IMPROVING AND TEACHING POPULATION HEALTH June 19, 2014 webinar AAMC / CDC / Duke collaboration

J. Lloyd Michener, MD Professor and Chair Department of Community and Family Medicine Director, Duke Center for Community Research Mina Silberberg, Ph.D. Associate Professor Vice-Chief for Research and Evaluation Division of Community Health Alisa Nagler, JD, EdD Assistant Dean, Graduate Medical Education Assistant Professor, Practice of Medical Education Gwen Murphy, RD, MS, PhD Assistant Consulting Professor Division of Community Health Department of Community and Family Medicine

Population Health: the health outcomes of a group of individuals, including the distribution of such outcomes within the group. Source: Kindig D, Stoddart G. What is Population Health? Am J of Public Health. 2003; 93(3): The Goal: “from Health Care to Health”

IMPROVING POPULATION HEALTH – In one sentence: Know the burden of preventable illness in your community, and partner with community practices and agencies to prevent these illnesses

Source: The Quality of Medical Care in the United States: A Report on the Medicare Program. The Dartmouth Atlas of Health Care The Center for the Evaluative Clinical Sciences Dartmouth Medical School Disease Burden / Practice Patterns Vary

Change In Female Mortality Rates From 1992–96 To 2002–06 In US Counties. Kindig D A, and Cheng E R Health Aff 2013;32: ©2013 by Project HOPE - The People-to-People Health Foundation, Inc.

Durham residents with diabetes ( ) 14,345 unique patients 8.7% of all patients >20 yo 14.3% of all patients >40 yo Durham County Stats (per CDC): 2008 ~ 10% of adults diagnosed with diabetes North Carolina (CDC): 2008 ~ 9% of adults diagnosed with diabetes By Race: 8.4% White 15.6% AA 12.4% NA 4.5% Hispanic 4.3% Other

w ww.iom.edu/primarycarepublichealth Degrees of Integration:

What is integration? The Institute of Medicine defines integration as ‘the linkage of programs and activities to promote overall efficiency and effectiveness and to achieve gains in population health.’  Principles of Integration:  Shared goal of population health  Aligned leadership  Community engagement  Sustainability  Collaborative use of data

Why integrate now? Call to Action – IOM Report – Affordable Care Act – New Funding Opportunities Changes in Health Care – Rise in Health Care Costs – Disturbing Health Trends – Increase in Health Research and Data – Impact of Social Determinants of Health – Drive to PCMHs and ACOs – Availability of Electronic Health Records

Just For Us What can integration do?

Just For Us

Percent Difference Between Medicaid Recipients Enrolled in CCNC and Those Not Enrolled in CCNC, for Rates of Asthma-Related Emergency Department Visits and Inpatient Admissions, 2008–2012 Note. CCNC, Community Care of North Carolina. NCMJ September/October 2013, Volume 74, Number 5

What is the Practical Playbook? A cornerstone of the next transformation of health, in which primary care and public health groups work collaboratively to achieve population health improvement.

National Advisory Committee American Academy of Family Physicians American Academy of Pediatrics American Association of Colleges of Osteopathic Medicine American Board of Family Medicine American College of Physicians American College of Preventive Medicine American Heart Association Association of Academic Health Centers Association of American Medical Colleges Association of Public Health Nurses Association of State and Territorial Health Officials Centers for Disease Control & Prevention Centers for Medicare & Medicaid Services Council of State and Territorial Epidemiologists Eastern Virginia Medical School Geisinger Health System Health Resources and Services Administration Kaiser Permanente Los Angeles County Health Department Multnomah County Health Department, Oregon New York City Health Department Pennsylvania Health Department University of California San Francisco University of Utah

Practical Playbook Overview

MASSACHUSETTS IMPROVES QUALITY OF LIFE FOR CHILDREN WITH ASTHMA The Community Asthma Initiative works to improve the health and quality of life for children with asthma.Community Asthma Initiative Boston Children’s Hospital designed the program to focus on medical interventions rather than environmental influences. Since its establishment, the program has worked in tandem with partners at every level, including the individual, family, and larger community. As a result, the Community Asthma Initiative helped reduce the percent of emergency department visits by 58 percent, the number of asthma-related hospitalizations, the number of school absences for children, and the number of work absences for their parents. CAI helped reduce the number of asthma-related hospitalizations by 80 percent. Massachusetts Improves Quality of Life for Children with Asthma

Maryland Prevents One Million Heart Attacks and Strokes The Maryland Million Hearts Initiative is part of a national campaign to prevent one million heart attacks and strokes by 2017.Maryland Million Hearts Initiative The statewide initiative is a partnership between the Department of Health and Mental Hygiene and local communities, health systems, nonprofit organizations, federal agencies and private-sector businesses. Since the program began, the state has seen an increase in blood pressure control at participating centers. The program has seen a 27 percent increase in blood pressure control at participating centers.

