Reforming Disease Prevention & Health Promotion: Opportunities at the Boundaries

1. Reforming Disease Prevention & Health Promotion:Opportunities at the Boundaries Kurt C. Stange, MD, PhD American Cancer Society Clinical Research Professor Professor of Family Medicine, Epidemiology & Biostatistics, Sociology and Oncology Case Western Reserve University Steven H. Woolf, MD, MPH Professor of Family Medicine Virginia Commonwealth University

2. 1000 persons 800 report symptoms 327 consider seeking medical care 217 visit a physician’s office (113 visit a primary care physician’s office) 65 visit a complementary or alternative medical care provider 21 visit a hospital outpatient clinic 14 receive home health care 13 visit an emergency dept 8 are hospitalized <1 is hospitalized in an academic medical center Fig. Results of a reanalysis of the monthly prevalence of illness in the community and the roles of various sources of health care. (Green LA et al., N Engl J Med 2001, 344:2021-2024)

3. It’s About Health Healthas Function & Meaningful Relationships

4. Person & Family It’s About People & Families Healthas Function & Meaningful Relationships

5. Patient-Centered Medical Home Person & Family It’s About Accessible Health Care Healthas Function & Meaningful Relationships

6. Patient-Centered Medical Home Person & Family Healthcare System It’s About Healthcare System Healthas Function & Meaningful Relationships

7. Patient-Centered Medical Home Person & Family Public Health System, Community Resources Healthcare System It’s About Public Health & Community Healthas Function & Meaningful Relationships

8. It’s About Spanning Boundaries

9. Patient-Centered Medical Home Person & Family Public Health System, Community Resources Healthcare System Personalized, prioritized, integrated health caring Abiding, Personalized Health Care Healthas Function & Meaningful Relationships

10. Patient-Centered Medical Home Person & Family Public Health System, Community Resources Healthcare System Healthcare environments that foster healing & integration Abiding, Personalized Health Care Healthas Function & Meaningful Relationships Healing Environments

11. Patient-Centered Medical Home Person & Family Public Health System, Community Resources Healthcare System Sustainable, grounded organizations Abiding, Personalized Health Care Healthas Function & Meaningful Relationships Healing Environments Prioritized, Sustainable Organizations

12. Patient-Centered Medical Home Person & Family Public Health System, Community Resources Healthcare System Healthy environments Abiding, Personalized Health Care Healthas Function & Meaningful Relationships Healing Environments Healthy Environments Prioritized, Sustainable Organizations

13. Model of Agents and Relationships for Disease Prevention & Health Promotion • Patient & Family • Financial resources (insurance and costs) • Access to communication resources and health care • Social context (education, income) • Teachable moments • Support for behavior change • Primary Care Practice • Time • Training • Medical records/info/IT • Reminders and prompts • Staff • Skills/self-efficacy • Rewards/reimbursement (P4P) • Medical home & redesign 1 3 2 • Health Care System • Specialists and lab/imaging referral and follow-up systems • Public health departments • Pharmacies • Worksite health clinics • School clinics • Group programs • IT support • Community • Work environment • School environment • Built environment/developers • Supermarkets • Parks and recreation authorities • Health clubs • Quit lines • Commercial weight loss firms • Retailers • Group initiatives • Individualized programs 5 4 6 7 Aligned economic incentives Interrelationships • #1. Practice ↔ Patient/family • - Group visits • - Outreach • - Follow-up • #2. Care system ↔ Patients • - Patient-centered service redesign for preventive care • - Information and engagement • #3. Community ↔ Individual Family • - Policy, supportive environments, & accessible, convenient programs that foster prevention where people live, work and go to school • - Motivational programs • #4. Practice ↔ System • - IT, system redesign, and financing to coordinate primary and specialty care • #5. Practice ↔ Community • - Referral systems, liaison workers • #6. Health Care System ↔ Community • - Advisory boards, shared community benefit fund, and other programs that link medical community with public/private stakeholders From: Policy Options in Support of High-Value Preventive Care Stange & Woolf at: http://www.prevent.org/content/view/197

14. Policy Options

15. The Person and Family • Incentivize and foster healthy built environments • Disseminate a free personal health record that guides HP/DP and interfaces with an interoperable electronic health record platform • Financial incentives for healthier behaviors and recommended clinical preventive services.

