Public Health and Vulnerable Populations
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These slides give an overview of public health and the role of local public health departments in keeping people healthy, presents housing, health and some of the vulnerable populations who are the primary focus of our work, and shows the Healthy Chicago Public Health Agenda - the blueprint for our work at the Chicago Department of Public Health. Lastly, it highlights some of our work and accomplishments with vulnerable groups.
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Public Health and Vulnerable Populations
- 1. Chicago Department of Public Health Commissioner Bechara Choucair, M.D. City of Chicago Mayor Rahm Emanuel Healthy Chicago Public Health and Vulnerable Populations July 16, 2013 Bechara Choucair, MD Commissioner Chicago Department of Public Health
- 2. Presentation Outline 1. Public Health Overview 2. Housing, Health, and Vulnerable Populations 3. Healthy Chicago Public Health Agenda 4. Current Work and Accomplishments
- 3. Population Health Kindig D, Stoddart G. What is population health? American Journal of Public Health 2003 Mar;93(3):380–3. • The health outcomes of a group of individuals, including the distribution outcomes within the group • Focuses on improving health inequities
- 4. Core Functions & Essential Services
- 5. Chicago Department of Public Health Mission: To make Chicago a safer and healthier place by working with community partners to promote health, prevent disease, reduce environmental hazards and ensure access to health care for all Chicagoans.
- 6. Presentation Outline 1. Public Health Overview 2. Housing, Health, and Vulnerable Populations 3. Healthy Chicago Public Health Agenda 4. Current Work and Accomplishments
- 8. Housing Influences Health Pollack C, et al. Where We Live Matters for Our Health: The Links Between Housing and Health. Robert Wood Johnson Foundation. September 2008. • Safe homes that are free from physical hazards • Positive physical, environmental, social, and economic conditions in neighborhoods • Housing costs less than 35% of a family’s income
- 9. Conditions within the Home • Lead-based paint affects brain and nervous system development • Substandard housing conditions can lead to respiratory conditions such as asthma • Radon, pollutants, and asbestos can lead to cancers and respiratory illness • Steep staircases, lack of security devices, and substandard heating can cause injuries
- 10. Neighborhood Conditions • Neighborhood crime, violence, pollution • Safe places to play and exercise • Grocery stores selling fresh produce • Convenience stores, fast food outlets & liquor stores • Employment, transportation & health care • Strong neighborhood ties and high levels of trust
- 11. Housing Affordability • “Affordable housing” is less than 35% of income • Shortages of affordable housing limits choice of neighborhood • High-cost housing prevents families from meeting other basis needs, including nutrition, heat, health care, prescriptions • Housing affordability impacts homelessness
- 12. Homelessness and Health • Respiratory diseases, HIV/AIDS, alcohol and drug dependence, mental health problems, accidents and violence are more common • Homes are important for overall well-being, providing a sense of security, privacy, and control • The majority of homeless patients at FQHCs do not have health insurance or ability to pay for health care • Life expectancy is about 30 years less for those on the streets
- 13. Poverty in Adults Connected to Poor Health Status and Health Behaviors • Higher rates of chronic health problems • Higher rates of negative health behaviors • Less likely to have access to health care and medication In poverty Not in poverty Depression 31% 16% Obesity 32% 26% Smoking 33% 20% Uninsured 38% 14% Can’t afford medicine 38% 17% Data Source: Gallup-Healthways Well-Being Index, 2012
- 14. Uncontrolled Diabetes Hospital Discharge Rates, Chicago Residents, 2007
- 15. Uninsured Have Higher Rates of Morbidity and Mortality In 2010, over 26,000 people between ages of 25-64 died prematurely due to lack of health coverage •5 times less likely to have regular source of care •4 times more likely to delay/forgo preventive care screening due to cost o Uninsured women half as likely to get mammogram than insured Data Source: Dying For Coverage: The Deadly Consequences of Being Uninsured. Families USA. June 2012
- 16. Uninsured Have Higher Rates of Morbidity and Mortality • 6 times as likely to go without needed medical care • More likely to be diagnosed at advanced stage of illness o At least 25 percent more likely to die prematurely • 60 percent of uninsured report problems will medical bills or medical debt Data Source: Dying For Coverage: The Deadly Consequences of Being Uninsured. Families USA. June 2012