Next steps – define what clinicians need to know and do in and with the community

The Population Health Competency Map Training Levels: 1. Foundational — Basic awareness of the principles and appreciation for their impact and importance in community health. 2. Applied — An intermediate level of learning, enabling skilled participation in community-engaged population health activities. 3. Proficient — Advanced learners who achieve competence for independent practice or leadership of the design and implementation of community-engaged health improvement activities. Competencies Public Health Community Engagement Critical Thinking Team Skills

Learners:medical PA,FMnurseFM PT studentsresidentsleadersfaculty Competency: Public HealthF P Community EngagementF P Critical ThinkingF P Team SkillsF P F = Foundational (Basic) Awareness A = Applied (Intermediate) Skilled participation P = Proficient (Advanced) Independent practice Competency Map: Integrating Population Health into Clinician Education

Training levelsBasicIntermediateAdvanced Learner types All students & residents Primary care residents CFM faculty Population Health Fellows & Faculty CH faculty Apply strategies that improve the health of populations Discuss potential population- based interventions to improve health Identify appropriate preventive strategies for a population, based upon literature, data assessment and stakeholder input  Develop and implement population- based prevention strategies in collaboration with community partners Learning Method Project: design an intervention Evaluation Assess intervention Population Health Curriculum

CDC/AAMC/Duke Project on Population Heath Convene primary care programs that are interested in improving population health training of residents. Identify training materials that are already available for medical students and residents, and develop a library of resources. Map training materials to the GME milestones using current GME population health milestones and program requirements for primary care.

Mina Silberberg, Ph.D. Associate Professor Vice-Chief for Research and Evaluation Division of Community Health IMPROVING AND TEACHING POPULATION HEALTH…

Readings or electronic modules followed by small group discussions or group exercises Community site visits Community health education Participation in local Healthy Carolinians coalition Integrated psychosocial/clinical patient assessment Projects –QI, community engagement, written and oral reports Participation in population health management innovations Work with data Shadowing care managers

Population Health Curriculum evaluation methods Discussion participation Project completion Final assessment Post-graduation activity Real test – health improvement in home communities

Population Health Curriculum – Faculty Development

Population Health Curriculum The result: Clinicians who can care for their patients in the context of their communities

IMPROVING AND TEACHING POPULATION HEALTH… Alisa Nagler, JD, EdD Assistant Dean, Graduate Medical Education Assistant Professor, Practice of Medical Education

ACGME Milestones Component of Next Accreditation System Organized under 6 domains of clinical competency 1.Patient Care 2.Medical Knowledge 3.Professionalism 4.Interpersonal Communication Skills 5.Systems Based Practice 6.Practice Based Learning Provide framework and shared language to describe learner expectations and progress Population Health Milestones??

ACGME Milestones Example 1.Review of published milestones for population health related content 2.Development of generic Population Health Milestones for GME Program adoption 3.Linking of existing resources to Population Health Milestones to support Programs with teaching and evaluation

ACGME Milestones Example Sub-competency General Competency Developmental Progression not linked to training level “Aspiration” or last level may NOT be achieved by graduating residents OR faculty! Milestone Documentation of evaluation of resident performance Mid-range evaluation indicates trainee has met some but NOT all of the expectations of the more advanced Milestone

ACGME Clinical Learning Environment (CLER) Review Component of Next Accreditation System 6 focus areas: 1.Patient Safety 2.Quality Improvement 3.Transitions of Care 4.Supervision 5.Duty Hours Oversight, Fatigue Management & Mitigation 6.Professionalism

ACGME Clinical Learning Environment (CLER) Review Component of Next Accreditation System 6 focus areas: 1.Patient Safety 2.Quality Improvement 3.Transitions of Care 4.Supervision 5.Duty Hours Oversight, Fatigue Management & Mitigation 6.Professionalism “Including how sponsoring institutions engage residents in the use of data to improve systems of care, reduce health care disparities and improve patient outcomes.” creditation/NextAccreditationSystem/ClinicalLearningEnvironmentR eviewProgram.aspx

BACK TO LLOYD FOR FINAL HOUSEKEEPING ITEMS

Next steps : 1)Share contact info 2)Volunteers for institutional presentations 3)Program evaluation 4)Other? address: Resources - Department of Community and Family Medicine webinar and slides posted here:

Milestones webinar schedule June 3 rd Tuesday 2:30pm EST repeated June 19 th Thursday 3:30pm EST July 1 st Tuesday 10am EST repeatedJuly 15 th Tuesday 9am EST August 5 th Tuesday 9am EST repeatedAugust 12 th Tuesday 9am EST September 9 th Tuesday 10am EST repeatedSeptember 16 th Tuesday 3pm EST October 8 th Wednesday 3pm EST repeatedOctober 14 th Tuesday 9am EST

AAMC-CDC Cooperative Agreement Webinar Series To promote increased public health awareness and encourage inclusion of public health perspectives throughout the AAMC community Inclusion and Integration of Population Health into Undergraduate Medical Curriculum June 26, 2014, 1:00 p.m. - 2:00 p.m. ET cdc/362178/webinarseries.html