Dave Law, PhD, Executive Director Joy-Southfield Community Development Corporation

Population Health in Detroit: Clinical- and Community-Based Prevention

UC Berkeley School of Public Health, Center for Health Leadership

5th Annual Leadership Conference Health 3.0: Transforming Community Health and Care Delivery

Upstream Innovations in an Era of Health Reform

Why Go Upstream? Even though “Going Upstream” is hard work, there is a compelling reason to do so…

… “Goin’ with the Flow” is harmful and lethal!

Overview of the U.S. Health Care System Disease

•  Common chronic diseases such as type-2 diabetes, hypertension & CVD account for 70% of deaths * •  Chronic diseases account for 75% of annual $2.5 trillion in healthcare costs * •  Communities of color and low SES individuals experience increased morbidity & mortality (preventable) •  Obesity epidemic is creating a tsunami of CD •  Access to care is important, but SDOH are also key •  Place and Race Matter (See Policy Link/CA Endowment)

* A Healthier America 2013: Strategies To Move From Sick Care To Health Care In The Next Four Years. Trust for America’s Health, January 2013. www.healthyamericans.org

http://www.policylink.org/site/c.lkIXLbMNJrE/b.6728307/k.58F8/Why_Place___Race_Matter.htm

Closing the racial/ethnic disparities gap would save more than 83,000 African American lives every year (http://www.americanprogress.org/issues/2011/01/war_minorities.html/print.html)

Satcher D, Fryer Jr. GE, McCann J, Troutman A, Woolf SH, Rust G. 2005. What If We Were Equal? A Comparison of the Black-White Mortality Gap in 1960 and 2000. Health Affairs 24:459-464.

36.4 49.9 36.6 Uninsured (Millions)

9.5 306.1 279.5 Population (Millions)

% Inc. 2010 2000

Income, Poverty, and Health Insurance Coverage in the United States: 2010 U.S. Census Bureau. Sep 2011.

Racial Health Inequality is Lethal

Racial Health Inequality is Lethal

Michigan Department of Community Health 2009 Health Disparities Report, February 2010

http://www.michigan.gov/mdch/0,1607,7-132-2940_2955_2985---,00.html

Examples of Black-White Health Disparities (MI): •  Overall mortality - 136% •  Infant mortality - 284% •  CVD mortality - 149% •  Stroke mortality - 136% •  HIV-AIDS prevalence - 858% •  Diabetes incidence - 201% •  Diabetes mortality - 156% •  Cancer incidence - 112% •  Cancer mortality - 127%

How can the U.S. legitimately criticize other nations for human rights violations?

County Health Rankings in MI

www.countyhealthrankings.org/michigan

2013 County Health Rankings County

www.countyhealthrankings.org/michigan

Overall ranking = 82 (dead last)

Bad news > mobilize action > create good news

Ecological Approach to Promoting Health Equity

PPACA: Increased Access to Healthcare a Necessary But Insufficient First Step Toward Health Equity

Source: CBO Briefing to House Speaker Pelosi, Mar 2010

Health Disparities Persist Even in Countries with Universal Access Alter DA, et al. "Lesson from Canada's Universal Care: Socially disadvantaged patients use more health services, still have poorer health" Health Affairs 2011; 30(2): 274-283.

Number of uninsured could be higher depending on

the extent of Medicaid expansion.

PPACA: Framework for Improved Health & Reduced Costs Prevention = ê Healthcare Costs é Health Outcomes

http://www.healthcare.gov/prevention/nphpphc

NATIONAL  PREVENTION  STRATEGY  

Healthy & Safe Community

Environments

Clinical & Community Preventive Services

Empowered People

Elimination of Health

Disparities

NPS Model Revisited

Revised NPS Model: D. Law, Dec 2012

Promoting Health Equity at the Grassroots Level

Joy-Southfield Health and Education Center

6 Treatment Rooms (1 dental)

Triage Reception Dispensary

Clinic Admin

Modular Classrooms Health Educ/CDM

CDC Admin

CDC Admin

Kitchen Lunchroom

Cooking Demos

Mech. Stor.

Stor. WC

WC WC Copier

FAX

Ecological Approach: Clinical Care

•  Free primary & preventive care for uninsured adults

•  Pediatric care for uninsured & insured

•  HFHS HANK

•  Preventive health education

•  Chronic disease management

•  Telehealth support

•  Pharmacy, labs/diagnostics (including POC)

•  Selected specialty care (diabetes, hypertension); referral for others

•  Oral health, behavioral health added to scope in 2012

•  Health IT to measure outcomes

•  Diverse pool of volunteer providers

Ecological Approach: Clinical Care

•  3,266 Adult Free Clinic Visits in 2012

•  8,047 Prescriptions (worth $550,230)

•  Volunteer in-kind value $81,314

Where would you have gone if this clinic were not available?

n = 1547

No Care 51.1% ER/ED 41.9%

Private Dr. 3.2%

Other Free Clinic 3.8%

Patient Satisfaction 2012

Treated with respect

Very Good 89.6%

Good 9.7%

Fair 0.7%

n = 1704 Clarity of instructions

Good 11.0%

Fair 0.6%

Very Good 88.4%

n = 1691

Wait time

Good 16.8%

Fair 5.6%

Poor 1.0%

Very Poor 0.5%

Very Good 76.1%

n = 1488

Good 11.1%

Fair 0.7%

Very Good 88.2%

Overall satisfaction n = 1688

Ecological Approach: Clinical Care

Laura W. - “I don’t know what I would have done without you.”

