COMMUNITY HEALTH

IMPROVEMENT

PLANNING Theresa Green

• Director of Community Health Policy and Education

Center for Community Health, URMC

• Faculty, Public Health Sciences Department

URMC Core Missions

2

1. Education

2. Research

3. Patient Care

4. Community Health (2004)

In 2006, Center for Community Health was established to

further advance the community health mission

“that the skills and talents be used

to make Rochester the healthiest

community in the world.”

- George Eastman

Comprehensive Approach to

Community Health

3

Provide community services and conduct community based

research, in order to

• INFORM policy makers and community about local health

challenges,

• EVALUATE the effectiveness of interventions, and

• SERVE as a foundation for evidence-based practices to

improve health and overall quality of life.

URMC Strategic Plan 2007-2012

Center for Community Health:

Staff, Faculty, Resources

• Over 60 full time staff

• Nancy (Nana) M. Bennett, MD, MS

Director, Center for Community Health

Professor of Medicine and of Public Health Sciences

• Five full time faculty – 30 secondary appointments

4

• 46 Prince Street

• Library and 2 conference rooms

• 2 exam rooms

• Teaching kitchen and physical

activity space

History of ‘Community Benefits’ • Commissioner of Health’s statewide mission to improve

the health of all New Yorkers; Prevention Agenda towards

the Healthiest State

• In April 2008, Commissioner called for hospital to

collaborate for community health assessment and

planning and to document those efforts in a hospital’s

Community Service Plan (CSP).

• Asked hospitals to work together with their community

partners, including local health departments, to address

the state’s Prevention Agenda

History

• New York Local Health Departments (LHDs) instructed to

participate in this process and to record their efforts in

their Community Health Assessments (CHA) and

Municipal Public Health Service Plans

• Hospital Community Service 3-year Plans were due in

2009 and updates were due in 2010, 2011, and 2012

Collaboration in Monroe County

• Monroe County successfully petitioned to complete a

JOINT Community Service Plan for Monroe County

• Partners:

• Strong Memorial Hospital - URMC

• Highland Hospital - URMC

• Lakeside Health System

• Rochester General Health System

• Unity Health System

• Monroe County Department of Public Health

• Finger Lakes Health System Agency

• Center for Community Health

New York 2013

• New York Health Commissioner Dr. Shah has asked local

health departments and hospitals to work together with

community partners to assess the health challenges in

communities, identify local priorities and develop and

implement plans to address them.

• Addressing at least two priorities in the new

2013 Prevention Agenda. At least one of

these priorities should address a health

disparity.

Prevention Agenda

• The Prevention Agenda vision is:

New York as the Healthiest State in the Nation.

• The plan features five priority areas:

• Prevent chronic diseases

• Promote healthy and safe environments

• Promote healthy women, infants and children

• Promote mental health and prevent substance abuse

• Prevent HIV, sexually transmitted diseases,

vaccine-preventable diseases and

healthcare-associated Infections

http://www.health.ny.gov

Meanwhile, Affordable Care Act

• New 501(r) Requirements

• Community Needs Assessment

• Financial Assistance Policy

• Limits on Charges

• Collections

• Apply to 501(c)(3) hospitals

• Requirements are mandatory and tax exemption depends

on compliance

• Reported in Schedule H (Form 990)

Community Health Needs Assessment

(CHNA)

Each hospital is required to conduct a community health

needs assessment:

• At least once every three years

• Includes input from individuals who represent the broad

interests of the community, including those with special

knowledge or expertise in public health

• Adopt implementation strategy to meet identified needs

• Make the assessment widely available to the public

• IRS due spring 2013 for Strong

IRS/NY Reporting Requirements

• Community Health (Needs) Assessment

• Description of the community

• Summary of assets and resources in community

• Documentation of the process for data and community input

• Identification of the main health challenges facing the community

• Community Health Improvement Plan

“Address needs identified in the CHNA?”

