Presentation on theme: "Jeffrey Levi, PhD Tennessee Public Health Association"— Presentation transcript:
1Prevention and Health System Change: New Opportunities to Advance Public Health Jeffrey Levi, PhDTennessee Public Health AssociationSeptember 10, 2014
2Bottom lineChanges in health financing driving the health system to think beyond their four walls—this requires new partnershipsPublic health can be the “chief health strategist,” catalyzing and negotiating this change using its strengths and adapting to a new role
3It is all about the Triple Aim “Better care for patients, better health for our communities, and lower costs” -- CMSQuadruple Aim: Add equityAchieving the Triple Aim requires new partnershipsCommunity-clinical; public health-health care; health-non health (social determinants)Nature of partnerships will vary based on capacity of all partiesPartnerships required regardless of your definition of population health
4Drivers of changeThe health system is changing only in part because of the ACAFocus on outcomesFocus on cost containmentExpectation of return on investment from both clinical and public health interventionsNot whether, but timeframe and extentWho shares the savings and how are they used?
5Status quo is not an option NCD mortality rate (16/17)CD mortality rate (14/17)Last in life expectancyYouth least likely to survive to 50Highest level of income inequality; poverty; child povertyThird lowest rate of pre-school education and secondary school completion
7It seems overwhelming…what matters is that we start Different communities at different starting pointsDifferent motivators – from traditional disease management to social determinants or community economic competitivenessAll paths lead to new partnerships and collaborations and to broader impact than imagined
8We know how to fix thisAddressing social determinants of health requires new partnershipsMoving beyond health in all policies to a Culture of HealthExamples abound of new partners across housing, education, community developmentNational Prevention Council/National Prevention Strategy as a federal base
9ACA envisions new partnerships -- National Prevention Council Bureau of Indian AffairsDepartment of LaborCorporation for National and Community ServiceDepartment of TransportationDepartment of AgricultureDepartment of Veterans AffairsDepartment of DefenseEnvironmental Protection AgencyDepartment of EducationFederal Trade CommissionDepartment of Health and Human ServicesOffice of Management and BudgetDepartment of Homeland SecurityOffice of National Drug Control PolicyDepartment of Housing and Urban DevelopmentWhite House Domestic Policy CouncilDepartment of JusticeDepartment of the InteriorOffice of Personnel ManagementGeneral Services Administration
10National Prevention Strategy: Goal ∙ Strategic Directions ∙ Priorities A new era for public health: to achieve the goals of the NPS requires a partnership across all sectors.
11NPS has catalyzed change within federal government Partnership for Sustainable CommunitiesHUD, DOT, EPAMetrics: active transportation use; access to healthy food choices; access to open spaceIncreased use of Health Impact AssessmentsCDC/NNPHI, Health Impact ProjectRegional “prevention council” in Region 8
12Moving NPS into communities National Collaborative on Education and HealthIntegrating health-relevant metrics into school report cardsAs health system moves into communities, including schools as locus for creating healthBraiding and blending funds to incentivize partnership in communitiesSchool Climate GrantsPerformance Partnership Pilots for Disconnected Youth
13Levers in the ACA Accountable Care Organizations (and variants) CMMI Innovation Awards (population health models that address social determinants)SIM grants and global budgetsMedicaid essential health benefits ruleCommunity benefit requirements for non-profit hospitalsPrevention and Public Health Fund
14Example: Hennepin Health – A Social ACO Medicaid expansion, full risk by countyVery high need population: continuum of care, behavioral health and social servicesEHR and social services linkages$1 million reinvested in first year from captured savingsDental clinic, sobering center, interim housing, behavioral health counselors, employment counselors
15Example: Health Systems Learning Group (Stakeholder Health) 40 nonprofit health systems--“invest in community health with a true integrative strategy”Quadruple aim: add reduced health disparitiesIntegrated care for socially complex people in socially complex neighborhoods: Social ROIIndividuals and place; redesign care; community based prevention; partner on social determinantsFinancial metrics and accountability
16CMMI Investments Health Care Innovation Awards State Innovation Models New partnershipsAn integrator agencyCoverage of non-clinical interventionsThinking beyond the patient population to the community’s health and well being
17SIM: 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.”
18DE: Nemours/ Alfred I. duPont Hospital for Children--Asthma Enhance family-centered medical homes in their community by adding community-based services for children with asthmaReduce asthma-related ER use and hospitalization by 50% by 2015Deployment of a “navigator” workforce that incorporates non-medical needs that promote respiratory health and address environmental asthma triggers
19CA 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.”
20MD: 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).
21Tapping resources beyond health Community Reinvestment ActLow-Income Investment Fund Social Impact CalculatorInnovative financing modelsSocial impact bondsSolving the “wrong pocket” issue
22What 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 officeBroad-based partnerships within and beyond the health systemROI is a goalPrimary vs. secondary prevention and ROIEach has an “integrator”Long-term financing issues remain
23How does public health change? New leadership roleConvener/integrator/catalystNew skills within health departmentsAssurance vs. delivery of services/programs
24Public 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
25Programs/Activities Specific to an HD and/or Community Needs Most of an HD’s Work is “Above the Line”Foundational AreasChronicDisease & Injury PreventionCommunicableDiseaseControlMaternal,Child, &Family HealthAccess to and Linkage w/Clinical CareEnvironmental Public HealthFoundationalPublicHealthServicesAssessment (Surveillance, Epidemiology, and Laboratory Capacity)All Hazards Preparedness/ResponsePolicy Development/SupportCommunicationsCommunity Partnership DevelopmentOrganizational Competencies (Leadership/Governance; Health Equity, Accountability/Performance Management , QI; IT; HR; Financial Management; Legal)Foundational Capabilities
26How does the workforce change? Foundational capabilitiesPolicy/systems/ community change“Health in all policies”Coalition buildingHealth ITIntegrated with EHRsTechnical and analytic capacityIntegrator roleIndividuals (CHWs)Systems – within health and outside health (convening/leadership)Direct services vs. quality assuranceHealth promotion beyond government public health
27Implementation challenges A system that is changing as we try to partner with itConstituency building just beginning beyond public healthScary fiscal times can result in circling the wagonsDevil is in the details, to say the least
28Can we do it?Four years ago we considered the following to be dreams or too much of a stretchAccreditationHealth reformEmbracing of population healthNational Prevention Council, StrategyMandatory funding for public healthMajor new prevention programmingStatus quo is not an option
29Questions? Jeff Levi email@example.com www.healthyamericans.org Thank you.