Public Health/Health Care PartnershipsAn Overview of the Landscape

National Association of Chronic Disease DirectorsDenver, ColoradoAugust 31, 2016

Lloyd Michener, MDProfessor and ChairDepartment of Community & Family MedicineDuke University Medical Center, Durham, NC

No Disclosures

While I have been a participant in the discussions cited, the conclusion and summaries are mine, and have not been endorsed by the sponsoring organizations.

No financial relationships with any commercial interests.

“From Health Care to Health”

There IS a plan…

OVERVIEW – A MONTAGE OF ORGANIZATIONS ENGAGED IN POPULATION HEALTH

State Innovation Models Initiative

Accountable Care Organizations(ACO)

Drivers:

1. Cost

2. Chronic Disease

3. Data

4. Policy

What is needed: Leadership (McGinnis, The Practical Playbook, pg 11)

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Exhibit 1 . International Com parison of Spending on Health, 1980–2010

A vera ge spending on health per capita ($U S P P P )

$8,000

US S W IZ

$7 ,000 NE TH

Total health expenditures as percentage of GDP 18 16

$6,000

$5,000

$4,000

$3,000

$2,000

$1,000

$0

C AN

G E R

FR

AUS

UK

JPN

14 12 10

8 US NE TH

6 FR G E R

4 CAN S W IZ UK

2 JPN AU S

0

N otes: PPP = purchasing power parity ; G DP = gross dom estic product. Source : Com m onw ealth Fund, based on O E C D Health D ata 2012.

w w w. co m m o nwea lth fun d .o rg

Most Illness is Chronic

*Source: Paez KA, Zhao L, Hwang W. Rising out of pocket spending for chronic conditions: A ten year trend. Health Affairs, Vol 28, Number 1, pp 15-23.

MEPS Survey 2005

16.5

19.9

24

20.214.8

3.78.4

16.7

21.5

20.2

1.2 4.4

22.4

45.354.2

10.813.1

36.9

67.678.6

0%10%20%30%40%50%60%70%80%90%

100%

0-19 20-44 45-64 65-79 80+

None One Two Three or more

Lochner KA, Shoff, CM. County Level Variation in Prevalence of Multiple Chronic Conditions Among Medicare Beneficiaries, 2012, Prev Chronic Dis 2015;12:140442

Change In Female Mortality Rates From 1992–96 To 2002–06 In US Counties.

Kindig D A , and Cheng E R Health Aff 2013;32:451-458

©2013 by Project HOPE - The People-to-People Health Foundation, Inc.

Signs of Change

Accountable Health Communities — Addressing Social Needsthrough Medicare and MedicaidDawn E. Alley, Ph.D., Chisara N. Asomugha, M.D., Patrick H. Conway, M.D., and Darshak M. Sanghavi, M.D.

Road EndsAll TrafficExit Here

“we see CMS as playing a catalytic role. By embedding population-based strategies in our programs and policies, CMS can help drive transformation that aligns health care systems with public healthand social service systems and thereby accelerate progress to- ward improved health for our whole country.”

Payors are paying attention – especially CMS:

Accountable Health Communities – Addressing Social NeedsThrough Medicare and MedicaidDawn E. Alley, Ph.D., Chisara N. Asomugha, M.D., Patrick H. Conway, M.D., and Darshak M. Sanghavi, M.D.

CMS:

CDC:

CDC IS COLLABORATING WITH PURCHASERS,PAYERS, AND PROVIDERS.TOGETHER WE CAN:

• Identify shared goals and interests that improve health and reduce costs

• Monitor shared progress to better understand impact

• Develop a common language across the public health and health care landscape that leads to healthier communities.

Facilitating

States:

John Auerbach, MBA. J Public Health Management Practice, 2016 00(00), 1-4

But what can we do?