• Identify 2 priority areas from prevention agenda

• Identify process for setting priorities including community input

• Identify goals and objectives, time-framed targets for 5-year plan

• Description of strategies and evidence-based practices

• Identify needs NOT addressed and state why

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CHNA – Assets and Resources

CHNA – Data

• Monroe County Adult Health Survey (AHS)

• Fourth survey of health risks and behaviors of adults in fall 2012

(2006, 2000, and 1997)

• Countywide random digit dial telephone survey for 18+year olds

• 1800 responses collected

• ½ in City zip codes

• 140 Latino, 1400 white, 225 African American

• Local information such as the Blood Pressure Registry

% All

residents

% African

Americans

% Latinos % Whites %

Residents

of the

Crescent

Obesity (BMI > 30) 27 39 37 24 36

Diabetes Mellitus 10 20 9 9 13

Hypertension 32 41 19 32 36

High Cholesterol 37 35 26 38 36

Taken from the Monroe County Adult Health Survey, 2006 self report indicators

Adult Health Survey 2006

(Monroe County Residents)

% All

residents

% African

Americans

% Latinos % Whites %

Residents

of the

Crescent

No past month

leisure time activity

15 33 36 11 27

Recommended

Physical Activity

53 46 43 54 42

Nutrition-5 +

fruit/vegs/day

21 12 10 22 13

Nutrition-most often

use whole milk

10 28 24 5 25

Nutrition-fast food

usually/almost

always

18 35 25 15 27

Tobacco use-

current

18 27 34 16 28

Monroe County Residents

Taken from the Monroe County Adult Health Survey, 2006 self report indicators

County Health Rankings 2013

www.countyhealthrankings.org

Even though our clinical

care score is very high,

our health outcomes

scores are low – maybe

due to socio-economic,

behaviors and

environmental factors?

Monroe County:

Results of the 2013

County Health

Rankings for New

York (62 counties)

26

43

30

9

33

23

33

43

18

Other sources of Data - NYS

• Mortality and natality data: New York State birth and death files

• Hospitalization data: Statewide Planning and Research Cooperative Systems (SPARCS) files, based on hospital discharges

• Disease and condition specific data: Department of Health disease registries, including cancer, AIDS/HIV, communicable disease, rabies, tuberculosis and sexually transmitted disease

• Program-based data: WIC program, Youth Tobacco Survey, Childhood Lead Poisoning Prevention Program, and Heavy Metals Registry

• National survey data: Behavioral Risk Factor Surveillance System (BRFSS) and Youth Risk Behavior Survey (YRBS)

• Pregnancy Risk Assessment Monitoring System (PRAMS): Prevalence of Smoking During Pregnancy

• Youth Tobacco Survey: Use of Cigarettes Among Middle and High School Students

New York Tracking PH Priority Indicators

http://www.health.ny.gov/prevention/prevention_agenda/

indicators/county/monroe.htm

Monroe County “Problem Areas”

Indicator US NYS Monroe Cnty

% Cigarette smoking in adults 21.2% 18.1% 19.6% (2009)

Lung Cancer Incidence – Male per 100K 76.4 75.8 80.6

Lung Cancer Incidence – Fem per 100K 52.7 53.9 59.7

Infant Mortality per 1,000 live births 6.1 5.1 7.7

Pregnancy rate 15-17 per 1,000 39.5 28.5 33.2

% of Adults who are obese 27.8% 24.5% 31.7% (2009)

% WIC mothers breastfeeding @ 6 mths 25.1% 38.8% 18.9%

Stroke mortality per 100,000 39.0 27.5 36.0

Gonorrhea case rate (per 100K) 100.8 94.3 180.7

http://www.health.ny.gov/prevention/preven

tion_agenda/indicators/county/monroe.htm

Leading Causes of Death by County, New York State, 2009

County and # of

Deaths

#1 Cause of Death

and # of Deaths

#2 Cause of Death

and # of Deaths

#3 Cause of Death

and # of Deaths

#4 Cause of Death

and # of Deaths

#5 Cause of Death

and # of Deaths

Age-adjusted

Death Rate

Age-adjusted

Death Rate

Age-adjusted

Death Rate

Age-adjusted

Death Rate

Age-adjusted

Death Rate

Monroe Cancer Heart Disease Stroke

Chronic Lower

Respiratory

Diseases (CLRD)

