Non-Medical Drivers of Health Marci Morgenlander, MD MPH Deborah Porterfield, MD MPH

1. Non-Medical Drivers of Health Marci Morgenlander, MD MPH Deborah Porterfield, MD MPH

2. Welcome to POPTOPs Population Health Topics brought to you by the UNC Preventive Medicine Residency Bringing population health information to AHEC residents in our state

3. This project is made possible through an AHEC Innovations Grant

4. What is Preventive Medicine? • One of 24 recognized board specialties • Definition from ACGME: • the medical specialty which focuses on the promotion, protection, and maintenance of health and well-being and the prevention of disease, disability, and the premature death of individuals in defined populations • Quick definition: population health practice. • 2 main settings: • Governmental public health • Health care management

5. What is PM training? • 2 years following one clinical year • MPH or equivalent degree • Required rotations (ACGME) • 4m total in individual patient care • 2m in governmental public health • 40+ competencies; 20+ milestones • At UNC, additional requirements • teaching • research • additional rotations specific to grant funding • electives

6. Residency Mission • increase the number of appropriately trained, board-certified preventive medicine physicians (total and underrepresented minority) in practice in North Carolina and the nation; • increase access to quality primary care and population health practice in North Carolina and the nation; and • improve the quality of the preventive medicine workforce by ensuring competency-based evaluations of residents and annual data-driven program improvement

7. Definitions • Population health • health outcomes of a group of individuals and the distribution of defined outcomes within the group (Donabedian, 1988) • Population health improvement/management • collective systems and policies that affect health care quality, access, and outcomes for a defined population (Meiris, 2008) • Population medicine • design, delivery, coordination, and payment of high-quality health care services to manage the Triple Aim for a population, using the resources available within a health care system (Lewis, 2014)

8. Why Non-Medical Drivers as a Population Health Topic?

9. Non-Medical Drivers Agenda • Definition of non-medical drivers of health • SDH • Pertinence to Primary Care Residents • Background • Current State • ACEs • Pertinence to Primary Care Residents • Background • Current State

10. What are “non-medical" drivers of health? • Social Determinants of Health (SDH) • Adverse Childhood Experiences (ACEs)

11. Why should you as a resident care about SDH/ACEs? • SDH/ACEs contribute to poor health and premature death in your patients • Addressing SDH/ACEs can save health care dollars

12. SDH Background

14. Determinants of Health (cdc.gov)

15. Social Determinants of Health: WHO Framework

16. Social Determinants of Health:KFF Framework

17. Social Determinants of Health: AAFP • Access to medical care • Access to nutritious foods • Access to clean water and functioning utilities (e.g., electricity, sanitation, heating, and cooling) • Early childhood social and physical environment, including childcare • Education and health literacy • Ethnicity and cultural orientation • Familial and other social support • Gender • Housing and transportation resources • Linguistic and other communication capabilities • Neighborhood safety and recreational facilities • Occupation and job security • Other social stressors such as exposure to violence and other adverse factors in the home environment • Sexual identification • Social status (degree of integration vs isolation) • Socioeconomic status • Spiritual/religious values

18. SDH by any other name… • Trending away from the term “determinants” • NC DHHS uses “Health Related Social Needs”

19. SDH Contribute to Premature Death

21. So what’s a physician to do?

22. SDH Current State

23. Action Steps • Collect Data • Analyze Data • Develop Interventions • Assess Interventions

24. AAP Response - 2016 Guideline • Create family centered medical homes • Screen for financial difficulties • Connect with resources/collaborate with community agencies • Implement integrated medical home programs • Identify family protective factors • Advocate (AAP, 2013)

25. AAFP Response 2013 • Identify SDH crucial to community of patients • Identify and partner w/community resources • Individualize care based on SDH • Engage in community to improve SDH • Advocate (AAFP, 2013)

26. SDH Data Sources • CDC https://www.cdc.gov/socialdeterminants/data/index.htm • RWJF https://www.rwjf.org/en/library/collections/better-data-for-better-health.html • NCDHHS http://nc.maps.arcgis.com/apps/MapSeries/index.html?appid=def612b7025b44eaa1e0d7af43f4702b

28. To Screen or Not to Screen That is not really the question anymore! • IOM screener 11 domains • CMS screen for 5 HRSN • NC Healthy Opportunities Pilots will screen and intervene for food insecurity, housing instability, transportation needs, and interpersonal safety

29. Screening: SDH Specific • Screening should be tailored to needs of community being served. • Screening should be appropriate to child’s developmental stage. • Screening tools may address multiple SDH or have one specific focus. • Universal screening reduces risk of stigmatization. (Chung, 2017)

