Nicole Alexander-Scott, MD, MPH Director, Rhode Island Department of Health President, Association of State and Territorial Health Officials December 6, 2018

The Rhode Island Department of Health (RIDOH)’s Strategic Priorities Outline The Rhode Island Department of Health (RIDOH)’s Strategic Priorities Two approaches to shift investments and promote health equity: Clinic-to-community investments Direct community investments 2019 ASTHO President’s Challenge

Life Expectancy vs. Healthcare Spending (1970-2014)

Investing in Social Services and Community In OECD, for every $1 spent on health care, about $2 is spent on public health and social services. In the US, for every $1 spent on health care, about 55 cents is spent on public health and social services.

The Case for Investing at the Community Level Determinants of Health Model based on frameworks developed by: Tarlov AR. Ann N Y Acad Sci 1999; 896: 281-93; and Kindig D, Asada Y, Booske B. JAMA 2008; 299(17): 2081-2083.

Address the Socioeconomic and Environmental Determinants of RHODE ISLAND STATEWIDE INTEGRATED POPULATION HEALTH LEADING PRIORITIES, STRATEGIES, AND GOALS Three Leading Priorities Guide Our Work Eliminate the Disparities of Health in Rhode Island and Promote Health Equity Ensure Access to Quality Health Services for Rhode Islanders, Including Our Vulnerable Populations Address the Socioeconomic and Environmental Determinants of Health in Rhode Island Five Strategies Will Move Us Forward 23 Integrated Population Health Goals and Metrics Align with Statewide Healthcare Planning

The Rhode Island Department of Health (RIDOH)’s Strategic Priorities Outline The Rhode Island Department of Health (RIDOH)’s Strategic Priorities Two approaches to shift investments and promote health equity: Clinic-to-community investments Direct community investments 2019 ASTHO President’s Challenge

Community Health Workers Hired for their understanding of the populations they serve (rather than just from expertise due to formal education). Examples include: Chronic disease case managers Substance use disorder peer recovery coaches Bi-lingual health systems navigators Public Housing Resident Coordinators

Community-Based Licensed Health Professionals Community Health Workers Important Workforce Distinction Community-Based Licensed Health Professionals Licensed Health Professional May or may not obtain additional certification Travels out to the patient’s home or community Focuses on clinical education tailored to the recipient Community Health Workers No previous health professional license Obtains CHW certification Focuses on helping to navigate social services

Community Health Workers CHW Certification Credentialing RIDOH and community partners, include Rhode Island College, established a Community Health Worker certification credential through the RI Certification Board Community Health Worker Certified Community Health Worker Certified Specialty Community Health Worker Community Health Worker Association of Rhode Island Re-established as a pathway for professional advancement Next Steps Continue to develop payment opportunities for a CHW workforce pipeline in the health system

ROI with Community Health Workers in RI Home Asthma Response Program After a child visits the ED for asthma, three home visits assess home environment, remove/mitigate triggers, educate caregivers on medications and environmental control options. Certified Asthma Educators and CHWs ensure caregiver understands how to obtain and use medications and/or devices, thus enhancing compliance with physician Asthma Action Plan. For families who don’t have an Action Plan, the Asthma Educator does outreach to get one from the primary care provider and reviews it with the caregiver.

ROI with Community Health Workers in RI Received actual claims from three insurers (N=158 eligible cases with claims for analysis) 75% reduction in overall costs 80% reduction in costs for high utilizers 92% reduction in asthma-related hospital and ED costs

Transforming Practices with CHWs

System Transformation Premise

System Transformation Strategies

Transforming Practices with CHWs

The Rhode Island Department of Health (RIDOH)’s Strategic Priorities Outline The Rhode Island Department of Health (RIDOH)’s Strategic Priorities Two approaches to shift investments and promote health equity: Clinic-to-community investments Direct community investments 2019 ASTHO President’s Challenge

Rhode Island Department of Health (RIDOH) Health Equity Zones Nine local collaboratives that represents the diverse strengths of the community. Equip residents and partners to collaborate to create healthy places for people to live, learn, work, and play. Innovative, community-led, place- based approach to building the infrastructure needed for sustained systems and policy change. Health Equity Zones

RIDOH Health Equity Zones: Public Health Principles in Action Organize a collaborative of diverse partners from the community’s self-defined zone, ranging in size from a neighborhood to a county. Conduct a baseline needs assessment of socioeconomic and environmental factors that drive health outcomes for better living. Create a Plan of Action targeting measurable objectives based on effective strategies shown to be successful. Implement and evaluate the Plan of Action.

RIDOH Health Equity Zones: Policy Change in Action Rhode Island Health Equity Zones have: Facilitated the passage and implementation of a town-wide ordinance banning cigarettes and vaping in parks. Partnered with the city planning department to develop a Complete and Green Streets ordinance enabling safe access to community roads for all users, regardless of age, ability or mode of transportation.

Hospital Community Health Needs Assessments Through the State’s Hospital Conversions Act, Rhode Island has required some health systems to: Invest in their local Health Equity Zones as a condition for approving applications for certain changes. Collaborate with their local Health Equity Zones when conducting needs assessments to fulfill Patient Protection and Affordable Care Act community benefit requirements.

The Rhode Island Department of Health (RIDOH)’s Strategic Priorities Outline The Rhode Island Department of Health (RIDOH)’s Strategic Priorities Two approaches to shift investments and promote health equity: Clinic-to-community investments Direct community investments 2019 ASTHO President’s Challenge

Aligned with the National Association of County and City Health Officials (NACCHO) and the U.S. Surgeon General’s focus on community health and economic prosperity Calls on health officials to change how we work with communities and who our partners should be – to support investments in community 2019 ASTHO President’s Challenge: Building Healthy and Resilient Communities Governmental public health has an important role to play in changing our mindset about how we should work with communities and who our partners should be.

1. Provide tools that equip health officials to mobilize community-led, place-based models (like RI’s HEZ) that are ready for investment. 2. Connect public health officials by reaching across sectors to business leaders and policymakers who want to invest in community and advance economic development. Two Goals Calls on health officials to establish or scale up community-led, place-based initiatives like Rhode Island’s Health Equity Zones. Strengthens efforts to promote positive social connectedness and community resilience.

Additional Highlights of the ASTHO President’s Challenge: “The opposite of addiction isn’t only sobriety. It’s connectedness.” - Jonathan Goyer Expert Advisor to the RI Governor’s Overdose Prevention and Intervention Task Force Promote Positive Social Connectivity: so communities can combat issues such as substance use disorders, emotional suffering, and social isolation. Improve Community Resilience: so communities can resist, respond to, and recover from adversity and “bounce forward” to better conditions, like fewer adverse childhood experiences and eliminating HIV or Hep C.

To reverse the life expectancy trend, we can keep moving from “talk” to action by working together to achieve the goals of the President’s Challenge: By shifting investments to support ready-made opportunities at the community level By engaging diverse partners to call for community development that does not cause community displacement. Our Role Has an important role to play in changing our mindset about how we should work with communities and who our partners should be. Together, we can implement both President’s Challenge goals by: Supporting outcome-driven, community-led, place-based collectives Attracting diverse investments from business leaders and policymakers who can help communities transform conditions for better living long-term. Strengthens efforts to promote positive social connectedness and community resilience.

Nicole Alexander-Scott, MD, MPH Director, Rhode Island Department of Health President, Association of State and Territorial Health Officials Nicole.AlexanderScott@health.ri.gov