Pneumonia and

Influenza

1,492 1,434 326 267 185

Total: 6,168 176 per 100,000 157 per 100,000 36 per 100,000 30 per 100,000 20 per 100,000

Ontario Cancer Heart Disease Stroke

Chronic Lower

Respiratory

Diseases (CLRD)

Unintentional Injury

231 226 52 51 31

Total: 949 175 per 100,000 169 per 100,000 39 per 100,000 39 per 100,000 25 per 100,000

Orleans Heart Disease Cancer

Chronic Lower

Respiratory

Diseases (CLRD)

Stroke Unintentional Injury

127 97 24 19 11

Total: 408 256 per 100,000 194 per 100,000 50 per 100,000 39 per 100,000* 25 per 100,000*

Wayne Cancer Heart Disease

Chronic Lower

Respiratory

Diseases (CLRD)

Stroke Liver Disease

193 184 59 35 32

Total: 780 182 per 100,000 175 per 100,000 59 per 100,000 33 per 100,000 31 per 100,000

Cancer and Heart Disease: Number of Deaths

Monroe County, 1994-2010

0

500

1000

1500

2000

2500

Num

ber

of D

eath

s

Cancer Heart

Source: Vital Records, MCDPH

Ultimate Priority Areas…

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Smoking

• Current smoking rate among adults is 16%, similar to

statewide rate of 18%, but…

2012 City Suburbs

Smoking rate 24.9 (21.0-28.8) 12.7 (9.6-15.7)

Infant Mortality (7.7 for County, but…) Monroe County By Race and Latino Origin, 2008-2010

0

2

4

6

8

10

12

14

16

18

African American Latino White

Rate

per

1,0

00 B

irth

s

Source: Vital Records, MCDPH

CHNA – Community Input

GOAL: to improve the health of the

citizens of Monroe County by aligning

community resources to focus on selected

priorities for action

Health Action • Going strong since 1995

• Steering committee establishes subcommittees that review data, and convene community forums to set action priorities.

• Health “report cards” are available • Maternal Child Health Report Card -2011

• Adolescent Health Report Card – 2012

• Adult/Older Adult Health Report Card – 2008 (slated for 2013)

• Community Action Priorities for Adult/Older Adult: • Increase Physical Activity and Improve Nutrition

• Improve Prevention and Management of Chronic Disease

• Improve Mental Health (reduce violence among adults and elder abuse among older adults).

http://www2.monroecounty.gov/health-healthdata.php#surveys

CHNA - Main Health Challenges

CANCER – HEART DISEASE – STROKE

Chronic Disease, especially HTN

Obesity, smoking, social

determinants of health

Not addressed: Infant mortality, STDs, teen pregnancy

CHIP – Process for Prioritization and

Community Input IMPORTANCE (How important is this goal?)

Number affected

How much disability/illness this will prevent

Long term impact on health

LIKELIHOOD of IMPACTFUL SUCCESS

What is the likelihood that setting this goal will

result in substantial health improvements in 3-5 years?

COMMUNITY SUPPORT

Is there willingness on the part of community

leaders and partner organizations, and

residents to address this goal?

HOSPITAL SUPPORT

How likely are hospital leaders to strongly

support this initiative and dedicate resources to

its success?

LEVEL of CURRENT COMPLEMENTARY ACTIVITY

What is the level of community plans, activities and

resources already directed to address similar goals?

