Nicole Flowers MD, MPHMedical Officer

Centers for Disease Control and PreventionDivision of Community Health

APRIL 25, 2012

ACHIEVE Action Institute:Clinical & Community Linkages for

Chronic Disease Prevention

Learning Objectives

Describe the burden of chronic disease and approaches to reducing the burden.

Understand how community efforts can work synergistically with clinical levers to address chronic disease.

Identify options for supporting individuals with chronic disease in your community.

Chronic Diseases145 million Americans are affected

Responsible for 7 of every 10 U.S. deaths

Cause major limitations in daily living

for 1 of 10 Americans

Account for ~75% of U.S. medical costs

Are inequitably distributed across the population

Chronic Diseases and Related Risk Factors

Leading Causes of Death*United States, 2000

Actual Causes of Death†

United States, 2000

Kidney disease

0 5 10 15 20

TobaccoPoor diet/

Physical inactivityAlcohol consumption

Microbial agents

Toxic agents

Firearms

Sexual behavior

Motor vehicles

Illicit drug use

Percentage (of all deaths)

Heart Disease

Cancer

Chronic lower respiratory disease

Unintentional Injuries

Pneumonia/influenza

Diabetes

Alzheimer’s disease

Stroke

0 5 10 15 20 25 30 35

* Miniño AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: final data for 2000. National Vital Statistics Reports 2002; 50(15):1-120.

† Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-1246.

Percentage (of all deaths)

LargestImpact

SmallestImpact

Factors that Affect HealthExamples

Eat healthy, be physically active

Rx for high blood pressure, high cholesterol, diabetes

Poverty, education, housing, inequality

Immunizations, brief intervention, cessation treatment, colonoscopy

Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax

Socioeconomic Factors

Changing the Contextto make individuals’ default

decisions healthy

Long-lasting Protective Interventions

ClinicalInterventions

Counseling & Education

Imagine a typical chronically ill patient who sees his doctor half an hour every three months. These four encounters each year—the physician’s opportunity to counsel, diagnose, and treat—constitute only 0.02% of this patient’s life. For all the rest—the 99.98% of the time that the patient is elsewhere, making decisions about his health in the context of his culture, family, and community—the doctor’s impact on the patient’s choices is minimal…. That 99.98% belongs to community medicine, to population health, and to public health.

Jarris et al, Acad Med. 2011;86:1347.

Imagine a typical chronically ill patient who sees his doctor half an hour every three months. These four encounters each year—the physician’s opportunity to counsel, diagnose, and treat—constitute only 0.02% of this patient’s life. For all the rest—the 99.98% of the time that the patient is elsewhere, making decisions about his health in the context of his culture, family, and community—the doctor’s impact on the patient’s choices is minimal…. That 99.98% belongs to community medicine, to population health, and to public health.

Jarris et al, Acad Med. 2011;86:1347.

This means that the greatest opportunities for addressing some problems are in the community, outside of the doctor’s office.

National Prevention Strategy

• Extensive stakeholder and public input

• Aligns and focuses prevention and health promotion efforts with existing evidence base

• Supports national plans 8

National Prevention Strategy

9

Clinical and Community Linkages to Address Chronic Disease

Clinical Preventive Services- Procedures, tests, counseling, or medications Aimed at preventing the onset or progression

of a health condition or illness

Clinical and Community Preventive Services

Linking clinical domain and community resources for systems change to promote improved health outcomes in the community.

Expanded Chronic Care Model

Medical Management Self-Management Ongoing Support

Critical Elements of Disease Management

Pharmacists Can Improve Care and Reduce Costs

Supporting medication adherence Improving the use of medications Improving treatment outcomes Helping patients with self-management

Community Health Workers

• Liaison between health systems and communities • Facilitate access to and improve quality and

cultural competence of medical care• Build individual and community capacity for health

by:• Increasing health knowledge and self-sufficiency of the

patients• Serving as community health educators• Providing social support • Advocating for the health care needs of patients and

communities

Sample community activities to support team- based care (TBC)

Influence coverage for TBC in private health plans, among self-insurers or public health plans.

Ensure standardized curriculum or protocols for health care extenders.

Support jurisdiction-wide defining of the scope of practice for the health care extenders

Gather and disseminate information about the return on investment for utilization of team-based care approaches

Increase awareness among patients with chronic disease about the availability of CHWs or pharmacists as healthcare extenders

State Example - Maryland

• P3 (Patients, Pharmacists, Partnership) is a program among worksites and community pharmacies using pharmacists to provide chronic disease self-management

• Participants have seen a sustained reduction in A1C , blood pressure, and lipids

State Examples• Minnesota passed legislation in 2009 to

make CHW services reimbursable under Medicaid and the state regulates CHW training, supervision, enrollment criteria, and billing

• Massachusetts’ broad-based policies, consistent and powerful advocacy from the CHW workforce, and partnership with state public health partners secured the ongoing integration of CHWs into health care systems

 

Chronic Disease Self-Management Program

Low-cost, community-based class for people with chronic diseases developed at Stanford University

A CDC meta-analysis of CDSMP showed improvements in fatigue, depression, health distress, etc.

CDC’s Arthritis Program funds 12 state arthritis programs that can offer CDSMP as a proven intervention

CDC’s Diabetes program and Heart Disease and Stroke Prevention program have refunded programs for CDSMP

Sample Activities of Community Organizations to support CDSMP

Possible PSE activities: Facilitate increased uptake of CDSMP sites. Sites

should be linked to a health care delivery system Campaign to increase awareness about

availability and benefits of CDSMP Support provider referrals to CDSMP Facilitate development of infrastructure for better

communication and data sharing between CDSMP and providers.

Engage populations with health disparities

State Example - Oregon Worked with other state agencies, local health

dept, health care providers, social service agencies, and CBOs to create a sustainable infrastructure for delivering CDSMP

Best estimates over four years show 557 emergency room visits avoided, saving $634,980 and 2,783 avoided hospital days, saving $6, 501,088

Currently engaged in discussions with public employees and educators’ benefit boards on inclusion of CDSMP as a covered benefit

Community – Clinic Partnership Community Clinic

Total Population Prediabetes Diabetes Complications

Informed Population

Strong Community Organizations

Partnership Zone

Information Systems

Decision Support

Proactive Practice Team

Screening forHigh Risk

Diagnosis of Prediabetes

Structured Lifestyle Programs

Regular Glucose

Monitoring

Reimbursement

InsurersEmployers}

Healthy Public Policy

Supportive Environments

Informed, ActivatedPatients

EnhanceFitness• Evidence based, community based exercise

program developed by the University of Washington PRC

• Increases strength, boosts activity, elevates mood

• One of six physical activity programs recommended by CDC Arthritis Program

• Offered by Group Health as a free benefit to all its Medicare enrollees since 1998

• In 2011 the YMCA began offering EF at Ys in 8 states and will continue expansion efforts

Community-Clinical Linkages

How can you support chronic disease prevention in your

community ?