- 17. Racial/Ethnic Minorities More Likely to have Poor Health Outcomes All Cause Mortality, 2008 Race/Ethnicity Adjusted Rate per 100,000 Non-Hispanic Black 1049.3 Non-Hispanic White 795.5 Hispanic 499.4 Non-Hispanic Asian 410.1 Data Source: Illinois Department of Public Health, 2008 Vital Statistics
- 19. Presentation Outline 1. Public Health Overview 2. Housing, Health, and Vulnerable Populations 3. Healthy Chicago Public Health Agenda 4. Current Work and Accomplishments
- 20. Healthy Chicago Policy Agenda • Released in August 2011 • Identifies priorities for action for next 5 years • Identifies health status targets for 2020 • Shifts us from one-time programmatic interventions to sustainable system, policy and environmental changes
- 21. HEALTHY CHICAGOHEALTHY CHICAGO Chicago Department of Public HealthChicago Department of Public Health Infrastructure
- 23. Presentation Outline 1. Public Health Overview 2. Housing, Health, and Vulnerable Populations 3. Healthy Chicago Public Health Agenda 4. Current Work and Accomplishments
- 24. Access to Care • Provide immunizations, family case management, WIC, HIV primary care, STI testing, and mammography • Serve mental health consumers through six clinics, prioritizing the uninsured • Invested $500,000 for expanded psychiatry services awarded to 8 partners • Partnered with FQHCs to provide primary care services for the uninsured
- 25. Access to Care • Over 113,000 students from 504 schools received dental health services through school-based oral health program (2011-2012) • New vision program will serve 30,000 students • Collaborate with state and local health authorities and providers to promote Medicaid Expansion and the Marketplace
- 26. Patient Protection and Affordable Care Act (ACA) • Health care reform will provide access to care for many at-risk populations o Medicaid Expansion o Health Insurance Marketplace • We are working to ensure that enrollment agents will be available at area shelters • Health care system will be challenged to provide comprehensive health care for formerly uninsured • Public health will continue to address population health needs for this vulnerable group
- 27. Adolescent Health Chicago Public Schools (CPS) Partnership •85% of CPS students receive free/reduced price lunch •Established Office of Adolescent and School Health o Oral health, vision services, teen pregnancy, and sexually transmitted infection prevention services •Hired CPS Chief Health Officer •Teen Pregnancy Prevention Initiative
- 28. HIV Prevention • In 2012, CDPH and delegate agencies provided housing services to over 2,600 residents, HIV testing to 43,000 persons, and STI clinical care to 21,000 persons. • Integrated planning for prevention, care and housing services for HIV o Strengthen prevention o Increase linkage & retention to care o Increase treatment access
- 29. Violence Prevention • CeaseFire partnership • Domestic violence assistance • Data collection partnership with police department • Psychological First Aid training • Chicago Dating Matters Initiative, $1.75 M federal grant
- 30. Obesity Prevention Neighbor Carts •Produce carts with whole fruits and vegetables •Vendors are homeless and at-risk individuals •At least one-half of the carts must be placed in neighborhoods underserved by grocery stores •30 carts operating by the end of 2013
- 32. Become a Healthy Chicago Partner • Partner to address specific health issues or multiple Healthy Chicago priorities • Adopt Healthy Chicago policies and practices in your agency • Receive our monthly updates and share your ideas
Editor's Notes
- This presentation provides some background on public health, the health of vulnerable populations, and a snapshot of our efforts with vulnerable populations. First I will give you an overview of public health and the role of local public health departments in keeping people healthy Second I will discuss housing, health and some of the vulnerable populations who are the primary focus of our work Third, I will discuss the Healthy Chicago Public Health Agenda, the blueprint for our work at the Chicago Department of Public Health Last, I will highlight, very briefly, some of our work and accomplishments with vulnerable groups
- I will start with a backdrop to help you understand our work and how we prioritize our public health work in a city of 2.7 million people. As a local public health department, we work on population health– rather than individual health. In doing so, we work to reduce health inequities between groups, which leads us to focus on improving the health of the most vulnerable populations.