What is the potential to address health disparity

OVERALL RANK

CHIP – Public Input and Collaboration

• Group discussion and prioritization

• Director of Perioperative Services - Lakeside

• Director of Marketing and Public Relations - RGH

• Chief Operating Officer - Unity

• Chief Operating Officer – Strong - designated CCH COO

• Director of Public relations - Highland

• Director of Community Engagement FLHSA

• Public Health Program Coordinator MCDPH

• Balance between hospital missions and public health

CHIP – Priority Areas

• Identify 2 Priority Areas from Prevention Agenda:

• Prevent Chronic Disease

• Promote a healthy and safe environment

• Promote healthy women, infants and children

• Promote mental health and prevent substance abuse

• Prevent HIV, STD, Vaccine preventable diseases and HAI

PREVENT

CHRONIC DISEASE

CHIP – Evidence Based Strategies

• NY PREVENTION AGENDA: Increasing physical activity, improving nutrition, and decreasing tobacco use form the core of the Preventing Chronic Disease action plan

Three key areas:

1. Health Promotion activities

2. Early detection opportunities

3. Successful management strategies

Focus Area 1:

Reduce obesity in children and adults • Goal 1.1: By December 31, 2017, reduce the percentage

of adults ages18 years and older who are obese by 5% from 27% (Monroe County AHS, 2009) to 22% among all adults.

• Goal 1.2: Expand the role of public and private employers in obesity prevention • Objective 1.2.1. By December 31, 2017 increase by 10% the

percentage of small to medium worksites that offer a comprehensive worksite wellness program for all employees and that is fully accessible to people with disabilities

• Objective 1.2.2. By December 31, 2017 expand the worksite wellness package at each hospital system by 3 effective interventions, as measured by increase in each hospital systems score on the Monroe County worksite wellness index

Intervention for Consideration

• Implement evidence-based wellness programs for all

public and private employees, retirees and their

dependents through collaboration with unions, health

plans and community partnerships that include but are not

limited to increased opportunities for physical activity;

access to and promotion of healthful foods and

beverages; and health benefit coverage and/or incentives

for obesity prevention and treatment, including

breastfeeding support (IOM Obesity Prevention)

• Use the worksite wellness index (FLHSA)

Focus Area 2: Reduce illness, disability and

death related to tobacco use and second hand

smoke exposure

• Goal 2.1. Promote tobacco use cessation, especially

among low SES populations and those with poor mental

health

• Objective 2.1.1.By December 31, 2017, increase the number of

unique callers from Monroe County to the NYS Smokers’ Quitline

by 20%, from *** (2012) to *** annually. (Data source: NYS

Smokers’ Quitline Annual Report)

• Through the CMMI medical homes to start

• Objective 2.1.2. By December 31, 2017, increase the number of

employers that provide insurance benefits for tobacco dependence

treatment, counseling and medications by 10%. (Baseline?)

Focus Area 3: Increase access to high quality chronic

disease preventive care and management in both

clinical and community settings

• Goal 3.1. Promote use of evidence-based care to

manage chronic disease.

• Objective 3.1.1. By December 31, 2017, increase the percentage

of adults ages 18+ years with hypertension who have controlled

their blood pressure (below 140/90) by 10% from **% for residents

in the blood pressure registry to **%

• Interventions: BP Ambassadors, BPAP, worksite demonstrations,

practice improvement consultants

• Objective 3.1.2. By December 31, 2017, provide 6 primary care

medical home practices serving at-risk patients with a meaningful,

comprehensive interface between care managers and community

resources

• Intervention: CMMI grant and CHW with electronic database

Next Steps:

• Clarify improvement strategies and performance measures

• Description of strategies and evidence-base

• Each hospitals’ specific role and responsibility

• Identify needs not addressed and why

• Board approval of CHNA and CHIP (May 2013)

• Disseminate plans community wide

Thank you!

•Theresa Green, AA-C, MBA Director of Community Health Policy and Education

Center for Community Heath URMC

Theresa_green@URMC.Rochester.edu