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achieve action institute clinical community linkages for chronic disease prevention

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ACHIEVE Action Institute:Clinical & Community Linkages for Chronic Disease Prevention

Nicole Flowers MD, MPH

Medical Officer

Centers for Disease Control and Prevention

Division of Community Health

APRIL 25, 2012

learning objectives
Learning Objectives
  • Describe the burden of chronic disease and approaches to reducing the burden.
  • Understand how community efforts can work synergistically with clinical levers to address chronic disease.
  • Identify options for supporting individuals with chronic disease in your community.
chronic diseases
Chronic Diseases

145 million Americans are affected

Responsible for 7 of every 10 U.S. deaths

Cause major limitations in daily living

for 1 of 10 Americans

Account for ~75% of U.S. medical costs

Are inequitably distributed

across the population

slide4

Chronic Diseases and Related Risk Factors

Leading Causes of Death*

United States, 2000

Actual Causes of Death†

United States, 2000

Tobacco

Heart Disease

Poor diet/

Physical inactivity

Cancer

Alcohol consumption

Stroke

Chronic lower respiratory disease

Microbial agents

Toxic agents

Unintentional Injuries

Motor vehicles

Diabetes

Firearms

Pneumonia/influenza

Alzheimer’s disease

Sexual behavior

Kidney disease

Illicit drug use

0

5

10

15

20

0

5

10

15

20

25

30

35

Percentage (of all deaths)

Percentage (of all deaths)

* Miniño AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: final data for 2000. National Vital Statistics Reports 2002; 50(15):1-120.

† Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-1246.

factors that affect health
Factors that Affect Health

Smallest

Impact

Largest

Impact

Examples

Eat healthy, be physically active

Counseling

& Education

Rx for high blood pressure, high cholesterol, diabetes

Clinical

Interventions

Immunizations, brief intervention, cessation treatment, colonoscopy

Long-lasting

Protective Interventions

Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax

Changing the Context

to make individuals’ default

decisions healthy

Poverty, education, housing, inequality

Socioeconomic Factors

slide6

Imagine a typical chronically ill patient who sees his doctor half an hour every three months. These four encounters each year—the physician’s opportunity to counsel, diagnose, and treat—constitute only 0.02% of this patient’s life. For all the rest—the 99.98% of the time that the patient is elsewhere, making decisions about his health in the context of his culture, family, and

community—

the doctor’s impact on the patient’s choices is minimal….

That 99.98% belongs to community

medicine, to population health,

and to public health.

Jarris et al,

Acad Med. 2011;86:1347.

slide7

This means that the greatest opportunities for addressing some problems are in the community, outside of the doctor’s office.

  • Imagine a typical chronically ill patient who sees his doctor half an hour every three months. These four encounters each year—the physician’s opportunity to counsel, diagnose, and treat—constitute only 0.02% of this patient’s life. For all the rest—the 99.98% of the time that the patient is elsewhere, making decisions about his health in the context of his culture, family, and

community—

the doctor’s impact on the patient’s choices is minimal….

That 99.98% belongs to community

medicine, to population health,

and to public health.

Jarris et al,

Acad Med. 2011;86:1347.

national prevention strategy
National Prevention Strategy
  • Extensive stakeholder and public input
  • Aligns and focuses prevention and health promotion efforts with existing evidence base
  • Supports national plans

8

clinical and community linkages to address chronic disease
Clinical and Community Linkages to Address Chronic Disease
  • Clinical Preventive Services-
    • Procedures, tests, counseling, or medications
    • Aimed at preventing the onset or progression of a health condition or illness
  • Clinical and Community Preventive Services
    • Linking clinical domain and community resources for systems change to promote improved health outcomes in the community.
pharmacists can improve care and reduce costs
Pharmacists Can Improve Care and Reduce Costs
  • Supporting medication adherence
  • Improving the use of medications
  • Improving treatment outcomes
  • Helping patients with self-management
community health workers
Community Health Workers
  • Liaison between health systems and communities
  • Facilitate access to and improve quality and cultural competence of medical care
  • Build individual and community capacity for health by:
      • Increasing health knowledge and self-sufficiency of the patients
      • Serving as community health educators
      • Providing social support
      • Advocating for the health care needs of patients and communities
sample community activities to support team based care tbc
Sample community activities to support team- based care (TBC)
  • Influence coverage for TBC in private health plans, among self-insurers or public health plans.
  • Ensure standardized curriculum or protocols for health care extenders.
  • Support jurisdiction-wide defining of the scope of practice for the health care extenders
  • Gather and disseminate information about the return on investment for utilization of team-based care approaches
  • Increase awareness among patients with chronic disease about the availability of CHWs or pharmacists as healthcare extenders
state example maryland
State Example - Maryland
  • P3 (Patients, Pharmacists, Partnership) is a program among worksites and community pharmacies using pharmacists to provide chronic disease self-management
  • Participants have seen a sustained reduction in A1C , blood pressure, and lipids
state examples
State Examples
  • Minnesota passed legislation in 2009 to make CHW services reimbursable under Medicaid and the state regulates CHW training, supervision, enrollment criteria, and billing
  • Massachusetts’ broad-based policies, consistent and powerful advocacy from the CHW workforce, and partnership with state public health partners secured the ongoing integration of CHWs into health care systems
chronic disease self management program
Chronic Disease Self-Management Program
  • Low-cost, community-based class for people with chronic diseases developed at Stanford University
  • A CDC meta-analysis of CDSMP showed improvements in fatigue, depression, health distress, etc.
  • CDC’s Arthritis Program funds 12 state arthritis programs that can offer CDSMP as a proven intervention
  • CDC’s Diabetes program and Heart Disease and Stroke Prevention program have refunded programs for CDSMP
sample activities of community organizations to support cdsmp
Sample Activities of Community Organizations to support CDSMP

Possible PSE activities:

  • Facilitate increased uptake of CDSMP sites. Sites should be linked to a health care delivery system
  • Campaign to increase awareness about availability and benefits of CDSMP
  • Support provider referrals to CDSMP
  • Facilitate development of infrastructure for better communication and data sharing between CDSMP and providers.
  • Engage populations with health disparities
state example oregon
State Example - Oregon
  • Worked with other state agencies, local health dept, health care providers, social service agencies, and CBOs to create a sustainable infrastructure for delivering CDSMP
  • Best estimates over four years show 557 emergency room visits avoided, saving $634,980 and 2,783 avoided hospital days, saving $6, 501,088
  • Currently engaged in discussions with public employees and educators’ benefit boards on inclusion of CDSMP as a covered benefit
community clinic partnership

Community – Clinic Partnership

Community

Clinic

}

Insurers

Partnership Zone

Proactive Practice

Team

Employers

Reimbursement

Screening for

High Risk

Informed Population

Diagnosis of

Prediabetes

Decision Support

Strong Community

Organizations

Structured Lifestyle

Programs

Information Systems

Healthy Public Policy

Informed, Activated

Patients

Regular Glucose

Monitoring

Supportive

Environments

Total Population

Prediabetes

Diabetes

Complications

enhancefitness
EnhanceFitness
  • Evidence based, community based exercise program developed by the University of Washington PRC
  • Increases strength, boosts activity, elevates mood
  • One of six physical activity programs recommended by CDC Arthritis Program
  • Offered by Group Health as a free benefit to all its Medicare enrollees since 1998
  • In 2011 the YMCA began offering EF at Ys in 8 states and will continue expansion efforts