Connecting Public Health and Medicine through Prevention: The SPARC Program Sickness Prevention Achieved through Regional Collaboration Doug Shenson, MD MPH Austin, TX June 15, 2010

THE RIGHT TOOLS FOR COMMUNITY-WIDE PREVENTION

Echocardiography Flu Vaccination Dementia Screening Pneumococcal Vaccine Mammogram Colorectal cancer Screening Pap Test Thyroid Disease screening Hepatitis B Vaccine STD Screening PPD test EKG Blood Pressure Screening HIV screening Downs Syndrome Screening Carotid artery stenosis Screening Cholesterol Screening Glaucoma Screening Skin Cancer Screening Prostate cancer Screening Diabetes Screening Lung cancer Screening Osteoporosis Screening Pregnancy Screening Abdominal Aortic aneurysm Screening PKU Screening

Clinical Preventive Services Flu Shots Flu Shots Pneumococcal immunization Pneumococcal immunization Mammography Mammography Pap Test Pap Test Colorectal cancer screening Colorectal cancer screening Hypertension screening Cholesterol screening Tetanus immunization Adolescent immunizations Child immunizations

HOW WELL ARE WE DOING?

Estimated Percentage Of U.S. Adults Aged >65 Up-to-date On Routine Clinical Preventive Services. 1997, 2002, 2004 Behavioral Risk Factor Surveillance System. Am J Prev Med 2007;32(1)

Estimated Percentage Of U.S. Adults Aged Up-to-date On Routine Clinical Preventive Services. 1997, 2002, 2004, 2006 Behavioral Risk Factor Surveillance System.

Adults and Infants Up-to-Date with Clinical Preventive Services (2006 BRFSS)

THE CURRENT STRATEGY

10 Patient Pulmonologist Cardiologist Low Community- wide Preventive Service Delivery Rate Patient Diffuse Responsibility: Primary Care Clinician Obstetrician / Gynecologist Gastroenterologist Geriatrician

Patient Primary Care Clinician Current Preventive Service Delivery Rates Patient Acute Care Visits

Adults Age >65 Up-to-date with CPS Insurance Status, Provider status, and Recent Checkup (2006 BRFSS)

THE CHALLENGE WE FACE

14 Obstacles to Preventive Service Delivery We Know About: Clinicians Poor office reminder and flagging systems Poor office reminder and flagging systems Disease prevention a lower priority Disease prevention a lower priority Doctors not aware of changing guidelines Doctors not aware of changing guidelines Low insurance reimbursement rates Low insurance reimbursement rates

15 Obstacles to Preventive Service Delivery We Know About: Patients Patients not aware of health benefits Patients not aware of health benefits Patient focused exclusively on treatment Patient focused exclusively on treatment Patient not aware that insurance covers preventive care Patient not aware that insurance covers preventive care

Patient Community Resident Primary Care Clinician Patient Primary Care Clinician Community-wide Preventive Service Delivery Community Resident Community Perspective

SPARC: Program Rationale and System Critique Currently no responsible local agency for population-wide provision of clinical preventive services Currently no responsible local agency for population-wide provision of clinical preventive services Currently no local accountability Currently no local accountability Currently no coordination of delivery Currently no coordination of delivery Clinical preventive services falls between the cracks of medicine and public health Clinical preventive services falls between the cracks of medicine and public health

DEVELOPING A FRESH STRATEGY

Patient Clinician Office System Community Resident New Community Access Point Increase Supply of CPS Increase Demand for CPS Higher Community-wide Delivery Population-Wide Perspective Accountable Agency (SPARC) Data

Build local collaborations of prevention service stakeholders Visiting nursing agencies Visiting nursing agencies Elder services Elder services Public health agencies Public health agencies Churches and synagogues Churches and synagogues Hospitals Public schools Medical practices Community centers

Elements of Success Establish a SPARC Steering Committee Establish a SPARC Steering Committee Selection of one or more geographically-bounded communities Selection of one or more geographically-bounded communities Selection of community (non-clinical) sites Selection of community (non-clinical) sites Selection of clinical preventive services to be delivered Plan community-base activities Plan evaluation strategy Develop information links back to the medical home

Outcomes Assessment Reach (inclusions and exclusions) Reach (inclusions and exclusions) Efficacy (meeting outcomes goals) Efficacy (meeting outcomes goals) Adoption assessment Adoption assessment Implementation assessment Maintenance assessment

BUILDING THE RIGHT TACTICAL APPROACH: EXAMPLES OF PROJECTS

Percent Change in Pneumococcal Immunization Rates, Connecticut Counties 1997 HCFA Reimbursement Claims

Bundling Preventive Services: Vaccinations and Cancer Screening Can mammography rates be improved by facilitating breast cancer screening at community-based flu clinics?