- Public health addresses 3 core functions– assurance, assessment, and policy development; and we focus on providing 10 essential services. The Chicago Department of Public Health ’s work is grounded in the core functions and essential services that you see here.
- Our mission is to make Chicago a safer and healthier place by working with community partners to promote health, prevent disease, reduce environmental hazards, and ensure access to health care for all Chicagoans.
- Why is it that some people are healthy are others are not? This pie chart shows the factors that influence health. What is surprising to many people is that genetics and medical care, together, only account for 40% of what influences our health. Social circumstances, environmental conditions, and behavioral “choices”– choices that are heavily influenced by our social circumstances and the environment– account for the majority. (Good health requires individuals make healthy decisions, but there are many obstacles that can make this difficult for people). A person ’s health is influenced by powerful social factors such as education, income, housing, and neighborhoods. Housing is a critical part of the picture– For example, our social circumstances– such as being poor– affect our housing choices, which in turn affect our environment, our access to medical care, and our so-called “choices”. (McGinnis et al, Health Affairs, Vol 22 (2)
- Let ’s look at how housing influences health. Conditions within the home and in neighborhoods, along with housing affordability, have a lot to do with health. Conditions within the Home- Homes must be safe and free from physical hazards. Poor and inadequate housing quality contributes to health problems such as infectious and chronic diseases, injuries, and poor childhood development. Neighborhood Conditions- Along with conditions in the home, the neighborhoods where homes are also have significant effects on health. This includes physical, environmental, social, and economic conditions. Housing Affordability- Affordable housing– housing that costs less than 35% of a family ’s income– is also essential for good health. Affordable housing ensures that individuals and families are able to remain housed, have safe and healthy living conditions, and have enough money for food, health care, and other basic needs.
- Most Americans spend the vast majority of their time indoors, and most that time is at home. Very young children spend even more time at home and are especially vulnerable to household hazards. Therefore, the conditions within the home are very important. Here are some common examples of how conditions within the home can negatively affect health: --Lead-based paint irreversibly affects brain and nervous system development, resulting in lower intelligence and reading disabilities --Substandard housing conditions such as water-leaks, poor ventilation, dirty carpets and pest infestation can lead to increased mold, mites, and other allergens, and result in respiratory illnesses such as asthma --Housing can be a source of carcinogenic pollutants – radon, tobacco smoke, pollutants from cooking with gas, and asbestos have been linked to cancer and respiratory illness --Injuries occurring at home result in ED visits and hospital admissions. Steep staircases, a lack of security devices such as window guards and smoke detectors, and substandard heating systems are among the culprits.
- The social, physical, environmental, and economic characteristics of a neighborhood affect short and long-term health quality and longevity. -There are many different facets of healthy neighborhoods, including crime, violence, & pollution; safe places to play and exercise; access to grocery stores with produce and reduced access to unhealthy foods through fast food outlets, convenience stores, & liquor stores; the ability to access employment, health care, and transportation; and strong neighborhood ties providing a sense of cohesion and social support.
