Wendy Davis: Leveraging Public Health Capacity to Improve Health System Efficiency

Vermont Department of Health

Leveraging Public Health Capacity to Improve Health System Efficiency

Wendy Davis, MD – CommissionerOctober 5, 2010


Objectives

Understand brief history of Vermont’s state health reform efforts: the Blueprint for Health initiative

Review Vermont Department of Health’s (VDH) approach to PH and Health Reform integration

Identify challenges and opportunities for synergy presented by the Patient Protection and Affordable Care Act


History of Vermont’s state health reform:

Or, “you don’t know where you’re

going if you don’t know where

you’ve been!”


Vermont Characteristics

Population = 621,760 (2009 est.) Land Area = 9.249 square miles VDH is a centralized public health

department (12 District Offices) 2009: #1 in America’s Health

Rankings (United Health Foundation)


“Rural”Vermont

WWAMI/RUCA Rural Health Research Center

More Cows than People?


Vermont Agency of Human Services

Office of the SecretaryDepartment for Children and Families (Child Dev., OCS, Family/Econ Svcs.)Department of CorrectionsDepartment of Disabilities, Aging and Independent Living (DAIL)

Department of Health (VDH)Department of Mental HealthDept. of Vermont Health Access (Medicaid: Catamount Health, Dr. Dynasaur, Blueprint for Health)


VDH Organization

Alcohol and Drug Abuse Programs

Health Promotion and Disease Prevention

Health Surveillance

Local Health

Maternal and Child Health

Medical Practice Board

Public Health Preparedness

Business, IT, Public Policy, Communications


VDH Framework: 10 Essential Public Health Services (CDC)Monitor health status to ID/solve community health problemsDiagnose and investigate health problems/hazards in the communityInform, educate, and empower people about health issuesMobilize community partnerships/ action to identify and solve health problemsDevelop policies and plans that support individual and community health efforts

Enforce laws and regulations that protect health and ensure safetyLink people to needed health services and assure provision of health care when otherwise unavailableAssure competent public and personal health care workforceEvaluate effectiveness, accessibility, and quality of personal and population-based health servicesResearch for new insights and innovative solutions to health problems



Health Disparities Report 2010


11


Vermont Blueprint History: Vermont Blueprint History: The good news . . .The good news . . .

Relatively good distribution of Primary Care Providers (PCPs) statewide

• 800 PCPs in 300 practices in 13 Hospital Service Areas

Three major health plan carriers + Medicaid + Medicare

Most PCPs participate in all plans

History of working together


Insurers

Providers

Health IT

Public Health

Hospitals

Benefits

ManagersContracted

Services

Pharmaceutical

Companies

Vermont Blueprint History:The Bad News!


Health Care Reform Goals

Increase Access Improve Quality

Contain Costs

60+ Initiatives


St. Albans Newport

Burlington

Middlebury

Rutland

Bennington

Barre

White River Jct.

Springfield

Brattleboro

St. Johnsbury Morrisville

History: Community Health and Wellness Grants

CHAMPPS (Coordinated Healthy Activity, Motivation, and Prevention Programs) grant program

Technical assistance provided by VDH

Community Grants

Prevention Specialists


Bennington

Burlington

St. Johnsbury

Barre

Windsor

Springfield2005—Initial two pilot Hospital Service Areas (Diabetes Focus)

Healthier Living Workshops

Community Physical Activity Grants

April 2007

2004—Planning

2003—Launch of the Blueprint

2006—Four new Hospital Service Areas (Diabetes Focus)

Blueprint HistoryBlueprint History

2006—Statutory Endorsement

2007— Medical Home Integrated Pilots in Statute

2008 - Integrated Medical Home Pilots(all chronic conditions + prevention)


Improved Outcomes-Healthier People

ProductiveInteractions

Self-Management

Support

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Health System

Health Care Organization

Community Resources and

PoliciesPublic HealthPolicies, Systems,

Environment

Supportive Environment

Informed,Activated

Patient

Prepared,Proactive

Practice Team

Adapted from the chronic care model which is used by permission of “Effective Clinical Practice.”

What is the Blueprint?