30. Intervention Approaches • Referral and linkage to community resources • Deployment of services or programs in the clinical setting • Identification and amplification of protective factors such as resilience, connectedness, family support

31. Other Approaches • Offering universal resource linkage • Co-location of community resources with medical clinics • Community Interventions • Education • Environmental modification • Legislation

32. North Carolina DHHS Initiative • Statewide SDH mapping • Healthy Opportunities Pilots • $650 million federal dollars over 5 years • Screening for food, housing, transportation, interpersonal safety • LPEs will oversee PHP/community interventions for eligible Medicaid recipients

33. North Carolina DHHS Initiative • NCCare360 • Partnership between state and FHLI • Statewide electronic platform • Available to healthcare and community partners • Allows closed loop referrals • EHR compatible

34. ACEs Background

35. The ACEs Study (Felitti, 1998)

36. Adverse Childhood Experiences (ACEs) • ACEs study, Felitti and Anda 1998 showed a dose-response relationship between the level of household dysfunction in childhood and subsequent development of substance use, depression, suicide, smoking, obesity, chronic heart and lung disease.

37. ACEs Facts • ACEs can lead to poor health outcomes in childhood with effects magnified over the lifecourse • Childhood adversity leads to “toxic stress” causing neuroendocrine, inflammatory, and immune system dysfunction • Physical and mental health, emotional well-being and educational achievement are affected

38. ACEs in NC

39. The ACE Pyramid (cdc.gov)

40. Current State

41. “At the beginning, they are equal, these beautiful bundles of potential, and knowing that they won’t always be is enough to break your heart.” -Nadine Burke Harris The Deepest Well

42. Protective Factors • ACEs ARE NOT DESTINY! • One single, supportive, loving adult relationship can change the trajectory • Resilience building changes the body’s neurobiologic response to toxic stress https://developingchild.harvard.edu › 2015/05 › The-Science-of-Resilience

43. Action Steps • Medical homes to provide family centered care and care coordination • Trauma informed care • Developing area • May feel daunting to overburdened practices • AAP recommends assessing readiness to change and beginning with QI initiatives https://www.aap.org › en-us › documents › ttb_aces_consequences

44. More Immediate Action Steps • Promote and highlight resilience factors • Identify and provide mental health, substance abuse treatment • Parenting support • Family meals • Reach Out and Read • Positive connections with family, school, neighborhood or worship communities

45. Action Steps by the Innovators • Dr. Burke Harris • Screening all children for ACEs • Referring all those with 4 or more ACEs or with any ACEs and a chronic condition to the Center for Youth Wellness for wrap around services • Routinely utilizing a “prescription” for healing toxic stress encompassing sleep, nutrition, activity, healthy relationships, mental health and meditation/mindfulness

46. ACEs Resources • https://nppcaces.org/ • http://www.practicenotes.org/v21n3/PB.htm • https://developingchild.harvard.edu/ • https://centerforyouthwellness.org/ • https://www.acesconnection.com/ • http://buncombeaces.org/

47. Action Steps Outside the Office • Support cross sectoral resilience initiatives across the country • NC spearheaded by Buncombe County, spread to Orange, Chatham, Wake, Pitt and many others • Promote policies to strengthen communities, families, education, jobs, prison reform, housing, and equity

48. Thank You! University of North Carolina Preventive Medicine Residency Program https://www.med.unc.edu/fammed/education/prevmed/

49. References CDC NCHHSTP Social Determinants of Health https://www.cdc.gov/nchhstp/socialdeterminants/faq.html Engel, GL The need for a new medical model: a challenge for biomedicine; Science April 1977:129-136 Disparities in Health and Healthcare: 5 Key Questions and Answers https://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/ AAFP Social Determinant of Health Policy; 2013 https://www.aafp.org/about/policies/all/social-determinants.html AAP Poverty and Child Health in the United States; 2016 https://pediatrics.aappublications.org/content/137/4/e20160339 NCDHHS Healthy Opportunities https://www.ncdhhs.gov/about/department-initiatives/healthy-opportunities

50. References Felitti VJV. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. AmJPrevMed 1998 14(4): 245-58 NC BRFSS https://schs.dph.ncdhhs.gov/data/brfss/2014/nc/nccr/ACEINDX1.html Shonkoff J. Supportive Relationships and Active Skill-Building Strengthen the Foundations of Resilience https://developingchild.harvard.edu › 2015/05 › The-Science-of-Resilience AAP Addressing Adverse Childhood Experiences and Other Types of Trauma in the Primary Care Setting https://www.aap.org › en-us › documents › ttb_aces_consequences