1. Indiana Health Issues: How CHWs Can Help
Annual CHW/CRS Conference
May 13, 2015
Indiana Health Issues: How CHWs Can Help
Christopher A. Maxey, MBA
Primary Care Office Manager
Division of Chronic Disease, Primary Care, & Rural Health

2. Overview Indiana State Department of Health’s Top Three Priorities
Reduce Indiana’s Infant Mortality Rate
Reduce Indiana’s Obesity Rate
Reduce Indiana’s Smoking Rate

3. Reduce Indiana’s Infant MORTALITY rate

4. Infant Mortality What is Infant Mortality?
When a baby dies after taking their first breath, but before he or she reaches their first birthday.

5. Infant Mortality Three Primary Causes of Infant Mortality
Perinatal Complications
Birth Defects
Sudden Unexpected Infant Death (SUIDs)

6. Indiana Infant Mortality
594 infants died before their 1st birthday in 2013
Indiana consistently worse than the US and national goal every year
IN 7.1 per 1,000 (2013) / US 5.98 per 1,000 (2012) / Healthy People 2020 Goal 6.0 per 1,000
Indiana has only been below 7 twice in 114 year recorded history (6.9 in 2008 and 6.7 in 2012)
Increase in black infant mortality from 12.3 in 2011 to 15.3 per 1,000 live births in 2013
Decrease in white infant mortality from in 2011 to 5.8 per 1,000 live births in 2013

7. Source: Indiana State Department of Health, Maternal & Child Health Epidemiology Division [Feb. 11, 2015]
United States Original Source: Centers for Disease Control and Prevention National Center for Health Statistics
Indiana Original Source: Indiana State Department of Health, PHPC, ERC, Data Analysis Team

8. Source: Indiana State Department of Health, Maternal & Child Health Epidemiology Division [February 11, 2015]

9. 2013 Indiana Infant Mortality by Hospital District

10. Risk Factors of Infant Mortality Where does Indiana stand?
Indiana has better preterm rates and similar low birthweight rates compared to the national average
Rate of SUIDs typically worse than the national rate
Smoking rate among pregnant women substantially worse than the national rate – Indiana always among the worst 10 states
One-third of Indiana pregnant women do not receive early prenatal care, worse than the US and national goal
Concerning racial disparities for ALL INDICATORS

11. ***US 2013 data pending SIDS = Sudden infant death syndrome (R95)
Source: Indiana State Department of Health, Maternal & Child Epidemiology Division [February 20, 2015]
United States Original: Centers for Disease Control and Prevention National Center for Health Statistics
Indiana Original Source: Indiana State Department of Health, PHPC, ERC, Data Analysis Team

12. SIDS = Sudden infant death syndrome (R95)
Source: Indiana State Department of Health, PHPC, ERC, Data Analysis Team, 2015

13. ***US 2013 data pending
Suffocation Deaths = Accidental suffocation and strangulation in bed (W75)
Source: Indiana State Department of Health, Maternal & Child Epidemiology Division [February 20, 2015]
United States Original: Centers for Disease Control and Prevention National Center for Health Statistics
Indiana Original Source: Indiana State Department of Health, PHPC, ERC, Data Analysis Team

14. Suffocation Deaths = Accidental suffocation and strangulation in bed (W75)
Source: Indiana State Department of Health, PHPC, ERC, Data Analysis Team, 2015

15. Source: Indiana State Department of Health, Maternal & Child Health Epidemiology Division [February 20, 2015]
United States Original: Centers for Disease Control and Prevention National Center for Health Statistics
Indiana Original Source: Indiana State Department of Health, PHPC, ERC, Data Analysis Team

16. Source: Indiana State Department of Health, PHPC, ERC, Data Analysis Team, 2015

17. Early Prenatal Care = First Trimester
Source: Indiana State Department of Health, Maternal & Child Health Epidemiology Division [February 20, 2015]
United States Original Source: Centers for Disease Control and Prevention National Center for Health Statistics
Indiana Original Source: Indiana State Department of Health, PHPC, ERC, Data Analysis Team

18. Source: Indiana State Department of Health, PHPC, ERC, Data Analysis Team, 2015

19. How CHWs Can Help Reduce Indiana’s Infant Mortality Rate
Encourage pregnant women to:
Seek early and routine prenatal care
Take folic acid
Stop smoking
Maintain a healthy weight
Encourage new moms to:
Practice safe sleep
Breastfeed

20. How CHWs Can Help Reduce Indiana’s Infant Mortality Rate
Encourage women of childbearing age (14-44) to:
Maintain a healthy weight
Avoid alcohol, tobacco, and drugs
Get immunized
If they are thinking of getting pregnant in the next couple of years
Take folic acid
Get prenatal care

21. Reduce Indiana’s Obesity Rate

22. Percentage of Overweight and Obese Adults – Indiana, 1995-2010, 2011-2013*
As you can see from this chart, obesity rates have increased steadily over the past 20 years, or so. Folks, when you combine the adults in Indiana that are overweight and obese, that number equals the entire population of Iowa. We are the ninth most obese state in the union, in the bottom 5 for physical activity and 48th worst in terms of being miserable.
*Beginning in 2011, the prevalence estimate was determined using a new, more precise methodology, including the addition of cell phone respondents and new weighting techniques; therefore, the estimates after 2010 should not be compared to earlier prevalence estimates.
Source: Indiana Behavioral Risk Factor Surveillance System

23. Prevalence* of Self-Reported Obesity Among Indiana Adults by County, BRFSS, 2013
In 2013, two states have surpassed the 35% mark for their obesity rate. Thankfully, Indiana is not there yet. Here you’ll see here a breakdown of obesity rates by county in Indiana. I’ll give you a second to find your county and see how you fall on the spectrum.
*Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before 2011.

