Return-on-Investment Simulation Model of Workplace Obesity Interventions. J Occup Environ Med. 2009;51(7):751-8 10.1097/JOM.0b013e3181a86656.

Trust for American’s Health. F as in fat: How obesity policies are failing in America. 2009; Available from: http://65.181.142.130/images/stories/obesity2009report.pdf; http://fasinfat.org/adult-obesity/; http://fasinfat.org/obesity-rates-trends-overview/. Accessed June 6, 2011.

References

48

University of Wisconsin. Population Health Institute. County health rankings, 2011.http://www.countyhealthrankings.org/ohio/summit

Wu SY, Green A. Projection of chronic illness prevalence and cost inflation. Santa Monica, CA: RAND Health; 2000. Office of the Actuary, Centers for Medicare and Medicaid Services, National Health Expenditure Data for 2007. U.S. Department of Health and Human Services, available at: http://www.cms.hhs.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage

References

49

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