Observation From the Field:Integration is a Process

Common Barriers: culture/languageCommon Facilitators: “bridge” organizations

Ideally, the process begins with data:

The intervention is targeted:

Just For UsOutcomes are tracked:

Durham County Connections Across Partnerships

healthydurham.org

1) Blue squares represent partnerships2) Red circles represent organizations3) The closer partnerships are located together on the map – the more members they share in common4) The farther partnerships are from each other – the less of a connection they have through shared members5) Organizations in the center of the map bridge across multiple partnerships

Partnerships are Developed:

Percent Difference Between Medicaid Recipients Enrolled in CCNC and Those Not Enrolled in CCNC, for Rates of Asthma-Related Emergency Department Visits and Inpatient Admissions, 2008–2012

Note. CCNC, Community Care of North Carolina. NCMJ September/October 2013, Volume 74, Number 5

Programs are scaled up and disseminated

CY2008 CY2009 CY2010 CY2011 CY2012 CY2013 SFY2014400

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1000Inpatient Admissions Per 1,000 MCC Beneficiaries per Year

All Nondual MCC MedicaidLinear (All Nondual MCC Med-icaid)UnenrolledLinear (Unenrolled)Enrolled

Inpa

tient

Adm

issio

ns p

er 1

,000

Ben

efici

arie

s

Inpatient Admission Trends among NC Medicaid Beneficiaries

with Multiple Chronic Conditions, 2008-FY2014

Programs are scaled up and disseminated

The Children’s Community Asthma Initiative (CAI) Boston’s Children’s Hospital • Care coordination by bilingual and bicultural nurses and Community Health Workers (CHWs)• Establishing family’s goals for asthma control• Identification of barriers to good control• Environmental assessment/remediation• Housing advocacy/inspectional services: • Referrals:

• Community medical-legal partnership, child care, and other resources

Outcomes: Decrease in % patients with any ED Visits or Admissions due to Asthma N=1470 (through March 31, 2015)

Woods, ER et al. Community Asthma Initiative: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care. Pediatrics, 2012;129:465-472.

56% decrease at 12 Months 80% decrease at 12 Months ED Visits Admissions

CY2008

CY2009

CY2010

CY2011

CY2012

CY2013

SFY2

014460

480

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520

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560

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Inpatient Admissions Per 1,000 MCC Beneficiaries per Year

Inpa

tient

Adm

issio

ns p

er 1

,000

Ben

-efi

ciar

ies

Inpatient Admission Trends among NC Medicaid Beneficiaries with Multiple Chronic Conditions,

2008-FY2014

This means >8,000 fewer inpatient admissions in SFY2014 compared to 2008 performance

www.practicalplaybook.org

Users: 38,759 Pageviews: 187,185

Bold Innovative solutions that bring forth new ideas and approaches for addressing complex problems

Upstream Focus on social, environmental, and economic factors that have the greatest influence on health across a community, rather than on the provision of direct services, health education, or individual behavior change

Integrated Strong commitment and partnership between a hospital or health system, a nonprofit organization, and a local public health department, including the option to involve other industry, educational, philanthropic, or governmental

organizations

Local Focus on solutions that are deeply rooted in and led by the urban community (city of metro area of 150,000 or more) for which the proposal is written

Data-Driven Focus on innovative uses of data and information sharing to identify key needs and opportunities, as well as to measure outcomes

A National Challenge Program to engage communities, public health organizations and health systems in improving health outcomes. The Program awarded $8.5M in monetary awards and low-interest loans over two years to support 18 community-driven projects, beginning January 1, 2015

Technical Support:

Cleveland, Ohio

Engaging the Community in New Approaches to Health Housing in Cleveland, Ohio is:• Creating a Healthy Homes Zone• Enacting prevention-based housing maintenance• Determining feasibility of HMO reimbursements for

asthma home visits

Key Partners• Environmental Health Watch• The MetroHealth System• Cleveland Department of Public Health

In partnership with:• Stockyards Clark-Fulton Brooklyn Center• The Cleveland Building and Housing Department• The Hispanic Alliance and Spanish American

Community• Cuyahoga Place Matters Team• HIP-C (a consortium of 50 partners)

Action Plan:ECNAHH seeks to improve asthma and lead poisoning outcomes related to unhealthy housing, as well as COPD and injury prevention.

Conclusion:

“What is most needed moving forward is the leadership, the partnership, and the tools necessary to forge the links between primary care and public health.”

J. Michael McGinnis, MD, MPPInstitute of Medicine, The National AcademiesWashington, DC, USA