This document provides an overview of partnerships between public health and healthcare organizations. It discusses several initiatives aimed at improving population health, including State Innovation Models, Accountable Care Organizations, and the Accountable Health Communities program through CMS. The document outlines key drivers of these partnerships as cost, chronic disease, data, and policy. It presents examples of programs that address issues like asthma, lead poisoning, and care coordination for patients with multiple chronic conditions. The conclusion emphasizes the need for leadership and partnerships between primary care and public health to improve health outcomes.

1. Public Health/Health Care Partnerships
An Overview of the Landscape
National Association of Chronic Disease Directors
Denver, Colorado
August 31, 2016
Lloyd Michener, MD
Professor and Chair
Department of Community & Family Medicine
Duke University Medical Center, Durham, NC

2. 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.

3. “From Health Care to Health”
There IS a plan…

4. OVERVIEW – A MONTAGE OF
ORGANIZATIONS ENGAGED IN POPULATION
HEALTH
State Innovation Models
Initiative
Accountable Care
Organizations(ACO)

5. Drivers:
1. Cost
2. Chronic Disease
3. Data
4. Policy
What is needed: Leadership
(McGinnis, The Practical Playbook, pg 11)

6. 1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
Exhibit 1. International Comparison of Spending on Health, 1980–2010
Average spending on health per capita ($US PPP)
$8,000
US
SWIZ
$7,000
NETH
Total health expenditures as percentage of GDP
18
16
$6,000
$5,000
$4,000
$3,000
$2,000
$1,000
$0
CAN
GER
FR
AUS
UK
JPN
14
12
10
8
US
NETH
6 FR
GER
4 CAN
SWIZ
UK
2
JPN
AUS
0
Notes: PPP= purchasing power parity; GDP = gross domestic product.
Source: Commonwealth Fund, based on OECD Health Data 2012.
www.commonwealthfund.org

7. 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
20.2
14.8
3.7
8.4
16.7
21.5
20.2
1.2 4.4
22.4
45.3
54.2
10.813.1
36.9
67.6
78.6
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

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

9. 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.

10. Signs of Change
Accountable Health Communities —
Addressing Social Needs
through Medicare and Medicaid
Dawn E. Alley, Ph.D., Chisara N. Asomugha, M.D., Patrick
H. Conway, M.D., and Darshak M. Sanghavi, M.D.
Road Ends
All Traffic
Exit Here

11. “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 health
and social service systems and thereby accelerate progress to-
ward improved health for our whole country.”
Payors are paying attention – especially CMS:

12. Accountable Health Communities – Addressing Social Needs
Through Medicare and Medicaid
Dawn E. Alley, Ph.D., Chisara N. Asomugha, M.D., Patrick H. Conway, M.D.,
and Darshak M. Sanghavi, M.D.
CMS:

13. CDC:

14. 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.

16. Facilitating
States:

18. John Auerbach, MBA. J Public Health Management Practice, 2016 00(00), 1-4
But what can we do?

19. Observation From the Field:
Integration is a Process
Common Barriers: culture/language
Common Facilitators: “bridge” organizations

20. Ideally, the process begins with data:

21. The intervention is targeted:

22. Just For Us
Outcomes are tracked:

23. Durham County Connections Across Partnerships
healthydurham.org
1) Blue squares represent partnerships
2) Red circles represent organizations
3) The closer partnerships are located together on the map – the more members they share in common
4) The farther partnerships are from each other – the less of a connection they have through shared
members
5) Organizations in the center of the map bridge across multiple partnerships
Partnerships are Developed:

24. 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

25. 400
450
500
550
600
650
700
750
800
850
900
950
1000
CY2008 CY2009 CY2010 CY2011 CY2012 CY2013 SFY2014
InpatientAdmissionsper1,000Beneficiaries
Inpatient Admissions Per 1,000 MCC Beneficiaries per Year
All Nondual MCC Medicaid
Unenrolled
Enrolled
Linear (All Nondual MCC Medicaid)
Linear (Unenrolled)
Linear (Enrolled)
Inpatient Admission Trends among NC Medicaid Beneficiaries
with Multiple Chronic Conditions, 2008-FY2014
Programs are scaled up and disseminated

27. 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

29. 460
480
500
520
540
560
580
600
InpatientAdmissionsper1,000
Beneficiaries
Inpatient Admissions Per 1,000 MCC
Beneficiaries per Year
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

31. www.practicalplaybook.org
Users: 38,759 Pageviews: 187,185

32. 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:

34. 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.

35. 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, MPP
Institute of Medicine, The National Academies
Washington, DC, USA