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Wendy Davis: Leveraging Public Health Capacity to Improve Health System Efficiency

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Many provisions of the ACA hold promise for public health agencies. The reorganization of the healthcare system in the wake of health reform also poses challenges for the public health system. This session will address how public health agency roles may change, opportunities to use public health agencies to lower health costs and improve health outcomes, and the integration of categorical funding streams to build a comprehensive public health system in a post-health reform world.

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Wendy Davis: Leveraging Public Health Capacity to Improve Health System Efficiency

  1. 1. Leveraging Public Health Capacity to Improve Health System Efficiency Wendy Davis, MD – Commissioner October 5, 2010
  2. 2. Objectives <ul><li>Understand brief history of Vermont’s state health reform efforts: the Blueprint for Health initiative </li></ul><ul><li>Review Vermont Department of Health’s ( VDH ) approach to PH and Health Reform integration </li></ul><ul><li>Identify challenges and opportunities for synergy presented by the Patient Protection and Affordable Care Act </li></ul>
  3. 3. History of Vermont’s state health reform: <ul><li>Or, “you don’t know where you’re </li></ul><ul><li>going if you don’t know where </li></ul><ul><li>you’ve been!” </li></ul>
  4. 4. Vermont Characteristics <ul><li>Population = 621,760 (2009 est.) </li></ul><ul><li>Land Area = 9.249 square miles </li></ul><ul><li>VDH is a centralized public health department (12 District Offices) </li></ul><ul><li>2009: #1 in America’s Health Rankings (United Health Foundation) </li></ul>
  5. 5. “ Rural”Vermont <ul><li>WWAMI/RUCA Rural Health Research Center </li></ul>More Cows than People?
  6. 6. Vermont Agency of Human Services <ul><li>Office of the Secretary </li></ul><ul><li>Department for Children and Families (Child Dev., OCS, Family/Econ Svcs.) </li></ul><ul><li>Department of Corrections </li></ul><ul><li>Department of Disabilities, Aging and Independent Living (DAIL) </li></ul><ul><li>Department of Health (VDH) </li></ul><ul><li>Department of Mental Health </li></ul><ul><li>Dept. of Vermont Health Access (Medicaid: Catamount Health, Dr. Dynasaur, Blueprint for Health ) </li></ul>
  7. 7. VDH Organization <ul><li>Alcohol and Drug Abuse Programs </li></ul><ul><li>Health Promotion and Disease Prevention </li></ul><ul><li>Health Surveillance </li></ul><ul><li>Local Health </li></ul><ul><li>Maternal and Child Health </li></ul><ul><li>Medical Practice Board </li></ul><ul><li>Public Health Preparedness </li></ul><ul><li>Business, IT, Public Policy, Communications </li></ul>
  8. 8. VDH Framework: 10 Essential Public Health Services (CDC) <ul><li>Monitor health status to ID/solve community health problems </li></ul><ul><li>Diagnose and investigate health problems/hazards in the community </li></ul><ul><li>Inform, educate , and empower people about health issues </li></ul><ul><li>Mobilize community partnerships/ action to identify and solve health problems </li></ul><ul><li>Develop policies and plans that support individual and community health efforts </li></ul><ul><li>Enforce laws and regulations that protect health and ensure safety </li></ul><ul><li>Link people to needed health services and assure provision of health care when otherwise unavailable </li></ul><ul><li>Assure competent public and personal health care workforce </li></ul><ul><li>Evaluate effectiveness, accessibility, and quality of personal and population-based health services </li></ul><ul><li>Research for new insights and innovative solutions to health problems </li></ul>
  9. 10. Health Disparities Report 2010
  10. 11.
  11. 12. Vermont Blueprint History: The good news . . . <ul><li>Relatively good distribution of Primary Care Providers (PCPs) statewide </li></ul><ul><ul><li>800 PCPs in 300 practices in 13 Hospital Service Areas </li></ul></ul><ul><li>Three major health plan carriers + Medicaid + Medicare </li></ul><ul><li>Most PCPs participate in all plans </li></ul><ul><li>History of working together </li></ul>
  12. 13. Insurers Providers Health IT Public Health Hospitals Benefits Managers Contracted Services Pharmaceutical Companies Vermont Blueprint History: The Bad News!
