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Improving health and healthcare at the population level SCHA Data Knowledge Academy

Improving health and healthcare at the population level SCHA Data Knowledge Academy Keynote Presentation October 13, 2016. The most important number for determining health status?. Genetic Code BMI Age Zip Code. The Neighborhood and The Need.

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Improving health and healthcare at the population level SCHA Data Knowledge Academy

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  1. Improving health and healthcare at the population level SCHA Data Knowledge Academy Keynote Presentation October 13, 2016

  2. The most important number for determining health status? Genetic Code BMI Age Zip Code

  3. The Neighborhood and The Need The 5.6 square mile area of CPN is marked by under-education, teenage pregnancy, poor healthcare, violent crime, unemployment, and intergenerational poverty. We aim to break that cycle. Note: 2016 Federal Poverty Line for a family of 4 (200% FPL) = $48,500

  4. population health big picture The overall health of people and populations is determined by a continuous interplay of social, environmental, economic and clinical factors/drivers. Certain populations are more adversely impacted by these factors resulting in inequitable differences in healthcare access and health outcomes. Effective solutions to the greatest health challenges at a community/population level will require collective actions that address both the major drivers of health and healthcare for the population overall and the equity gaps for those subpopulations most at risk

  5. Population Health "the health outcomes of a group of individuals, including the distribution of such outcomes within the group"

  6. Population Health Management The actions through which care providers can improve clinical and financial outcomes for a defined population The aggregation of data to provide a comprehensive clinical and financial picture at the patient and population level Built around an integrated clinical delivery network and intensive care management for high risk patients within the defined population

  7. Key Triple Aim Measurement Principles The need for a defined population- measures of population health require a population denominator The need for data over time- to distinguish between common and special cause variation, and to better understand the relationship between cause and effect and impact of specific interventions The need to distinguish between outcome and process measures, and between population and project-based measures The value of benchmark or comparison data

  8. social determinants of health conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks

  9. Understanding Health Equity

  10. the health equity challenge Health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment.

  11. Health Equity Triad Location and Built Environment Race and Ethnicity Income and Assets Education Level Living in poverty- amplified in early childhood Lack of access to high quality education & jobs Unstable/unhealthy housing options Unfavorable work or neighborhood conditions Exposure to neighborhood violence

  12. Disparities in Mortality Rates for Three Health Status Indicators: Black and White Americans (1990 and 2005) Source: Orsi JM, Margellos-Anast H, Whitman S. Black-white health disparities in the United States and Chicago: A 15-year progress analysis. American Journal of Public Health. 2010;100(2):349-356.

  13. Relative Risk of All-Cause Mortality by US Annual Household Income Level Sources: McDonough P, Duncan GJ, Williams D, House J. Income dynamics and adult mortality in the United States, 1972 through 1989. American Journal of Public Health. 1997;87(9):1476-1483. Williams D. “Race, Racism, and Racial Inequalities in Health.” Presentation to Harvard Kennedy School Multidisciplinary Program in Inequality and Social Policy. February 8, 2016. http://inequality.hks.harvard.edu/files/inequality/files/williams16slides.pptx?m=1455915158

  14. South Carolina’s Health Hundreds of people and organizations in our state are doing great work, ..but we have not been as coordinated and aligned as we should be. For the first time in our state’s history. We are working together to change this. People in 41 other states have better health than people in South Carolina …people who live in low-income neighborhoods or rural areas, and people of color have even worse outcomes …our children are the first generation projected to live shorter lives than their parents

  15. The Alliance for a Healthier South Carolina Mission: Coordinating action on shared goals to improve the health of ALL people in South Carolina.

  16. Alignment of goals and actions: our primary way of impacting health in SC

  17. Our Common Agenda for Health Improvement

  18. Key Alliance metrics Metrics for overall improvement and disparity reduction: Infant mortality and low-birthweight Reading at grade level and well-child visits Primary-care-preventable utilization of acute care hospitals by people with and without behavioral health conditions Appropriate management of asthma, diabetes, hypertension, and depression Self-rated mental health status

  19. Recent South Carolina Wins (2014 data) Healthy Babies 338 5% 12% 58 Fewer babies born with Low-Birthweight Reduction in Low-Birthweight Rate Reduction in Infant Mortality Rate. Met 2020 Alliance Goal. Fewer baby deaths Healthy Children 17 7.1% 2,372 Position improvement in America’s Health Rankings for Childhood Immunizations Improvement in Asthma Medication Ratio Fewer Pediatric ED visits due to Primary Care Preventable Conditions.

  20. Recent South Carolina Wins (2014 data) Healthy Minds People with existing behavioral health conditions spent We consolidated in a public, online map, all statewide drop-boxes for prescription drugs. 4,272 fewer days hospitalized due to primary care preventable conditions. Healthy Bodies 136,624 4,276 12% Fewer uninsured Fewer hospitalizations due to Primary Care Preventable Conditions. Reduction in proportion of people who needed a doctor but couldn’t see one due to cost. Met 2020 Alliance Goal.

  21. SC Call to Action for Health Equity

  22. Alliance equity metrics

  23. Equity Call to Action- Obesity 1: Stratify data to identify what populations to target. 2: Maximize the potential of diversity in your organization to develop culturally sensitive solutions WITH the community.

  24. The health equity ripple effect Obesity/Chronic Disease of the mom prior to conception is a risk-factor for Low-birthweight. Low-birthweightis a risk factor for Infant Mortality and for difficulty to learn. Difficulty to learn is a risk factor for high-school graduation. High-school graduation is a major socioeconomic determinant of health.

  25. Guide to Preventing Readmissions among Racially & Ethnically Diverse Medicare Beneficiaries Prepared for CMS OMH by the Disparities Solutions Center at Massachusetts General Hospital in collaboration with the National Opinion Research Center at the University of Chicago

  26. key differentiating factors between hospital systems with lower and higher Medicare readmission rates • Lower household income • Lower supplemental health insurance • Higher depression scores • Lower cognition scores • Worse self rated health • Higher difficulty with ADLs Higher minority population Higher unmarried population Lower education level Higher proportion not in labor force Lower total financial assets

  27. All Payor Readmission Rates by Diagnosis

  28. Racial Readmission Disparity Gap

  29. 1. Stratify the data

  30. 2. Maximize the potential of diversity in your organization to develop culturally humble solutions WITH the community. And you would move your Overall Readmission Rate from Orange to Yellow in the comparative dashboard

  31. Centering Pregnancy Results P=0.01 P=0.50

  32. Achieving population health equity- key collective upstream solutions Collect and analyze all health data through an equity lens Build a culture of diversity and inclusiveness that reduces the negative impact of implicit bias Adopt a life course perspective to education and early childhood development (from cradle to career) Deliver culturally and linguistically tailored health and social programs for specific at risk populations Target urban planning and community development to healthy food access, safe spaces for physical activity, safe and affordable housing, public transportation and safety Invest in community-based programs and resources

  33. HealthierSC.org

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