24. How do we even start…?
“…USPSTF review [sic] concluded that all adults should be screened for obesity and those with obesity should be offered intensive behavioral counseling to promote sustained weight loss.”
USPSTF based this decision on a systematic review that concluded that behavioral interventions for weight loss were safe and effective, generally leading to 4-7kg of weight loss after one year with sessions of counseling. The review suggested that patients that received quarterly counseling from their physician lost a little weight. Less than a kg. Those that received counseling from counseling from their physician, PLUS office support for the delivery intervention was the only group that showed significant difference from the control intervention.
On average, these primary care based interventions do not produce clinically significant weight loss (≥5%). This may be because the interventions used were still relatively low to moderate intensity, with a frequency of contacts ranging from one per six months to 1.5 per month. What does work? Interventions such as Diabetes Prevention Program.
Bottom line: the role of the primary care office is to inform, start the conversation and encourage the achievement of a healthy life style.

25. How CHWs Can Help Reduce Obesity in Indiana
Use Brief Action Planning with your patients to help them build self confidence and self efficacy to help them lose weight

26. What is Brief Action Planning?
Brief Action Planning is a highly structured, stepped-care, self-management support technique grounded in the principles and practice of Motivational Interviewing and behavior change theory and research (Gutnick et al 2014)

27. What is Brief Action Planning?
Brief Action Planning is a structured way of interacting with individuals interested in making a concrete action plan for some aspect of their health.
It is based on the principles and practice of Motivational Interviewing and is supported by evidence from behavioral science and self-management support.
The core skills of Brief Action Planning can be learned by anyone interested in supporting others to make change.

28. The Spirit of Motivational Interviewing
The Spirit of Motivational Interviewing underlies Brief Action Planning
1. Compassion: Actively promote the other’s welfare.
2. Acceptance: Respect autonomy and the right to change or not change.
3. Partnership: Work in collaboration.
4. Evocation: Ideas come from the person, not the clinician or helper.

29. “Is there anything you would like to do for your health in the next week or two?”
Have an idea?
Not sure?
Behavioral Menu
Not at this time
Permission to check next time
SMART Behavioral Plan
Specific
Measureable
Achievable
Relevant
Timely
1) Ask permission to share ideas.
2) Share 2-3 ideas.
3) Ask if any of these ideas or something else might work.
Elicit a Commitment Statement
“How confident (on a scale from 0 to 10) do you feel about carrying out your plan?”
Confidence ≥7
Confidence <7,
Problem Solving
“Would you like to set a specific time to check back in with me so we can review how things have been going with the plan?”
Follow-up

30. Follow-up “How did it go with your plan?”
Success
Partial success
Did not try or no success
Recognize success
Recognize partial success
Reassure that this is common occurrence
A stepped response to three possible results of an action plan: success, partial success, or did not try/no success.
For those who experienced success, affirm success: “You really made that happen.” “You followed through on your plan.” (for example) and see if they want to continue their plan, add to it or make a new plan.
Partial success: if they felt successful, it’s the same thing as completing the whole plan, so continue as with success. If they didn’t feel successful, affirm what they did accomplish: “Trying it once shows willingness. What did you learn?”
The goal is to help people turn any “failures” into lessons learned so that they can make a SMARTer plan and achieve success to build confidence.
“What would you like to do next?”

31. Reduce Indiana’s Smoking Rate

32. Smoking Burden in Indiana
11,100 deaths/annually
Nearly 1 in 4 adults smoke (22%-2013)
For every death, two new youth start and 30 are living with a chronic disease

33. Smoking Burden in Indiana
$2.08 billion in annual health care costs
$487 million in Medicaid costs
Indiana taxpayers pay $566 per household to treat tobacco-related disease
For every pack of cigarettes sold in Indiana, it spends $15.90 in health care costs related to tobacco

34. How CHWs Can Help Reduce Smoking in Indiana
Refer smokers who want to quit in the next days to the Indiana Tobacco Quitline

35. Indiana Tobacco Quitline
The Indiana Tobacco Quitline is a free cessation counseling service that helps Indiana smokers quit tobacco.
This phone-based one-on-one coaching offers tobacco users who have decided to quit help through the process to quit for life.

36. What is a Quitline? Telephone-based Cessation Services
Offered Toll-free
Evidence-based
Proactive
Coaches
Highly trained in cognitive behavioral therapy
240 hours of training
Spanish speaking competency (170 other languages)
Educated up to graduate level
Over 50% with 3+ years prior experience in counseling

37. The Program 4 prearranged calls w/coach
10 prearranged calls for pregnant woman (special program)
5 prearranged calls for youth
Unlimited Web coaching
Unlimited call in privileges and access to coaches
Free 2-week NRT starter kit (uninsured, Medicaid,Medicare)
Stage-based Support Material

38. The Program Works Practices based on 25 yrs of research helped hundreds of thousands of smokers quit & stay quit
Quit at personal pace
Conquer urges to smoke
Use Pharmacology if necessary
Don’t just Quit,
become NON-SMOKER
Choose own Quit Date, personal Quit Coach help prepare & get ready
Learn when & where urges strike & how to cope & manage stress w/o smoking
Recommend meds if necessary and teach how to use correctly
QUIT for good- support to make this the LAST Quit, help with weight issues

39. Indiana Tobacco Quitline
Served over
100,000
Hoosiers
since its
launch in 2006

40. Brief Intervention
ASK Do you use tobacco? ADVISE Quit tobacco products! REFER QUIT-NOW

41. Resources Infant Mortality Smoking
Labor of Love
Smoking
Quit Now Indiana

42. Resources
Obesity
Brief Action Planning
Indiana Healthy Weight Initiative
INShape Indiana

43. Contact Information
Chris Maxey

44. Questions