  13. 14. Health Care Reform Goals Increase Access Improve Quality Contain Costs 60+ Initiatives
  14. 15. St. Albans Newport Burlington Middlebury Rutland Bennington Barre White River Jct. Springfield Brattleboro St. Johnsbury Morrisville History: Community Health and Wellness Grants <ul><li>CHAMPPS (Coordinated Healthy Activity, Motivation, and Prevention Programs) grant program </li></ul><ul><li>Technical assistance provided by VDH </li></ul>Community Grants Prevention Specialists
  15. 16. Bennington Burlington St. Johnsbury Barre Windsor Springfield April 2007 Blueprint History 2008 - Integrated Medical Home Pilots ( all chronic conditions + prevention) 2005—Initial two pilot Hospital Service Areas (Diabetes Focus) Healthier Living Workshops Community Physical Activity Grants 2004—Planning 2003—Launch of the Blueprint 2006—Four new Hospital Service Areas (Diabetes Focus) 2006—Statutory Endorsement 2007— Medical Home Integrated Pilots in Statute
  16. 17. Improved Outcomes-Healthier People Productive Interactions Self- Management Support Delivery System Design Decision Support Clinical Information Systems Health System Health Care Organization Community Resources and Policies Public Health Policies, Systems, Environment Supportive Environment Informed, Activated Patient Prepared, Proactive Practice Team Adapted from the chronic care model which is used by permission of “ Effective Clinical Practice.” What is the Blueprint?
  17. 18. <ul><li>Vermont State Health Reform Components: </li></ul><ul><li>Advanced Primary Care foundation (PCMHs + CHTs) </li></ul><ul><li>Multi-Insurer Payment Reforms </li></ul><ul><li>A focus on prevention (public health health care delivery) </li></ul><ul><li>A statewide health information exchange </li></ul><ul><li>An evaluation infrastructure to support ongoing improvement </li></ul><ul><li>Facilitators & support for a learning health system </li></ul>
  18. 19. <ul><li>State Public Health Leadership Role in Comprehensive Health Reform: </li></ul><ul><li>Advanced Primary Care foundation (PCMHs + CHTs ) </li></ul><ul><li>Multi-Insurer Payment Reforms— Policies/Systems </li></ul><ul><li>A focus on prevention (public health health care delivery)— All levels of “the Egg” </li></ul><ul><li>A statewide health information exchange- PH data/registries </li></ul><ul><li>An evaluation infrastructure to support ongoing improvement </li></ul><ul><li>Facilitators & support for a learning health system— PH EBP </li></ul>
  19. 20. <ul><li>Primary Care PCMH </li></ul><ul><li>Docs </li></ul><ul><li>NPs </li></ul><ul><li>Staff </li></ul>Community Care Team (CCT) e.g. NP, RN, MSW, Dietician, Behavior Specialist, Community Health Worker, VDH Public Health Specialist Referrals & Communication Vermont Health Information Platform (VITL) Hospital -Educators -Transitional care -Ambulatory center (wellness programs) Referral & care support Education & Improvement Public Health & Prevention Support for evidence based public health, prevention, & policy Model for Health & Prevention Policies and Systems Local, state, and federal policies and laws, economic and cultural influences, media Community Physical, social and cultural environment Organizations Schools, worksites, faith-based organizations, etc Relationships Family, peers, social networks, associations Individual Knowledge, attitudes, beliefs Adapted from: McElroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Education Quarterly 15:351-377, 1988.
  20. 21. <ul><li>Central – Public Health Prevention Team </li></ul><ul><li>State level assessments </li></ul><ul><li>State level strategic planning </li></ul><ul><li>Data review & interpretation </li></ul><ul><li>Design campaigns / programs </li></ul><ul><li>Technical assistance / support </li></ul><ul><li>Regional – Public Health Prevention Teams </li></ul><ul><li>Local assessments </li></ul><ul><li>Local intervention planning </li></ul><ul><li>Organizing & coordination </li></ul><ul><li>Multidisciplinary Services </li></ul>Surveillance HPDP ADAP Blueprint MCH Preparedness Rural Health Business Office <ul><li>Program content </li></ul><ul><li>Best practices </li></ul><ul><li>Domain expertise </li></ul><ul><li>Data analysis </li></ul><ul><li>Reporting </li></ul>Transportation Education Labor Medicaid Corrections Mental Health Children & Families DAIL <ul><li>Input </li></ul><ul><li>Review </li></ul><ul><li>Domain expertise </li></ul><ul><li>Coordination </li></ul><ul><li>Planning </li></ul>Departments VDH Programs State & Local Coalitions Community Groups Community Stakeholders Community Health Teams VDH Prevention Teams Functional Map – Public Health Operations Community Care Team # 1 Community Care Team # 2 Community Care Team # 3 Community Care Team # 4