16. Health Care Delivery System • Expand access to fundamental care and coverage for the uninsured and under-insured • Reorganize the delivery system to support HP/DP • Disseminate and promote the work of the National Commission on Prevention Priorities to target high-yield preventive services for individuals, medical practices, health care systems, and payers. • Require the Secretary of HHS to file annual reports on the state of primary care in the US, the integrity of the public health infrastructure, and the delivery of evidence-based clinical and community preventive services.

17. Health Care Delivery System • Invest in the National Center for Health Statistics to provide serial data on preventive service delivery rates and the prevalence of modifiable risk factors among all Americans and priority populations • Develop a national authority to oversee improvements in coordinating health-related data and IT • Engage medical software developers in a coordinated effort to standardize features

18. Primary Care PracticeAccess for the Underserved • Expand support for community health centers • Expand funding for Title VII to reprise its success in the 1970s in training health professionals to provide primary and preventive care and a patient-centered medical home for the U.S. population • Triple the size of the National Health Services Corps and include health informatics experts as qualifying assignees • Universal health care coverage

19. Primary Care PracticeSystem Redesign to Improve the Delivery, Quality, and Intensity of Preventive Services • Implement the patient-centered medical home to make it easier for providers to offer the right services to the right people at the right time • Align financial incentives to reward primary care clinicians for delivering effective preventive services

20. Community • Invest in public health infrastructure to support evidence-based community preventive services • Support coordination of community and clinical preventive service delivery • Explore applying and expanding the Agricultural Extension Agent and Forestry Service models to help communities build collaborative linkages to foster prevention

21. Financing • Universal health insurance for the U.S. population • Define & annually update a core set of evidence-based preventive services for uniform coverage based on • U.S. Preventive Services Task Force • Advisory Committee on Immunization Practices • Task Force on Community Preventive Services • National Commission on Prevention Priorities • Expand coverage under federal and state programs (e.g., Medicare, Medicaid, Federal Employees Health Benefits Program) and private insurance to include the core set of evidence-based preventive services • Offer first-dollar coverage (e.g., no copayments) for the core set of evidence-based preventive services • Incentivize business consideration of the social determinants of health

22. Financing • Explore progressive approaches to reimbursement of preventive services for asymptomatic populations and for services delivered outside clinical settings • Reform health care payment to support the elements of the patient-centered medical home • Support the transitional costs for investment in IT, and reward those who already have made this investment and can document its benefits • Provide tax credits/deductions for participation in effective worksite and community behavior change programs • Shape pay-for-performance policies to provide incentives for evidence-based preventive services and for not delivering services that lack evidence

23. Infrastructure for Interface, Relationships & Coordination • Promote human systems and public and professional education programs that enable coordination of preventive services and the sharing of responsibility among individuals, families, primary and secondary care, health care systems, public health, & communities • Support research to better integrate health care and public health by expanding funding for the AHRQ and/or establishing a new NIH Institute for Integrated Health Care • Establish a CDC-based communication vehicle for supporting a culture of priority setting and shared responsibility • Establish a new CDC service equivalent to the Epidemiological Intelligence Service officer based on the U.S. Department of Agriculture’s Extension Agent model, or expand the Extension Agent model to include promoting healthy behaviors. Charge this officer to serve as a “boundary spanner” between public health agencies, medical practice networks, and community groups and agencies

24. Opportunities for Reforming DP & HP • Health as function and meaningful relationships • Health care as relationships more than commodities • Health promotion as enabling environments and people • Boundaries between health an illness • Interfaces between people and systems • Recognizing commonality

25. Policy Options in Support of High-Value Preventive CareKurt C. Stange, MD, PhD Steven H. Woolf, MD, MPH http://www.prevent.org/content/view/197

26. Patient-Centered Medical Home Person & Family Public Health System, Community Resources Healthcare System Opportunities at the Interfaces Abiding, Personalized Health Care Healthas Function & Meaningful Relationships Healing Environments Healthy Environments Prioritized, Sustainable Organizations