SPARC VNA DPH MD RAD PLANNING Mamm. Scheduling Radiology Dept. Community Flu Clinics Medical Home Residents Data

Mammography rates, Litchfield County, CT, women age >65. Am J Prev Med 2001;20(2).

Offering Annual Fecal Occult Blood Tests at Annual Flu Shot Clinics Increases Colorectal Cancer Screening Rates Michael B. Potter, MD 1, La Phengrasamy, MPH 1, Esther S. Hudes, PhD, MPH 2, Stephen J. McPhee, MD 3 and Judith M.E. Walsh, MD, MPH 2,3 1 Department of Family and Community Medicine, University of California San Francisco, San Francisco, California 2 Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California 3 Department of Medicine, University of California, San Francisco, San Francisco, California CORRESPONDING AUTHOR: Michael B. Potter, MD Department of Family and Community Medicine Box 0900, UCSF, San Francisco, CA

Why Vote & Vax? More than 126 million Americans vote in national elections. More than 126 million Americans vote in national elections. Approximately 70% the voters are over age 50. Approximately 70% the voters are over age 50. Fewer than 40% of adults ages receive an annual flu shot. Fewer than 40% of adults ages receive an annual flu shot.

Why Polling Places? They attract residents from all communities. They attract residents from all communities. They are mandated to be maximally accessible. They are mandated to be maximally accessible. They are widely distributed throughout all communities. They are widely distributed throughout all communities. There are 186,000 of them There are 186,000 of them

Vote & Vax Guidelines Permission from Local Election Authority Permission from Local Election Authority Not Just for Voters Not Just for Voters Charge for Vaccine as Usual Charge for Vaccine as Usual For All Communities For All Communities

Vote & Vax National Collaborators AARP American Public Health Association (APHA) Association of Immunization Managers (AIM) Association of State and Territorial Health Officials (ASTHO) Immunization Coalitions Technical Assistance Network (IZTA) National Association of Area Agencies on Aging (n4a) National Association of Chronic Disease Directors (NACDD) National Association of County and City Health Officials (NACCHO) National Association of State Units on Aging (NASUA) Visiting Nurse Associations of America (VNAA)

How Did We Do in 2008? Vote & Vax clinics delivered 21,434 flu vaccinations at 331 locations in 42 states plus the District of Columbia.

Vote & Vax: A Nationwide Success

We hit the most important targets… 67% were in CDC priority groups.

We reached new populations… 48 % were irregular or unlikely flu shot recipients – that is, they did not receive a shot last year or would not have otherwise received one this year. 48 % were irregular or unlikely flu shot recipients – that is, they did not receive a shot last year or would not have otherwise received one this year. 52% were regular flu shot recipients. 52% were regular flu shot recipients.

Including underserved populations… Percent irregular and unlikely flu shot recipients: 60% among African-Americans 65% among Hispanics 71% among uninsured

SUMMING UP

The SPARC Program Community-based program focused on expanding prevention across entire population Community-based program focused on expanding prevention across entire population Emphasis on primary and secondary prevention of major chronic diseases (USPSTF A or B) Emphasis on primary and secondary prevention of major chronic diseases (USPSTF A or B) Builds community-wide accountability for better access to preventive services Builds community-wide accountability for better access to preventive services Vehicle for public health & healthcare integration Vehicle for public health & healthcare integration

Tools and Assistance Project manuals and research findings Project manuals and research findings SPARC presentations SPARC presentations Conference Calls Conference Calls Technical Assistance Site Visits SPARC Action Guide

Lessons Learned Ambition Ambition Systems Systems Sustainability Sustainability Allies Creativity

Leading SPARC Funders National AARP CDC Healthy Aging Program CDC National Immunization Program HRSA Local Initiatives Funding Partners Program of RWJF Pfizer Foundation Robert Wood Johnson Foundation (RWJF) Regional and Local Atlanta Regional Commission Berkshire Taconic Community Foundation Jessie B. Cox Trust Patrick and Catherine Donaghue Foundation QIOs of CT, MA, NY Seth Sprague Foundation Weinberg Foundation