1. Diabetes Measures in EHRs Linked to Improved Care
Omar A. Contreras, MPH
Diabetes Prevention and Control Program
Arizona Department of Health Services
June 27, 2014

2. What does What does medicine do? public health do?
Saves lives one at a time Saves lives millions at a time
Public health touches EVERY individual, EVERY day.
Addressing the cause of death and emergencies cannot be done one person at a time.
Population-based public health means strategy is needed.

3. Essential Services of Public Health
Monitor health status
Diagnose and investigate
Inform, educate, and empower
Mobilize community partnerships
Develop policies and plans
Enforce laws and regulations
Link people to needed services/assure care
Assure a competent workforce
Evaluate health services
Research
The last part of the Public Health in America statement that defined public health also defines the “Essential Services of Public Health.” The ten essential services are shown here.
Monitor health status to identify and solve community health problems
Diagnose and investigate health problems and health hazards in the community
Inform, educate, and empower people about health issues
Mobilize community partnerships to identify and solve health problems
Develop policies and plans that support individual and community health efforts
Enforce laws and regulations that protect health and ensure safety
Link people to needed personal health services and assure the provision of health care when otherwise unavailable
Assure a competent public and personal healthcare workforce
Evaluate effectiveness, accessibility, and quality of personal and population-based health services
Research for new insights and innovative solutions to health problems
Source of Ten Essential Public Health Services: Core Public Health Functions Steering Committee, 1994

4. Framework for Improving the Performance of Public Health
Department +
PH System
Community
Partners
Workforce
Operational
Capacity
(Infrastructure)
Every
Community
Program and
Public Health
Activity
(Chronic Disease,
Inf. Disease, EH)
Better Health
Outcomes
Reduced
Disparities
Better
Preparedness
Which
leads to
Builds
Impacts
So how does this all fit together?
<1> Investments in the health department and the public health system by community partners and funders, including developing the workforce,
<2> builds operational infrastructure and capacity.
<3> This capacity impacts all community programs and public health activities, and
<4> leads to better health outcomes, reduced disparities, and better preparedness to meet public health challenges.
The National Public Health Performance Standards and the accreditation program are ways to identify what investments are needed in public health, and the National Public Health Improvement Initiative is a way of building operational capacity to address those needs.
<5> Investments in the three core functions of public health, directed by a PHSSR (Public Health Services and Systems Research) research agenda, lead to big dividends in public health outcomes over the long term.
Investments here
Pay big dividends here
Source: D. Lenaway. Centers for Disease Control and Prevention, Office of Chief of Public Health Practice (unpublished)

5. Governmental Public Health
State and Local Health Departments
Retain the primary responsibility for health under the US Constitution
State and the District of Columbia Health Departments
51**
Tribal Health Departments
Local Health Departments
2,565*
Territorial Health Departments
8**
Naccho-National association of city and county health officials.
* Number based on 2010 National Profile of Local Health Departments (NACCHO, 2011)
** Numbers cited from ASTHO, Profile of State Public Health, Volume Two, 2011

6. 51** 8** 2,565* State and the District of Columbia Health Departments
Territorial Health Departments
8**
Federally Qualified Health Centers
Local Health Departments
2,565*
Tribal Health Departments
Naccho-National association of city and county health officials.

7. Outline Arizona Department of Health Services/Arizona Diabetes Program
Diabetes in Arizona
Epidemiology and Surveillance
Trends and Cost Analyses
The Arizona Diabetes Coalition
Diabetes measures and systems change
Public Health in Action Grant
EHR and non-physician team base approach to diabetes care
Summary

8. Arizona Department of Health Services Hierarchy
Office of Chronic Disease Programs
Bureau of Tobacco and Chronic Diseases
Division of Public Health Prevention Services
Arizona Department of Health Services
Agency Director
Assistant Director
Bureau Chief
Diabetes
Arizona Diabetes Coalition and Leadership Council
Heart Disease and Stroke
Healthy Aging
CPR
CHW
Arizona Department of Health Services
Hierarchy

9. Arizona Diabetes Program
What we do and what we provide?
Ongoing technical assistance to internal and external partners
Information and guidance on funding resources
Develop diabetes specific strategies and public health interventions at a systematic, policy, and environmental levels
Supports and oversees the activities Arizona Diabetes Coalition and Leadership Council

10. Diabetes in Arizona

11. Leading causes of death in the United States for 2011
Leading Death
Death rate per 100,000
1. Heart disease
191.4
2. Cancers
184.6
3. Chronic lung diseases
46.0
4. Strokes
41.4
5. Accidents
39.4
6. Alzheimer’s disease
27.2
7. Diabetes mellitus
23.5
8. Pneumonia and influenza
17.2
9. Kidney diseases
14.7
10. Suicides
12.3
Rates are age adjusted per 100,000 to the US population in the year 2000 according to the US. Census
Source: National Center for Health Statistics,

12. Diabetes in Arizona 1/9 Arizonans have diabetes
1/3 of those who have diabetes in Arizona are unaware that they have it
Diabetes is the leading cause of new cases of blindness and kidney failure
Known risk factors
Obesity
Physical inactivity or increase in sedentary lifestyle
Built environment
2010 age-adjusted obesity in the general population in Arizona
Mention:
According to the 2011 Behavioral Risk Factor Surveillance System (BRFSS), 7.8% of Arizonans are reported as having prediabetes and 9.5% reported having type 2 diabetes.
1/3 of Arizonans are unaware they have diabetes; approximately 600,000 individuals.