Robert M. - “They saved my life. I had no medicine for my pressure and they gave me the pills and took care of me.”

Anonymous - “When I come to this place, I never want to go home. I can sit and be happy.”

Anonymous client survey - Q: “ Where would you have gone if the clinic were not available?” A: “Grave.”

Johnny C. - “This clinic help me to get medicine for my health. They have been good helping me and others to stay well and get help that we need. Please let this place stay open so it can help with low or no income like me.”

Linda C. - “God Bless you all. Thanks a million!”

Mario A. - “I need this clinic like I need oxygen. The clinic has been a blessing beyond what I can think of.”

Ecological Approach: Clinical Care

•  Patient feedback is compelling & valuable, however it is limited by its subjectivity

• Utilizing a health IT intervention to improve health outcomes and efficiency

•  Chronic disease management, quality assurance (HEDIS*), prompting & reminding, rapid outcomes measurements

•  Web-based, secure and HIPAA-compliant

•  Pharmacy management software to enhance adherence

* Healthcare Effectiveness Data and Information Set (nationally recognized set of key health indicators)

Ecological Approach: Clinical Care

Successful Health Interventions Ultimately Boil Down to Respect

Losing her job was “a blessing in disguise.”

Message to health care reformers: Spend more time with patients!

Ecological Approach: Physical Environment Downtowns of Promise Economic Redevelopment Strategy

•  Grant from the Michigan State Housing Development Authority (MSHDA)

•  Provided detailed assessments, asset mapping and community engagement to provide framework strategy for redeveloping the local commercial corridor (Joy Rd from Evergreen to Southfield)

•  Currently identifying partners for implementation over the next 3 to 5 years, including: City of Detroit, Wayne County, MSHDA, federal government, TCAUD, Ross Business School, & many others

•  11 new businesses to date

•  Façade improvement grants totaling $250,000 (matching funds)

Downtowns of Promise Economic Redevelopment Strategy

Downtowns of Promise Economic Redevelopment Strategy

Commercial Façade Improvements

Safe & Functional Places to Exercise: Renovating Local 25-Acre Park

Knowledge is Power: Especially When it Comes to Health

Health IT Tools for Quality Improvement: •  BP cuffs with memory •  Glucometers with memory •  Pharmacy management software to improve prescription drug adherence

We use the carrot 99% of the time. Sticks don’t work, especially for the “under-served”.

Kidney Rock

Knowledge is Power: Especially When it Comes to Health

Trip to Berkeley

Empowerment: Health Education

•  Showing is better than telling

•  Extended family = extended lifespan

Treatment, Education, Management & Prevention

•  Mission: To reduce ethnic health disparities in ESRD (kidney failure)

•  Detroit among 6 U.S. cities with exceptionally high ESRD rates

•  NIH-funded study (Howard University) to test efficacy

•  Developing a similar intervention for type-2 diabetes (Howard University)

Empowerment: Bringing Healthy Options to the Table

•  Addressing the food desert issue •  Community gardening with youth involvement •  Sowing Seeds, Growing Futures Farmers Market •  Healthy Corner Stores Project (WSU SEED)

“We just wanted to bring a sense of unity back into the neighborhood.”

- Kaleb, 7th grade visionary for community gardens & farmers market

What About the Last Piece of the Pie? Saving the Best for Last

http://www.healthcare.gov/prevention/nphpphc

Public Policy Advocacy

“It has long been understood that many factors beyond health care actually influence health. Social and economic determinants of health include income, education, physical environment, social isolation, and concentration of poverty. Given this reality, there is a growing realization of the potential for synergies between work to revitalize low-income communities and the need to promote and improve health.”

Conclusions •  The resources exist to provide universal access to quality health care

•  Runaway health care costs can be mitigated by increasing prevention

•  Effective patient engagement reduces costs & improves health outcomes

•  Health IT improves quality & efficiency

•  Reducing/Eliminating health disparities requires an ecological approach, i.e. addressing all determinants

•  RESPECT is key to engaging previously under-served populations

•  Health SYSTEM reform will require multi-disciplinary intervention, but will pay for itself over time

Conclusions (cont.) •  ACA implementation is necessary, but not sufficient to reduce health disparities

•  Need more integration of medicine & public health (PCMH meets population health) •  The persistence of disparities adversely affects health outcomes for all people (particularly uninsured & underserved)

•  Partnerships between health systems and CBOs will enhance development of place-based health strategies

•  CBOs & safety net organizations will remain an integral part of a reformed health care system

Contact Info:

Dave Law, Executive Director

djlaw@joysouthfield.org

(313) 581-7773, ext. 105

joysouthfield.org