Primary Care – Public Health Integration

and the Role of Data and Epidemiology

J. Lloyd Michener, MDProfessor and ChairDepartment of Community and Family MedicineDirector, Duke Center for Community ResearchDuke University Health System

Council of State and Territorial EpidemiologistsAnnual ConferenceNashville, TennesseeJune 23, 2014

www.iom.edu/primarycarepublichealth

Released: March 28, 2012

What Do We Mean By Integration?

“The linkage of programs and activities to promote overall efficiency and effectiveness and achieve gains in population health.”

Degrees of Integration:

Why integrate now?

Call to Action

• IOM Report

• Affordable Care Act

• New Funding Opportunities

Changes in Health Care

• Rise in Health Care Costs

• Disturbing Health Trends

• Increase in Health Research and Data

• Impact of Social Determinants of Health

• Drive to PCMHs and ACOs

• Availability of Electronic Health Records

Principles for Successful Integration

• Shared goal of population health improvement

• Community engagement in defining and addressing population health needs

• Aligned leadership

• Sustainability

• Shared data and analysis

System Overview

CalPERS Excess Medical Spendingattributable to selected preventable conditions

by county (2008)

THE URBAN INSTITUTE

CalPERS Excess Medical Spendingper person per year (2008)

   

ConditionAnnual ExcessExpenditurePer Person

Short run conditions  

Diabetes only $2,863Hypertension only $1,595Diabetes and Hypertension only $3,920

 

Medium run conditions 

Diabetes with Heart, Cerebrovascular or Renal Disease $21,181Hypertension with H, C, or R $14,576Diabetes and Hypertension with H, C, or R $24,215H, C, or R without Diabetes or Hypertension $10,743

THE URBAN INSTITUTE

CalPERS Center for Innovation

• Center for Innovation (CFI) is a proposed Division that will research, develop and test high-potential health and retirement innovations.

• Division consolidates research for health and retirement programs - prototype versions of proposed new health and retirement products to be tested for appeal and scalability

- staff to propose modifications based on research and models in a comprehensive approach to long term strategic planning, program sustainability, cost containment, and value

- Priority Care, BSC-Hill-CHW, and VBPD pilots are examples of projects and innovations that CFI will manage and expand upon

Emergency Department Utilization for Primary Care in Charlotte, NC

Neighborhoods Matter

Note: density plots depict ACTUAL patients and respective blood pressures in Durham County

Source:

DSR data from 1/1/06-5/1/09; patients seen at DUHS

Neighborhoods MatterPeople with Hypertension in Durham

DM patients seen at Duke 2007-2009

14,345 unique patients

8.7% of all patients >20 yo

14.3% of all patients >40 yo

Durham County Stats (per CDC):2008 ~ 10% of adults diagnosed with diabetes

North Carolina (CDC):2008 ~ 9% of adults diagnosed with diabetes

 By Race: 8.4% White15.6% AA12.4% NA4.5% Hispanic 4.3% Other

HbA1C >9 HbA1C >9, AA

HbA1C >9, AA   40-60,    60+

Just For Us

Integrated Intervention – Durham, NC

Just For Us

DHI teams are connecting community partners and working with neighborhood residents to ensure:

• Healthy schools and neighborhoods

• Safe places to exercise• Access to healthy foods• Access to health information

Building Neighborhood Capacityin Durham, NC

Percent Difference Between Medicaid Recipients Enrolled in CCNC and Those Not Enrolled in CCNC, for Rates of Asthma-Related Emergency Department Visits and Inpatient Admissions, 2008–2012

Note. CCNC, Community Care of North Carolina. NCMJ September/October 2013, Volume 74, Number 5

The Practical Playbook

A cornerstone of the next transformation of health, in which primary care and public health groups work collaboratively to achieve population health improvement.

www.practicalplaybook.org

 

Target Audience

• Public Health Professionals

• Primary Care Teams

• Additional Stakeholders – Hospitals– Health Care Investors– Academic Institutions– Community Organizations

Steering Committee

Duke Community and Family Medicine– Lloyd Michener

de Beaumont Foundation– Brian Castrucci– Jim Sprague

Centers for Disease Control and Prevention– Denise Koo

National Advisory Committee

Practical Playbook Overviewwww.practicalplaybook.org

Maryland Prevents One Million Heart Attacks and Strokes

The Maryland Million Hearts Initiative is part of a national campaign to prevent one million heart attacks and strokes by 2017.

The statewide initiative is a partnership between the Department of Health and Mental Hygiene and local communities, health systems, nonprofit organizations, federal agencies and private-sector businesses.

The program has seen a 27 percent increase in blood pressure control at participating centers.

The Community Asthma Initiative works to improve the health and quality of life for children with asthma.

Boston Children’s Hospital designed the program to focus on medical interventions rather than environmental influences.

Since its establishment, the program has worked in tandem with partners at every level, including the individual, family, and larger community.

CAI helped reduce the number of asthma-relatedhospitalizations by 80 percent.

Massachusetts Improves Quality of Life for Children with Asthma

Playbook Google analytics

Visitors: 14,131

- Returning visitors: 31.7%

- New visitors: 68.3%

Page views: 59,348

March 5 - June 18, 2014 (3 ½ months)6

KEY ELEMENTS:

• Aggregated data from healthcare and public health

• Hot spotting for avoidable illness

• Coordinated community interventions

• IT as key infrastructure

Introducing PCORnet:The National Patient-Centered Clinical Research Network

PCORnet embodies a “community of research” by uniting systems, patients & clinicians

31

11 Clinical

Data Research Networks(CDRNs)

18 Patient-Powered Research Networks(PPRNs)

PCORnet:

A nationa

l infrastructure

for patient-centere

d clinical researc

h

29 CDRN and PPRN awards were approved on December 17th by PCORI’s Board of Governors

32

This map depicts the number of PCORI-funded Patient-Powered or Clinical Data Research Networks that have coverage in each state.

PCORnet organizational structure

33

Other related activities

Improving Population Health by working with communitiesDraft report available at www.qualityforum.org

Community Health Improvement Technical Package

-Roundtable on Population Health Improvement

-Building Capacity for Population Intervention Research in Primary Care

-Opportunity Knocks: Population Health in State Innovation Models

-Paying for Population Health: A View of the Opportunity and Challenges in Health Care

June 2014 Report to the Congress: Measuring population-based outcomes

What this means to Epidemiologists:

• More activity with and across health systems

16 Epidemiologists in Duke Department of Community of Family Medicine

(8 with PhD in Epidemiology)

• Collaboration and Competition