  21. 22. Health IT Framework Global Information Framework Evaluation Framework Operations PCMH PCMH PCMH PCMH Hospitals Public Health Prevention Community Health Team Nurse Coordinator Social Workers Dieticians Community Health Workers OVHA Care Coordinators Public Health Prevention Specialist Behavioral Health & Substance Abuse Services Blueprint Integrated Pilots Coordinated Health System Prevention Programs Policies and Systems Local, state, and federal policies and laws, economic and cultural influences, media Community Physical, social and cultural environment Organizations Schools, worksites, faith-based organizations, etc Relationships Family, peers, social networks, associations Individual Knowledge, attitudes, beliefs
  22. 23. Prevention Strategies for Tobacco Use <ul><li>Increased tax on tobacco </li></ul><ul><li>products </li></ul><ul><li>Smoking restrictions </li></ul><ul><li>(workplaces, schools, </li></ul><ul><li>restaurants, public places) </li></ul><ul><li>Reduced access to underage </li></ul><ul><li>youth </li></ul><ul><li>Community coalitions </li></ul><ul><li>Media </li></ul><ul><li>Smoking cessation services </li></ul><ul><li>Provider counseling </li></ul>
  23. 24. <ul><li>Coalesce Community Partners </li></ul><ul><li>Community Assessments </li></ul><ul><li>Prevention Planning & Implementation </li></ul><ul><li>Public Health Services </li></ul><ul><li>Ongoing Tracking & Quality Improvement </li></ul><ul><li>Community Snapshots </li></ul><ul><li>Rates of risk factors in each community </li></ul><ul><li>5 Year Aggregate Data (2002 – 2006) </li></ul><ul><li>2006 Statewide Comparison </li></ul><ul><li>State Level Assessment </li></ul><ul><li>Factors assoc with hospitalizations & costs </li></ul><ul><li>10 year trend analysis </li></ul><ul><li>Univariate & multivariate modeling </li></ul><ul><li>Program products </li></ul><ul><li>Tools, Resources </li></ul><ul><li>Services & Technical support </li></ul><ul><li>Training </li></ul>Community Health Team Public Health District Office Director, Prevention specialist (chronic disease), Prevention consultant (ADAP) Care Delivery NP, RN, MSW, Dietician, Behavior Specialist, Community Health Worker VDH Health Promotion Disease Prevention Programs Diabetes Substance Abuse / Alcohol Exercise Cardiovascular Disease Nutrition Tobacco Asthma Cancer VDH Surveillance Data Integration Analyses Report Generation Routine Assessment Data Sources Behavioral Risk Factor Surveillance Survey Data Adult Tobacco Study Data Hospital Discharge Data Vital Statistics Data (Deaths) Department of Transportation Data US Census Data Department of Labor Data Medical Practice Board Survey Data
  24. 25. <ul><li>Quit Tools </li></ul><ul><li>Quit Net </li></ul><ul><li>Quit By Phone </li></ul><ul><li>Quit In Person </li></ul>Blueprint Integrated Pilots: Coordinated Health System Patient Centered Medical Home Community Health Team Vermont Quit Network Coordinated care & referrals Health Information Infrastructure EMRs – HIE – DocSite Access for Program Coaches Track Referrals Self Management Goals Reports for outreach & evaluation Training to enhance counseling skills
  25. 26. Health IT Framework Global Information Framework Evaluation Framework Operations PCMH PCMH PCMH PCMH Hospitals Public Health Prevention Community Health Team Nurse Coordinator Social Workers Dieticians Community Health Workers OVHA Care Coordinators Public Health Prevention Specialist Behavioral Health & Substance Abuse Services Blueprint Integrated Pilots Prevention Tobacco Cessation Community messaging & education, facilitate linkages and broad access to cessation programs Coordinated referrals & patient support between PCMHs + CHTs + Tobacco Cessation Services (phone based counselors, community based group programs) Expand counseling capacity by training behavioral health counselors and social workers on CHTs. Trained counselors as part of the CHT who can broadly support enhanced self management. DocSite clinical tracking & reporting that supports outreach by Tobacco Cessation Counselors and coordination between care delivery and cessation programs VDH Surveillance generates population indicators re prevalence, risk behaviors & exposures, co-morbidities, healthcare utilization & costs. Supports policy making, planning for care delivery and public health strategies, quality improvement, and tracking of program impacts. Policies and Systems Community Organizations Relationships Individuals