- --Affordable housing is less than 30% of income. Low income families are more likely to lack affordable housing. An estimated 17 million households in the U.S. pay more than 50% of their incomes on housing (Joint Center for Housing Studies of Harvard University. The State of the Nation ’s Housing: 2008. Cambridge MA, 2008) -- Shortages of affordable housing limit choices about where to live, often relegating lower income families to substandard housing in unsafe, overcrowded neighborhoods with high rates of poverty, fewer resources for health (sidewalks, bike paths, recreation centers, etc.) --Unaffordable housing means families often choose to pay rent/mortgage over other needs that impact health: healthy food, heat, health care, medication --And of course, a lack of affordable housing contributes to homelessness
- What about the connections between homelessness and health? ---In 2010, the Chicago Coalition for the Homeless and UIC estimated that there were 57,379 homeless in Chicago. (The Facts Behind the Faces: A Fact Sheet from the Chicago Coalition for the Homeless. November 2011. ) ---There are high rates of respiratory diseases (TB), HIV/AIDS, schizophrenia, depression, anxiety, alcohol and drug problems, suicide, and other problems among persons who are homeless. Some problems predate homelessness and others are caused by it. Lack of shelter results in health problems due to exposure and also makes recovery from health problems slow and difficult --Homes contribute to overall well-being in other ways too– homes are secure bases; homes offer privacy; people are in control of their lives in their home -- Access to care for this population is limited. ( Lebrun-Harris, L, et al. Health Status and Health Care Experiences among Homeless Patients in Federally Supported Health Centers: Findings from the 2009 Patient Survey. Health Services Research 48(3) 2013 DOI: 10.1111/1475-6773.12009 ) --Life expectancy is about 30 years less for persons who live on the street than for those who are housed (James O ’Connell, Premature Mortality in Homeless Populations: A Review of the Literature)
- At the Chicago Department of Public Health, we focus a great deal on the health of low-income adults as a whole. Adults in poverty are more likely to have poor health status and higher rates of problematic health behaviors. Data show that adults in poverty have higher rates of chronic health problems: especially those diagnosed with depression, with a difference of 15 percentage points between those in poverty and those not in poverty. Higher rates of chronic diseases for those in poverty were noted also for: asthma, diabetes, high blood pressure, and heart attacks -- which are likely related to the higher level of obesity found for this group -- 32% vs. 26% for adults not in poverty Health behaviors also were worse in those in poverty, especially smoking, 33% of poor adults, compare to 20% of adults not in poverty. Not unexpected, those in poverty had lower rates of regular exercise (48% v. 52%) and healthy eating (5+ servings fruit and vegetables , 4 days/week—50% v. 56%). In addition, those in poverty were less likely to be insured and be able to afford medication. Gallup Wellbeing The Gallup-Healthways Well-being Index is based on more than 288,000 interview during 2011 with American Adults. Poverty is based on the U.S. Census levels. http://www.gallup.com/poll/158417/poverty-comes-depression-illness.aspx?version=print
- The map on the left shows areas of economic hardship, as indicated by poverty level, crowded housing, unemployment, low levels of education, and per capita income, with darker purple areas experiencing more hardship. The map on the right shows uncontrolled diabetes hospitalization rates, with higher rates shown in darker green. By comparing these maps, it documents that areas with a higher economic hardship index have higher rates of diabetes hospitalizations, which are often indicators of inadequate access to care and community resources to stay healthy.
- The uninsured have much higher rates of morbidity and mortality than the insured. In 2010, over 26,000 people in the U.S. between the ages of 25-64 died prematurely due to a lack of health care coverage. The uninsured are 5 times less likely to have a regular source of care, and 4 times more likely to delay or forgo preventive care screenings because of the cost. For example, uninsured women are half as likely to get a mammogram.
- The uninsured are also 6 times as likely to go without medical care And more likely to be diagnosed, at an advanced stage, of an illness. This takes a financial toll, with 60 percent of the uninsured reporting problems with medical bills or medical debt.
- Racial/ethnic minorities are also more likely to have poor health outcomes. This charts shows all cause mortality by racial/ethnic group, with Non-Hispanic Black having a rate 32% higher than Non-Hispanic Whites.