13. How do rate by county? County* Diabetes Arizona Hypertension** Obesity
Apache
8.0%
10.6%
17.5%
28.1%
25.1%
26.0%
Cochise
15.7%
44.4%
27.4%
Coconino
13.3%
17.2%
22.3%
Gila
15.6%
28.8%
Graham
17.0%
27.5%
34.5%
Greenlee
15.9%
27.0%
34.3%
La Paz
16.0%
34.8%
32.0%
Maricopa
10.0%
26.5%
Mohave
14.6%
38.2%
29.4%
Navajo
12.1%
31.1%
Pima
12.2%
25.6%
23.5%
Pinal
14.4%
35.7%
25.7%
Santa Cruz
10.3%
33.7%
Yavapai
38.5%
33.8%
Yuma
11.8%
40.8%
28.6%
*Source: Arizona Behavioral Risk Factor Surveillance System, (AZ-BRFSS, 2013)
** 2011 Numbers shown as 2012 data not available

14. Arizona Adults with Diabetes by Race/Ethnicity, 2012
Prevalence (%)
Source: AZ Health Matters (2012), AZ BRFSS

15. Arizona Age-adjusted Death Rate due to Diabetes, by Gender (2012)
Source: AZ Health Matters (2012), AZ BRFSS

16. Arizona Age-adjusted Death Rate due to Diabetes, by Race/Ethnicity (2012)
Rate per 100,000 population
Source: AZ Health Matters (2012), AZ BRFSS

18. Estimated Costs of Diabetes, 2007 Estimated Costs of Diabetes, 2012
Total
$174 billion
Direct medical costs
$116 billion
Indirect medical costs
$58 billion
Estimated Costs of Diabetes, 2012
Total
$245 billion
Direct medical costs
$176 billion
Indirect medical costs
$69 billion
Hospital readmission= poor quality of care.
-The estimated diabetes costs, including
both direct and indirect costs totals $174
billion
-Indirect costs include disability, work loss,
premature mortality
-Medical expenses for people with diabetes
are two times higher than people without
diabetes
Electronic health records- provide better management for diabetes, triggers providers for immediate action to manage the care of diabetes.
Health information exchange-to better manage care of chronic diseases and holds great promise in chronic disease
Management
-Provides important clinical information
about the patient when and where needed
-Enhances greater care coordination and
clinical decision support at the point of
Care
-Better measurement and improvement
Source: retrieved 11/25/2013

19. Estimated costs AZ, cont.
Parameter
Treated Population
Cost per Person
Total Costs (2010)
Adjusted to 2013
All Payers
416,200
$5,420
$2,258,000,000
$2,412,300,000
MEDICAID
81,800
$3,750
$307,000,000
$327,980,000
MEDICARE
168,100
$3,580
$602,000,000
$643,140,000
Private Insurers
236,500
$2,580
$610,000,000
$651,680,000
2011 Arizona Hospital Discharge Data indicated a total of 7,065 discharges related to diabetes and chronic conditions.
$167,815,464
Arizona Diabetes Cost Data (2010) – CDC Chronic Disease Cost Calculator

20. Arizona Diabetes Coalition
Purpose of the coalition: To reduce the burden of diabetes on individuals, families, communities, the health care system, and the State.
This shall be done by:
Increasing awareness of diabetes,
Advocating for and promoting policies and programs that improve access to care, treatment, and outcomes for people with diabetes and those at risk for developing diabetes.
Leveraging from a diverse group of partners to improve diabetes health in Arizona

21. A state without diabetes
Vision
A state without diabetes
Mission
To reduce the health, social, and economic burden of diabetes in Arizona

22. How are the Coalition and Council structured?
Arizona Diabetes Program and ADHS
Arizona Diabetes Leadership Council
Chair: Sandra Leal
Arizona Diabetes Coalition
Advocacy
Electronic Health Records
DSMT/E
Pre-Diabetes
SALUD (Supporting Action for Latinos Against Diabetes)
Tribal
How are the Coalition and Council structured?

