Ccdphp grant and state strategic plan
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CCDPHP Grant and State Strategic Plan. Linda Scarpetta, MPH, DCDIC Integration Coordinator MCC Board of Directors Meeting September 19, 2012. Overview of CCDPHP Grant. CDC provided grants to all state health departments in Sept 2011 Purpose:

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CCDPHP Grant and State Strategic Plan

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Ccdphp grant and state strategic plan

CCDPHP Grant and State Strategic Plan

Linda Scarpetta, MPH, DCDIC Integration Coordinator

MCC Board of Directors Meeting

September 19, 2012

Overview of ccdphp grant

Overview of CCDPHP Grant

  • CDC provided grants to all state health departments in Sept 2011

  • Purpose:

    • Build and strengthen state health department capacity and expertise to effectively prevent chronic disease and promote health

    • Maximize reach of categorical programs

    • Provide leadership and expertise to work collaboratively across conditions and risk factors

Overarching areas

Overarching Areas

  • Communication

  • Epidemiology/Surveillance

  • Evaluation

  • Health Systems Improvements

  • Community Mobilization

  • Community Linkages

  • Health Disparities

  • Policy and Environmental Change

  • Partnerships

Strategic planning process

Strategic Planning Process

Cdc expectations for state ccdphp plans

CDC Expectations for State CCDPHP Plans

  • Reduce burden of chronic disease and injuries/violence in the state as a whole

  • Include strategies led by governmental and non-governmental partners

  • Address the four domains

  • Address health disparities and achieve health equity

  • Living document

  • Consistent with existing categorical plans

Cdc state plan guidance

CDC State Plan Guidance

  • Goals, strategies and objectives will achieve major population-level change

  • Reach large numbers of people in the state

  • Strategies and objectives should be of interest to multiple programs and partners, impact multiple diseases, outcomes and/or risk factors

  • A coordinated effort of multiple partnerships with organizations that can achieve large-scale systems changes affecting multiple diseases or risk factors

Michigan s ccdphp state plan

Michigan’s CCDPHP State Plan

Aligns with 3 major initiatives:

  • MI Health & Wellness 4x4 Plan

  • MI Primary Care Transformation Project

  • Community Linkages – Pathways/Community HUB Project

Rationale for selection of initiatives

Rationale for Selection of Initiatives

  • Cross-cutting

  • Evidence-based

  • Broad reach

  • Mutually synergistic with CD and injury efforts

  • Systems level change

  • Diverse partners

  • Address social determinants of health/health disparities

  • Encompass 4 CDC domain areas

  • Potential for greatest impact

Four domains

Four Domains

  • Epidemiology and Surveillance

  • Environmental Approaches

  • Health Systems Interventions

  • Clinic-Community Linkages

Mi health wellness 4x4 plan

MI Health & Wellness 4x4 Plan

Mi health wellness 4x4 plan1

MI Health & Wellness 4x4 Plan

  • Multimedia campaign

  • Deployment of local coalitions

  • Engagement of partners to support implementation

  • Formation of MDCH infrastructure

  • Acquisition of funding

Michigan primary care transformation

Michigan Primary Care Transformation

  • 3-year (2012-2014) demonstration project

  • MI is one of eight states

  • 36 physician organizations, 410 primary care practices, and 1,700 physicians are involved

  • Reform primary care payment models

  • Expanding capabilities of Patient-Centered Medical Homes

Patient centered medical home pcmh

Patient-Centered Medical Home (PCMH)

  • Goal to improve overall population health via:

    • Risk reduction for healthy individuals

    • Self-management support to prevent patients with moderate chronic disease levels from progressing to the complex category

    • Care coordination and case management support for patients with complex chronic diseases

    • Appropriate, coordinated end-of-life care.

Community linkages

Community Linkages

  • Holistically address factors that contribute to a person’s overall health

  • Integrate medical care system with community resources

  • Healthcare has a limited impact on a person’s health

  • Social and economic factors have a greater impact

Pathways community hub model

Pathways/Community HUB Model

  • Uses Community Health Workers (CHW)to address social and economic determinants of health

  • Incentivized by success in:

    • Identifying individuals at greatest risk

    • Assessing needs and identifying barriers

    • Referring to evidence-based services

    • Documenting results of referrals, progess and final outcomes

  • Bridge between health and social systems

Mi pathways community hub pilot

MI Pathways/Community HUB Pilot

  • 3-year cooperative agreement from CMMS

  • Started July 1, 2012

  • Co-directed by MPHI and MDCH

  • Pilot Counties: Ingham, Muskegon and Saginaw

  • Hire 90 CHW and other staff

  • Target population is Medicare and Medicaid beneficiaries in pilot counties

Overview of michigan s ccdphp plan

Overview of Michigan’s CCDPHP Plan

  • Goal: By 2020, all people living in Michigan will have access to a community integrated health care system supporting the prevention and control of chronic disease and injuries.



  • Strategies

    • Based on National Prevention Council’s recommendations in the National Prevention Strategy

    • Evidence-based

    • Potential to significantly reduce disease and injury burden

    • Improve health equity

    • Align with the three initiatives

    • Address four domain areas

    • Consistent with current work of statewide partners

    • Opportunities to build upon these efforts

Long term objectives

Long-Term Objectives

  • Long-term 1 : By 2020, 10% improvement in the following indicators from 2011 baseline:

    • A: Percent of Michigan adults reporting all four healthy behaviors

    • B: Percent of Michigan adults with timely screening for blood pressure, cholesterol and glucose level

    • C: Percent of Michigan adults with timely age and gender appropriate cancer screening

  • Long-term 2: By 2020, reduction in disparity (evidence of increased equity) in above indicators among racial/ethnic, geographic, and disability status populations

Epidemiology surveillance


  • Strategy: Develop a chronic disease and injury surveillance system (including use of health information technology) with analysis and dissemination capacity to inform, prioritize and evaluate impact of programs and policies as well as ensure strategic focus on communities and populations of greatest risk.

Environmental approaches

Environmental Approaches

  • Strategy: Engage and empower people and communities to plan and implement prevention policies and programs to promote tobacco-free living, healthy eating and active living.

Health systems interventions

Health Systems Interventions

  • Strategy: Enhance coordination and integration of clinical, behavioral, and complementary services through support and enhancement of patient-centered medical homes and coordinated care management.

Community linkages1

Community Linkages


  • a) Promote and support coordinated implementation of chronic disease and injury community-based preventive services and enhance linkages with clinical care.

  • b) Reduce barriers to accessing clinical and community preventive services, especially among populations at greatest risk.

Next steps

Next Steps

  • Implementation and evaluation planning

  • Partner engagement


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