1. Brianna Gass, MPH November 17, 2014 Local Needs, Local Data

2. 2  Understand local data integration efforts  Highlight potential application of integrated and mapped data  Identify ways integrated data can assist in targeting health improvement activities Objectives

3. 3 2010 Census data CountyNation Total population161,000313,874,000 % Population over age 6516.013.7 % Population below poverty level18.114.9 % Bachelors degree or higher21.028.5 % Hispanic or Latino42.016.9 % Self report health status as fair or poor*20.717.0 About the County

4. 4  Key informant interviews  Data catalog  Dashboards and Key user sessions  Community case studies  Focus groups with stakeholders  Network analysis Methods

5. 5 Key informant interviews Facilitators of integration:  Visionary organizational leadership  Committed community members  Necessity created by shrinking resources  Experience with benefits of integrated data Barriers to data integration:  Regulatory complexity  Technical challenges of integrating data on different platforms  Lack of consistent variable definitions, analytic methods Results

6. 6 Key informant interviews Desire for data and service integration:  Utilization data – Behavioral health – Substance abuse treatment – Medicare & Medicaid  Health care quality indicators  Disease prevalence Results

7. 7 Key informant interviews Use of integrated data  Describe service utilization patterns  Measure success of social programs  Plan for integration of services for individuals  Create efficiencies, maximize resources Results

8. 8 Data Catalog  Medicare beneficiaries – Age (including beneficiaries under 65) – Admissions/30-day readmissions – Payment per beneficiary for inpatient stays, ED visits, observation stays, SNF admissions  Population variables – Poverty status – Education – Age – Households with no vehicle – Housing Choice Vouchers  FQHC locations  Medicaid Expenditures Results

9. 9 Key user sessions and Dashboards  Tableau dashboards displayed interactive maps and graphs – Medicare utilization data – Demographic data – Elements based on key informant interviews  Key user chosen for access to and familiarity with local data sources, demonstrated leadership with integration efforts  Key user additions or modifications to the dashboards – Percent of Civilian Non-institutionalized Populations With No Health Insurance Coverage, – ZIP Code level live births to mothers <=18 (Teenage pregnancy rates), – various county health rankings, – metrics around community needs assessment and surveying efforts, and – Senior housing locations and program outcomes. Results

10. 10 Focus groups Community characteristics:  High poverty; poor health outcomes  Many organizations provide social services  Limited resources drive desire to create efficiencies  Existing and active community collaboratives  Leaders are well connected and used to working together Results

11. 11 Data elements desired by participants Results- Network Analysis

12. 12 County priorities  Access to poverty and income data  Micro-target census tracts identified as areas of need – Target services under circumstances of limited resources  Engage residents in process to identify local needs  Leverage existing collaboratives to break down silos and share information  Integrate data from diverse sources to inform program interventions Many participants expressed desire for raw data Discussion

13. 13 Limitations  Platform license structure created limitations  Stakeholder competing agendas  Reluctance to share  Lack of community resources – Limited resources available to invest in integration – Few stakeholders have skills necessary, key user cannot act alone Above factors limited key users’ ability to incorporate dashboard into workflow and take full advantage of functionality Discussion

14. 14 Recommendations  Align funding cycles for initiatives that target similar populations  Identify common measures for health improvement  Improve local agency access to federal data sources  Develop maps that show utilization, demographics, prevalence of conditions, and social determinants of health at the census tract level Discussion

15. 15 Acknowledgements  This material was prepared under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Sequence #: 11SOW-QINNCC-00033-11/10 For more information:  Jane Brock, MD, MPH – jbrock@telligen.comjbrock@telligen.com  Brianna Gass, MPH – bgass@telligen.combgass@telligen.com More information