23. Arizona Diabetes Leadership Council
Reorganized Fall 2006
>18-21 member leadership council
Representation from academia, health plans, government, private companies, non-profit organizations, etc.
Meet 6 times a year as a council and quarterly with the coalition
Each Coalition workgroup chair is represented in the Leadership Council.
Ex-Officio members
Well established by-laws:
Constant communication between leadership body and ADHS Diabetes Program
Long term goals
By Dec. 31, 2014, establish the Arizona Diabetes Coalition as a leader in promoting evidence-based disease management of diabetes
Integrate the AZ Diabetes Program and its activities into an overall state chronic disease prevention plan
Continue to identify and work with current stakeholders and partners to decrease the burden of diabetes in Arizona
Collaborate with internal and external partners to leverage resources that will maximize interventions to reduce and prevent chronic diseases in Arizona

24. Diabetes Measures and Systems Change

25. Health Care Flowchart

26. Pillars of Health Care Reform
Cost
Access
Coverage
Quality
Controlling Cost
Expanding Access
Increasing Coverage
Improving Quality

27. Quality and access to Care There are thousands of new doctors and nurses in communities around the country and millions more patients getting care.
We all know that health insurance doesn’t guarantee you’ll get the care you need. In the past, you’d call up your doctor and too often you’d hear that the next appointment was in four months. Or you’d only see your doctor for ten minutes because they had to rush on to their next patient.
That’s why the health care law also invests in training and placing thousands of new doctors and nurses in communities that need them most. And it creates and expands community health centers across the country.
These investments will make it easier for you to see your doctor and spend more time with them.
[FOR THE SPEAKER’S REFERENCE:
-Community health centers are an economic engine of local employment and growth in many underserved and low-income communities.
-Since the beginning of 2009, health centers have added more than 18,600 new full time positions in many of the nation’s most economically distressed communities, and because of the health care law, they are expected to create thousands more.]

28. Improving Quality
Increase the utilization of EHR in multiple healthcare systems
Encourage completion of NQF standard measures for diabetes and hypertension
Require reporting and accountability for health plans
Coordinate care and medical home models
Improve patient safety, reduce medical errors, promote health and wellness
Capacity development for FQHCs and other health systems
Ensure proper fields are reported, developing reports to identify patients who are due for a particular measure

29. National Quality Forum (NQF) Measures (Diabetes)
Recommended Measure Title
0055
Eye Exam (no evidence of retinopathy)
0056
Foot Exam
0059
HbA1c Poor Control (HbA1c >9%)
0061
Blood Pressure Management
0062
Urine Screening
0064
LDL Management and Control
0575
HbA1c Control (<8%)
0018
Controlling High Blood Pressure
ADD RECOMMENDED MEASURE DESCRIPTIONS HERE
Based on percentage of patients aged years of age with type 1 and type 2 diabetes.
NQF 18 = Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled during the measurement year.
NQF 0061 (who had BP <140/90mmHg)

30. Role of EHR systems in FQHCs
Advocate for your patients
Referral mechanism for DSME and prevention programs
Provision of preventative care for chronic care patients
EHRs can help avoid re-admission rates and improve and adherence to self-management

31. Public Health in Actions Grant

32. What is the Public Health in Actions Grant?
5 year collaborative grant
Focuses on policy, system, and environmental change
32 states funded
Basic and Enhanced components
Year 1 has been completed
5 year grant that addresses obesity, diabetes, hypertension, and school health.

33. Implementation of EHR system change and performance measures
Proportion of health care systems reporting on NQF measures 18 and 59
Proportion of health care systems with EHRs appropriate for treating patients with high blood pressure and diabetes
Increase the institutionalization and monitoring of aggregated/standardized quality measures at the provider and systems level

34. System level changes and non-physician team based care in Federally Qualified Health Centers
Talk about team based approach contract with NOAH and other FQHCs

35. Summary
Diabetes remains a prevalent disease in Arizona, specifically in rural areas
Diabetes NQF measures offers the ability to detect care when the recommended care was given or when recommended care was not received.
Non-physician staff will continue to be on high demand and integration into a team base approach to diabetes health should be warranted
Health systems changes via the utilization of electronic health records show positive trends in the improvement of diabetes care

36. Looking into the future
Establish a data sharing agreement between ADHS and FQHCs and/or the Alliance for Community Health Centers
Ability to generate standardize reports on patients with diabetes and hypertension
Reducing the gaps and inconsistencies resulting in lack of data within the EHR

37. Our ever changing public health system
Home Health
Police
FQHCS
Churches
MCDPH
EMS
ADHS
Laboratory Facilities
Parks
Schools
Doctors
Nursing Homes
Elected Officials
Philanthropist
Hospitals
Mass Transit
Environmental Health
When I talk about the LPHS, it is all the entities that, collectively, address local public health…these include government, private and non-profit organizations and agencies. It also includes the state and CDC.
State: A Public Health System is complex. Here is a depiction of the complexity of a public health system and examples of organizations and groups that comprise the network.
You can see many of the system partners represented who contribute to health and delivery of the Essential Public Health Services.
Civic Groups
Fire
Urban Planners
Economic Development
Tribal Health
Employers
Drug Treatment
Corrections
Mental Health 37

38. Questions?
Contact Information Omar A. Contreras, MPH Diabetes Prevention and Control Program Manager Arizona Department of Health Services (602)