Prevention and Health System Change: New Opportunities to Advance Public Health

1. Prevention and Health System Change: New Opportunities to Advance Public Health Jeffrey Levi, PhD Tennessee Public Health Association September 10, 2014

2. Bottom line • Changes in health financing driving the health system to think beyond their four walls—this requires new partnerships • Public health can be the “chief health strategist,” catalyzing and negotiating this change using its strengths and adapting to a new role

3. It is all about the Triple Aim • “Better care for patients, better health for our communities, and lower costs” -- CMS • Quadruple Aim: Add equity • Achieving the Triple Aim requires new partnerships • Community-clinical; public health-health care; health-non health (social determinants) • Nature of partnerships will vary based on capacity of all parties • Partnerships required regardless of your definition of population health

4. Drivers of change • The health system is changing only in part because of the ACA • Focus on outcomes • Focus on cost containment • Expectation of return on investment from both clinical and public health interventions • Not whether, but timeframe and extent • Who shares the savings and how are they used?

5. Status quo is not an option • NCD mortality rate (16/17) • CD mortality rate (14/17) • Last in life expectancy • Youth least likely to survive to 50 • Highest level of income inequality; poverty; child poverty • Third lowest rate of pre-school education and secondary school completion

6. Bradley, et al. BMJ Qual Saf

7. It seems overwhelming…what matters is that we start • Different communities at different starting points • Different motivators – from traditional disease management to social determinants or community economic competitiveness • All paths lead to new partnerships and collaborations and to broader impact than imagined

8. We know how to fix this • Addressing social determinants of health requires new partnerships • Moving beyond health in all policies to a Culture of Health • Examples abound of new partners across housing, education, community development • National Prevention Council/National Prevention Strategy as a federal base

9. ACA envisions new partnerships -- National Prevention Council

10. National Prevention Strategy:Goal ∙ Strategic Directions ∙ Priorities

11. NPS has catalyzed change within federal government • Partnership for Sustainable Communities • HUD, DOT, EPA • Metrics: active transportation use; access to healthy food choices; access to open space • Increased use of Health Impact Assessments • CDC/NNPHI, Health Impact Project • Regional “prevention council” in Region 8

12. Moving NPS into communities • National Collaborative on Education and Health • Integrating health-relevant metrics into school report cards • As health system moves into communities, including schools as locus for creating health • Braiding and blending funds to incentivize partnership in communities • School Climate Grants • Performance Partnership Pilots for Disconnected Youth

13. Levers in the ACA • Accountable Care Organizations (and variants) • CMMI Innovation Awards (population health models that address social determinants) • SIM grants and global budgets • Medicaid essential health benefits rule • Community benefit requirements for non-profit hospitals • Prevention and Public Health Fund

14. Example: Hennepin Health – A Social ACO • Medicaid expansion, full risk by county • Very high need population: continuum of care, behavioral health and social services • EHR and social services linkages • $1 million reinvested in first year from captured savings • Dental clinic, sobering center, interim housing, behavioral health counselors, employment counselors

15. Example: Health Systems Learning Group (Stakeholder Health) • 40 nonprofit health systems--“invest in community health with a true integrative strategy” • Quadruple aim: add reduced health disparities • Integrated care for socially complex people in socially complex neighborhoods: Social ROI • Individuals and place; redesign care; community based prevention; partner on social determinants • Financial metrics and accountability

16. CMMI Investments • Health Care Innovation Awards • State Innovation Models • New partnerships • An integrator agency • Coverage of non-clinical interventions • Thinking beyond the patient population to the community’s health and well being

17. SIM: Minnesota Accountable Health Model • Expands patient-centered, team-based care through service delivery and payment models that support integration of medical care, behavioral health, long-term care and community prevention services… establishment of up to 15 Accountable Communities for Health to develop and test strategies for “creating healthy futures for patients and community members.”

18. DE: Nemours/ Alfred I. duPont Hospital for Children--Asthma • Enhance family-centered medical homes in their community by adding community-based services for children with asthma • Reduce asthma-related ER use and hospitalization by 50% by 2015 • Deployment of a “navigator” workforce that incorporates non-medical needs that promote respiratory health and address environmental asthma triggers

19. CA SIM: Accountable Care Community Pilots • “model how population health can be advanced through collaborative, multi-institutional efforts that promote a shared responsibility for the health of the community. Pilots will include a Wellness Trust, which will serve as a vehicle to pool and leverage funding from a variety of sources for long-term sustainability.”

20. MD: Community-Integrated Medical Home • “integrate patient-centered medical care with community-based resources while enhancing the capacity of local health entities to monitor and improve the health of individuals and their communities as a whole.” Developed in consultation with local health improvement coalitions (panels of local health departments, hospitals, physicians, community organizations, and other local entities).

21. Tapping resources beyond health • Community Reinvestment Act • Low-Income Investment Fund Social Impact Calculator • Innovative financing models • Social impact bonds • Solving the “wrong pocket” issue

22. What does this have to do with preventing the biggest drivers of health care cost? • Each model in different ways: • Recognizes the relationship between what happens inside and outside the doctor’s office • Broad-based partnerships within and beyond the health system • ROI is a goal • Primary vs. secondary prevention and ROI • Each has an “integrator” • Long-term financing issues remain

23. How does public health change? • New leadership role • Convener/integrator/catalyst • New skills within health departments • Assurance vs. delivery of services/programs

24. Public Health as Chief Health Strategist for Communities • “State and local health departments will be more likely to design policies than provide direct services; more likely to convene coalitions than work alone; and be more likely to access and have real-time data than await the next annual survey. These new required skills and abilities characterize a new role for health departments as the “chief health strategist” for a community.” • Public Health Leadership Forum http://www.resolv.org/site-healthleadershipforum/

25. Programs/Activities Specific to an HD and/or Community Needs Most of an HD’s Work is “Above the Line” Foundational Areas Chronic Disease & Injury Prevention Communicable Disease Control Access to and Linkage w/Clinical Care Maternal, Child, & Family Health Environmental Public Health Foundational Public Health Services • Assessment (Surveillance, Epidemiology, and Laboratory Capacity) • All Hazards Preparedness/Response • Policy Development/Support • Communications • Community Partnership Development • Organizational Competencies (Leadership/Governance; Health Equity, Accountability/Performance Management , QI; IT; HR; Financial Management; Legal) Foundational Capabilities

26. How does the workforce change? • Foundational capabilities • Policy/systems/ community change • “Health in all policies” • Coalition building • Health IT • Integrated with EHRs • Technical and analytic capacity • Integrator role • Individuals (CHWs) • Systems – within health and outside health (convening/leadership) • Direct services vs. quality assurance • Health promotion beyond government public health

27. Implementation challenges • A system that is changing as we try to partner with it • Constituency building just beginning beyond public health • Scary fiscal times can result in circling the wagons • Devil is in the details, to say the least

28. Can we do it? • Four years ago we considered the following to be dreams or too much of a stretch • Accreditation • Health reform • Embracing of population health • National Prevention Council, Strategy • Mandatory funding for public health • Major new prevention programming • Status quo is not an option

29. Questions? Jeff Levi jlevi@tfah.org www.healthyamericans.org Thank you.