- The map on the left shows community areas that have a majority racial/ethnic population. The green communities are Non-Hispanic Black, the orange, Hispanic, and the purple are majority non-Hispanic White. The map on the right shows female breast cancer mortality. The areas with the darker purple have higher rates of mortality. What these maps show is that areas of higher mortality are overwhelmingly in non-Hispanic Black communities. Maps for many other health outcomes look very similar to the breast cancer mortality map, demonstrating the link between racial/ethnic minorities and poor health outcomes.
- In the time remaining, I will tell you about our efforts to improve the health of vulnerable populations.
- The Healthy Chicago public health agenda was released in August 2011, and serves as our framework for how the Chicago Department of Public Health will lead and work with partners to improve the health and well-being of Chicagoans. The agenda identifies our priorities for the next 5 years, and includes health status targets for 2020. Our agenda moved us from working on one-time programmatic interventions to making longer term changes for more people through working on sustainable system, policy, and environmental changes.
- Our 12 priority areas are shown here….
- Partnerships are essential to our efforts….
- Now I will discuss our current work and accomplishments. This is only a small snapshot of our efforts.
- Through our role in assuring health care access, we provide, as well as partner to provide, many health care services for vulnerable populations. We provide immunizations, family case management, WIC, HIV primary care, STI testing, and mammography services directly We also serve mental health consumers– primarily uninsured-- through six clinics Recognizing the limited capacity for community-based psychiatry services, we invested $500,000 in community psychiatric services last year. Beginning last year, we partnered with six FQHCs to provide primary care services. The transition included a $4.7 million investment to cover the costs of care for uninsured patients.
- In 2011-2012 school year, over 113,000 Chicago students from 504 schools received dental health services through school-based oral health program; Services expanding to 106 high schools City invested $1.4 M in new vision program; 30,000 students will get optometry exam and eyeglasses as needed We are collaborating with health authorities and providers to promote the Medicaid expansion and the marketplace
- However, through Health Care Reform access to care for many at-risk populations will be provided Medicaid Expansion Health Insurance Marketplace Because it is difficult to access this population, an “all hands on deck” approach to getting homeless enrolled is needed. We will work with DFSS and other not-for-profit to make sure that enrollment agents will be available at shelters for enrollment. Health care system will be challenged to provide comprehensive health care for formerly uninsured
- The large student population at Chicago Public Schools is largely Hispanic (45%), African American (41%), and low income (85% receive free/reduced price lunch), providing opportunities to improve the public health of vulnerable populations The CDPH Office of Adolescent and School Health was established in late 2011. The Office has united oral health, vision services, teen pregnancy, and sexually transmitted infection prevention efforts under a single leader, and provides a liaison and focal point for several other public health programs Expanded STI screening project to 28 schools. Educated 9215, screened 6147, identified 436 The Chief Health Officer for Chicago Public Schools (CPS) is a new position that oversees critical student health programs within CPS and collaborate with the Chicago Department of Public Health (CDPH) on the “Healthy Schools” component of the citywide “ Healthy Chicago ” initiatives. The Teen Pregnancy Prevention Initiative is a $19.7m initiative funded by the U.S. Dept. of Health and Human Services ’ Office of Adolescent Health. The Initiative is jointly administered by CDPH and CPS. It is a five year initiative funded through August 31, 2015. The aim of the initiative is to reduce teen pregnancies in Chicago and improve access to care for adolescents. It includes youth development curriculum, public awareness, peer health ambassadors, a condom availability program, and an adolescent data repository
- We manage over $51 million in City and grant funding to support HIV /STI prevention and care services. Over 40 million are delegated to community agencies to implement activities in support of citywide goals. In 2012, we provided housing services to over 26,000 residents, HIV testing to 43,000 persons, and STI clinical care to 21,000 persons. One specific accomplishment I ’d like to highlight is our integrated planning efforts. In 2012, Chicago became the one of the first large metropolitan areas in the country to integrate planning for the prevention, care, and housing services for HIV. Prior to the establishment of the Chicago Area HIV Integrated Services Council, HIV planning had been conducted by three separate bodies. Aligned with the National HIV/AIDS strategy, the 42-member HIV Integrated Services Council provides guidance for service delivery and informs the allocation of HIV community partner funding for Chicago and nine collar counties. The integration of prevention, care and housing allows our Department to ensure a more strategic approach to planning and a more effective use of resources across the HIV continuum of services.