  26. 27. Prevention Strategies for Obesity <ul><li>Menu labeling </li></ul><ul><li>Built environment (rail trails) </li></ul><ul><li>Community gardens </li></ul><ul><li>Changes in school cafeteria </li></ul><ul><li>selections (Farm to School) </li></ul><ul><li>Running/bike/hiking clubs </li></ul><ul><li>Weight control programs </li></ul><ul><li>Increased awareness </li></ul><ul><li>Health care provider recommendation </li></ul>
  27. 28. St. Johnsbury Family HC Chronic Care Coor .5 FTE Beh. Health Spec. .5 FTE Concord Health Ctr. Chronic Care Cood .5 FTE Beh. Health Spec. .5 FTE Danville Health Center Chronic Care Coor .5 FTE Beh. Health Spec .5 FTE Corner Medical Chronic Care Coor 1 FTE Beh. Health Spec 1 FTE Other DVHA Care Managers Hospital Care Managers Hospital-based CC Educators Community-based Advocates Community Connections Community Health Workers CC Comm. Health Worker VDH District Office Public Health Specialist Ladies First Coordinator Calodenia Int. Medicine Chronic Care Cood .5 FTE Beh. Health Spec. .5 FTE St. Johnsbury Community Health Team Care Integration Coordinator 1 FTE
  28. 29. Public Health Integrated Prevention Teams <ul><li>VDH Strategic Plan Goal: “Communities will have the capacity to respond to public health needs </li></ul><ul><ul><li>Capacity building efforts integrated and aligned internally and with (external) community partners </li></ul></ul><ul><li>Training </li></ul><ul><ul><li>“ Prevention and Health Promotion Basics” </li></ul></ul><ul><li>Team development </li></ul><ul><ul><li>Central office—cross disciplinary mgt. team </li></ul></ul><ul><ul><li>District (local) office—cross disciplinary fcnl. teams </li></ul></ul>
  29. 30. Pilot Locations thru July 2010
  30. 31. Blueprint Integrated Health System - Proposed Expansion 10/05/10 July 2008 Jan 2009 July 2009 Jan 2010 July 2010 Jan 2011 July 2011 Jan 2012 July 2012 Jan 2013 July 2013 Pilot # 1 St Johnsbury HSA St Johnsbury HSA Expansion Pilot # 2 Burlington HSA Burlington HSA Expansion Readiness Pilot # 3 Barre HSA Barre HSA Expansion Readiness HSA # 4 Rollout Readiness HSA # 5 Rollout Readiness HSA # 6 Rollout Readiness HSA # 7 Rollout Readiness HSA # 8 Rollout Readiness HSA # 9 Rollout Readiness HSA # 10 Rollout Readiness HSA # 11 Rollout Readiness HSA # 12 Rollout Readiness HSA # 13 Rollout Implementation Phase Demonstration Phase (Medicare?) Target Population % of VT Population # CHTs 42,179 6.7% 2 126,286 20% 6 316,662 50% 16 508,17 80% 25 637,130 100% 32
  31. 32. Health IT Framework Evaluation Framework BP Integrated Pilots: Building an Integrated System of Health PCMH PCMH PCMH PCMH Hospitals Public Health Prevention Community Health Team Nurse Coordinator Social Workers Dieticians Community Health Workers OVHA Care Coordinators Public Health Prevention Specialist Mental Health & Substance Use Disorders <ul><ul><li>Integrated Health Service Model </li></ul></ul><ul><ul><li>Payment Reform to support prevention & health maintenance </li></ul></ul><ul><ul><li>Health Information Infrastructure </li></ul></ul><ul><ul><li>Evaluation Infrastructure </li></ul></ul><ul><ul><li>Generalizable (other services) </li></ul></ul><ul><ul><li>Scalable (larger populations) </li></ul></ul><ul><ul><li>Sustainable (financially) </li></ul></ul>PCMH
  32. 33. Community Health Team Patient Centered Medical Homes Multi-insurer payment reform Health Information Infrastructure Evaluation Infrastructure AMPC Foundation Blueprint: A Foundation for integrated services Targeted Services Specialty Care Disease Management Programs Case Management Social Services Economic Services <ul><li>Areas of Focus </li></ul><ul><li>Family Wellness & Children's Services </li></ul><ul><li>Mental Health & Substance Use </li></ul><ul><li>Medicaid Care Coordination </li></ul><ul><li>Senior Services (SASH) </li></ul><ul><li>Disease Specific (CHF) </li></ul><ul><li>Steps </li></ul><ul><li>Clinical Services Model </li></ul><ul><li>Financial Impact Model </li></ul><ul><li>Payment Reforms </li></ul><ul><li>IT Infrastructure & Enhancements </li></ul><ul><li>Implementation Plan </li></ul><ul><li>Evaluation Plan </li></ul>
  33. 34. Even silos can be systematic!
  34. 35. QUESTIONS??? Web address: www.healthvermont.gov

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