Vermont State Health Reform Components:

Advanced Primary Care foundation (PCMHs + CHTs)

Multi-Insurer Payment Reforms

A focus on prevention (public health health care delivery)

A statewide health information exchange

An evaluation infrastructure to support ongoing improvement

Facilitators & support for a learning health system


State Public Health Leadership Role in Comprehensive Health Reform:

Advanced Primary Care foundation (PCMHs + CHTs)

Multi-Insurer Payment Reforms—Policies/Systems

A focus on prevention (public health health care delivery)—All levels of “the Egg”

A statewide health information exchange-PH data/registries

An evaluation infrastructure to support ongoing improvement

Facilitators & support for a learning health system—PH EBP


Primary Care PCMH-Docs-NPs-Staff

Community Care Team (CCT)e.g. NP, RN, MSW, Dietician,Behavior Specialist, Community Health Worker, VDH Public Health Specialist

Referrals &Communication

Vermont Health Information Platform (VITL)

Hospital-Educators-Transitional care-Ambulatory center (wellness programs)

Referral & care support Education & Improvement Public Health & Prevention

Policies and SystemsLocal, state, and federal policies and laws, economic and cultural influences, media

CommunityPhysical, social and cultural

environment

OrganizationsSchools, worksites, faith-based

organizations, etc

RelationshipsFamily, peers, social networks, associations

IndividualKnowledge, attitudes,

beliefs

Adapted from: McElroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Education Quarterly 15:351-377, 1988.

Support for evidence basedpublic health, prevention, & policy

Model for Health & Prevention


Central – Public Health Prevention Team•State level assessments•State level strategic planning•Data review & interpretation•Design campaigns / programs•Technical assistance / support

Regional – Public Health Prevention Teams•Local assessments•Local intervention planning•Organizing & coordination•Multidisciplinary Services

Surveillance

HPDP

ADAP

Blueprint

MCH

Preparedness

Rural Health

Business Office

•Program content•Best practices•Domain expertise•Data analysis•Reporting

Transportation

Education

Labor

Medicaid

Corrections

Mental Health

Children & Families

DAIL

•Input•Review•Domain expertise•Coordination•Planning

Departments VDH Programs

State & Local Coalitions

Community Groups

Community Stakeholders

Community Health Teams

VDH Prevention Teams

Functional Map – Public Health Operations

Community Care Team # 1





Health IT Framework

Global Information Framework

Evaluation Framework

Operations

PCMH

PCMH

PCMH

PCMHHospitals

Public Health Prevention

Community Health TeamNurse Coordinator

Social WorkersDieticians

Community Health WorkersOVHA Care Coordinators

Public Health Prevention Specialist

Behavioral Health &

Substance Abuse Services

Prevention Programs

Policies and SystemsLocal, state, and federal policies and laws, economic and cultural influences, media

CommunityPhysical, social and cultural environment

OrganizationsSchools, worksites, faith-based organizations, etc

RelationshipsFamily, peers, social networks, associations

IndividualKnowledge, attitudes, beliefs

Blueprint Integrated PilotsCoordinated Health System


Prevention Strategies for Tobacco Use

• Increased tax on tobacco

products

• Smoking restrictions

(workplaces, schools,

restaurants, public places)

• Reduced access to underage

youth

• Community coalitions

• Media

• Smoking cessation services

• Provider counseling


Community Health Team

Public Health District Office Director, Prevention specialist (chronic disease), Prevention consultant (ADAP)

Care Delivery NP, RN, MSW, Dietician, Behavior Specialist, Community Health Worker

VDH Health Promotion Disease Prevention Programs

Diabetes Substance Abuse / Alcohol

Exercise Cardiovascular Disease

Nutrition Tobacco

Asthma Cancer

VDH Surveillance

Data Integration

Analyses

Report Generation

Routine Assessment

• Coalesce Community Partners• Community Assessments• Prevention Planning & Implementation• Public Health Services• Ongoing Tracking & Quality Improvement

Data Sources

Behavioral Risk Factor Surveillance Survey Data

Adult Tobacco Study Data

Hospital Discharge Data

Vital Statistics Data (Deaths)

Department of Transportation Data

US Census Data

Department of Labor Data

Medical Practice Board Survey Data

Community Snapshots•Rates of risk factors in each community•5 Year Aggregate Data (2002 – 2006)•2006 Statewide Comparison

State Level Assessment•Factors assoc with hospitalizations & costs•10 year trend analysis•Univariate & multivariate modeling

Program products•Tools, Resources•Services & Technical support•Training


•Quit Tools•Quit Net•Quit By Phone•Quit In Person

Blueprint Integrated Pilots: Coordinated Health System

Patient Centered MedicalHome

Community HealthTeam

Vermont Quit

NetworkCoordinated care & referrals

Health Information InfrastructureEMRs – HIE – DocSite

Access for Program CoachesTrack ReferralsSelf Management GoalsReports for outreach & evaluation

Training to enhance counseling skills


Health IT Framework

Global Information Framework


Operations

PCMH

PCMH

PCMH

PCMHHospitals






Behavioral Health &

Substance Abuse Services

Prevention Tobacco Cessation

Community messaging & education, facilitate linkages and broad access to cessation programs

Coordinated referrals & patient support between PCMHs + CHTs + Tobacco Cessation Services (phone based counselors, community based group programs)

Expand counseling capacity by training behavioral health counselors and social workers on CHTs. Trained counselors as part of the CHT who can broadly support enhanced self management.