- In June 2012, the City announced a $1 million partnership between the Chicago Police Department, CDPH, and CeaseFire. CeaseFire uses a public health approach to reduce violence by working to mitigate conflicts before they become violent. In 2012 with funding from the Chicago Department of Family and Support Services, domestic violence agencies in Chicago helped nearly 9,000 domestic violence agencies victims and their children. A safe location was provided for visitation for nearly 200 families, and more than 26,000 domestic violence help line calls were answered. We are making strides in better understanding childhood exposure to violence through a partnership with the Chicago Police Department. With support from the California Endowment Fund, Chicago Police Department is expanding data collection to provide better insight into the scope and types of childhood exposure to violence. Our Office of Violence Prevention provides training and technical assistance on Psychological First Aid and community-focused stress reduction to substance abuse treatment providers, youth, youth leaders, and community leaders. Our CDC-funded teen dating violence program just completed its first year. The program is being implemented in 12 middle and high schools in high need communities. The program includes parent & teacher training, the delivery of evidence-based curriculum, social media, and youth ambassadors. Over 9,000 students, parents, and educators will be served.
- Through Healthy Chicago, we are developing action plans to serve as roadmaps to address the health needs of particular populations. We have action plans developed specific to the needs of LGBT populations and Chicago Public Schools students. We also have an oral health plan and community-developed policy recommendations. The LGBT Community Action Plan serves as a road map to address the health needs of Chicago ’s Lesbian, Gay, Bisexual, and Transgender Community (LGBT). It is also a supplement to Healthy Chicago, the City of Chicago’s public health agenda that identifies 12 priority areas for action including tobacco use, obesity, violence prevention and access to care. The Community Action Plan was put together with the help of community based organizations, health providers, partners and stakeholders who have the same dedication that the Chicago Department of Public Health (CDPH) does to the overall health of our city with a keen understanding of the health challenges faced in the LGBT community. The Plan outlines strategic ways to address disparities in health status and health care access in the LGBT community As an extension of the Healthy Chicago Initiative, The IMPACT Program at Northwestern University has created a new report to document the health disparities of Chicago ’s LGBT youth. The report follows the framework of the Healthy Chicago Initiative and focuses on the areas of mental, physical, and sexual health, as well as substance use and violence prevention. Issues such as suicide, HIV/AIDS, tobacco and alcohol use, dating violence, and victimization are examined in the paper. Over 50 community leaders delivered a 20-page set of policy recommendations to our Department following a 10-week effort by a special community committee of the Local Initiatives Support Corporation (plus their local partners) on health issues. More than 70 leaders – organized into three subcommittees –researched and brainstormed what can be done to make their communities healthier. Ultimately they settled on eight core recommendations on matters ranging from gun violence to alcohol and tobacco sales, from fresh food access to breast feeding. The Plan was the result of the combined efforts of stakeholders, representing over 60 organizations, at the first Chicago Area Oral Health Summit held in January of this year. The three main goals of the Plan are to expand and strength the current oral health infrastructure, increase utilization of the oral health system, and promote oral health through educating the public and non-oral health professionals. Healthy CPS provides a roadmap for how the Chicago Public Schools will work with CDPH and other partners to create systems, policy and programmatic changes to improve the health and wellness of CPS students. The strategies presented on the following pages align directly with the broader Healthy Chicago agenda and identify concrete steps for action.
- In closing, for those of you who are in Chicago, we invite you to become a Healthy Chicago partner. You can partner with us to address specific health issues or multiple Healthy Chicago priorities We can talk with you about adopting Healthy Chicago policies and practices in your agency I would like to invite all of you, both in and outside of Chicago, to receive our monthly updates and share your ideas with us.