DocSite clinical tracking & reporting that supports outreach by Tobacco Cessation Counselors and coordination between care delivery and cessation programs

VDH Surveillance generates population indicators re prevalence, risk behaviors & exposures, co-morbidities, healthcare utilization & costs. Supports policy making, planning for care delivery and public health strategies, quality improvement, and tracking of program impacts.

Policies and Systems

Community

Organizations

Relationships

Individuals

Blueprint Integrated Pilots


Prevention Strategies for Obesity• Menu labeling

• Built environment (rail trails)

• Community gardens

• Changes in school cafeteria

selections (Farm to School)

• Running/bike/hiking clubs

• Weight control programs

• Increased awareness

• Health care provider recommendation

Vermont Department of HealthSt. Johnsbury Family HCChronic Care Coor .5 FTEBeh. Health Spec. .5 FTE

Concord Health Ctr.Chronic Care Cood .5 FTEBeh. Health Spec. .5 FTE

Danville Health CenterChronic Care Coor .5 FTEBeh. Health Spec .5 FTE

Corner MedicalChronic Care Coor 1 FTEBeh. Health Spec 1 FTE

OtherDVHA Care ManagersHospital Care ManagersHospital-based CC EducatorsCommunity-based Advocates

Community ConnectionsCommunity Health WorkersCC Comm. Health Worker

VDH District OfficePublic Health SpecialistLadies First CoordinatorCalodenia Int. Medicine

Chronic Care Cood .5 FTEBeh. Health Spec. .5 FTE

St. Johnsbury Community Health TeamCare Integration Coordinator

1 FTE


Public Health Integrated Prevention Teams

VDH Strategic Plan Goal: “Communities will have the capacity to respond to public health needs• Capacity building efforts integrated and aligned

internally and with (external) community partners Training

• “Prevention and Health Promotion Basics” Team development

• Central office—cross disciplinary mgt. team• District (local) office—cross disciplinary fcnl. teams


Pilot Locationsthru July 2010

Vermont Department of HealthJuly

2008Jan 2009

July 2009

Jan 2010

July 2010

Jan 2011

July 2011

Jan 2012

July 2012

Jan 2013

July 2013

Pilot # 1 St Johnsbury HSA St Johnsbury HSA Expansion

Pilot # 2 Burlington HSA Burlington HSA Expansion

Readiness Pilot # 3 Barre HSA Barre HSA Expansion

Readiness HSA # 4 Rollout










Implementation Phase Demonstration Phase (Medicare?)

Target Population% of VT Population# CHTs

42,1796.7%

2

126,28620%

6

316,66250%16

508,1780%25

637,130100%

32

Blueprint Integrated Health System - Proposed Expansion

04/11/23 31


Health IT Framework


BP Integrated Pilots: Building an Integrated System of Health

PCMH

PCMH

PCMH

PCMHHospitals






Mental Health & Substance

Use Disorders

Integrated Health Service Model

Payment Reform to support prevention & health maintenance

Health Information Infrastructure

Evaluation Infrastructure

Generalizable (other services)

Scalable (larger populations)

Sustainable (financially)

PCMH


Community Health Team

Patient Centered Medical Homes

Multi-insurer payment reform

Health Information Infrastructure

Evaluation Infrastructure

AM

PC

Foundation

Blueprint: A Foundation for integrated services

Targeted S

ervices

Specialty Care

Disease Management Programs

Case Management

Social Services

Economic Services Areas of FocusFamily Wellness & Children's ServicesMental Health & Substance UseMedicaid Care CoordinationSenior Services (SASH)Disease Specific (CHF)

StepsClinical Services ModelFinancial Impact ModelPayment ReformsIT Infrastructure & EnhancementsImplementation PlanEvaluation Plan


Even silos can be systematic!


QUESTIONS???

Web address:

www.healthvermont.gov

Health & Medicine

Wendy Davis: Leveraging Public Health Capacity to Improve Health System Efficiency