NATIONAL ASSOCIATION OF CHRONIC DISEASE DIRECTORS 2200 Century Parkway, Suite 250 Atlanta, GA

Transcription

1 NATIONAL ASSOCIATION OF CHRONIC DISEASE DIRECTORS 2200 Century Parkway, Suite 250 Atlanta, GA

2 1. Agencies and organizations providing training to state staff working on 1305/SPHA should coordinate their efforts, especially CDC, its contractors, and NACDD. 2. The roles and responsibilities of state staff have shifted, in that most now report working on multiple chronic conditions or risk factors. Therefore, all training opportunities should be offered to all state staff working on 1305/SPHA. 3. Content for training can be presented in several ways including webinar, virtual roundtable discussion, communities of practice, in-person meeting or website. 4. Training during Year 2 of 1305/SPHA should focus on the top 5 training needs identified in the assessment. State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health (CDC-RFA- DP ) Domains 3 and 4 Training Needs Assessment Final Report Introduction The National Association of Chronic Disease Directors (NACDD) conducted a survey to assess the training needs of state staff working in Domains 3 and 4 in the State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health (CDC-RFA-DP ) program. (We will refer to this program as 1305/SPHA from this point forward.) The purpose of this survey is to identify states' top training needs and the level of training needed. This survey is organized around the primary knowledge, skills and abilities (KSAs) needed to implement 1305/SPHA strategies in both Domains 3 and 4. Respondents to this survey were state health department managers or staff working in any capacity on Domains 3 or 4 in the 1305/SPHA program. In the 1305/SPHA Funding Opportunity Announcement, CDC has defined the Domains in this way: * Domain 1: Epidemiology and surveillance * Domain 2: Environmental approaches that promote health and support and reinforce healthful behaviors * Domain 3: Health system interventions to improve the effective delivery and use of clinical and other preventive services * Domain 4: Community-clinical linkages to support cardiovascular disease (CVD) and diabetes prevention and control efforts and the management of chronic diseases. 1

3 In the survey (see Appendix B) each section explains the strategies, interventions or focus areas covered. Every question using KSAs is the same: Please indicate the level of training you need for the following Knowledge, Skills and Abilities (KSAs). Please also select THREE KSAs that are high priority for training. For each KSA listed in each question, respondents selected the level of training they need for that KSA great deal, some, no training, and not relevant. Respondents then selected their top 3 priority KSAs for each question. (See Appendix A for selected priorities for each question.) Executive Summary This assessment of states training needs focused only on Domains 3 and 4 of the 1305/SPHA strategies; training needs specific to Domains 1 and 2 were not covered. The assessment provides insight into several issues that are useful to consider when planning training for state staff working in Domain 3 or 4: Most state staff are experienced public health practitioners. Working with health systems, accessing their data and influencing their efforts to improve the quality of care for chronic conditions is a new area for most state health department staff working in chronic disease prevention and control. Most state staff working in 1305/SPHA are addressing multiple conditions and risk factors, and no longer working in siloes on only one condition or risk factor. State staff working in the different Domains, or addressing different conditions or risk factors, report similar training needs. Knowledge of current quality improvement efforts by each payer, including their reach was a KSA among the top 5 training needs regardless of who responded. Other KSAs that were selected frequently regardless of the condition or risk factor of primary interest were: o Knowledge of the terminology needed when working with payers, such as payer, insurer, capitated payment, risk sharing, self-insured; o Knowledge of new and traditional health care payment mechanisms, (e.g. fee for service and managed care, Accountable Care Organizations, value-based payment, Patient Centered Medical Homes.) o Knowledge of how to influence the decisions among providers and payers to prioritize (diabetes/hypertension) for measurement, reporting and improvement. Recommendations Agencies and organizations providing training to state staff working on 1305/SPHA should coordinate their efforts, especially CDC, its contractors, and NACDD. This can be done through joint planning teams; use of webinar series rather than one-time-only opportunities, and more widespread use of Virtual Roundtables telephonic meetings for small groups of state staff to discuss content of trainings previously provided. The roles and responsibilities of state staff have shifted, in that most now report working on multiple chronic conditions or risk factors. Therefore, all training opportunities should be offered to all state staff working on 1305/SPHA. This will require wider distribution of all training opportunities, as well as better coordination, as mentioned above. 2

4 Content for training can be presented in several ways including webinar, virtual roundtable discussion, communities of practice, in-person meeting or website. All webinars should be recorded and available for use by state staff. Ideally, content presentation will be followed by opportunities for state-to-state sharing and discussion. Training during Year 2 of 1305/SPHA should focus on the top 5 training needs identified in the assessment. The top training needs are clearly focused on working with health systems to improve the quality of care for patients with hypertension or diabetes. TOP 5 TRAINING NEEDS: 1. KNOWLEDGE OF NEW AND TRADITIONAL HEALTH CARE PAYMENT MECHANISMS 2. ABILITY TO OBTAIN DATA FROM THE LARGE HEALTH SYSTEMS THAT HAVE POPULATION-LEVEL DATA 3. KNOWLEDGE OF CURRENT QUALITY IMPROVEMENT EFFORTS BY EACH PAYER, INCLUDING THEIR REACH 4. ABILITY TO ENGAGE WITH OTHER PAYERS 5. KNOWLEDGE OF HOW TO INFLUENCE THE DECISIONS AMONG PROVIDERS AND PAYERS TO PRIORITIZE HYPERTENSION AND DIABETES FOR MEASUREMENT, REPORTING, AND IMPROVEMENT 3

5 Information about Respondents There were 245 respondents from 49 states and the District of Columbia. Respondents were asked about their years of experience in public health and in chronic disease prevention, as well as their roles and responsibilities in 1305/SPHA. Responses are depicted in Figures 1 and 2 below. Figure 2. Number of years worked in chronic disease prevention or control. 20% 19% 16% 20% Less than 2 years 2 4 years 5 9 years years More than 15 years 25% 4

6 Figure 3. Role in 1305/SPHA program 1305/SPHA Principal Investigator Manager / Director / Coordinator / Domain Lead Staff Domain 1 Responsibilities Domain 2 Responsibilities Domain 3 Responsibilities Domain 4 Responsibilities Evaluator Epidemiologist / Data Manager Chronic Disease Director / other supervisor of 1305/SPHA staff Other Figure 3, above, describes the program responsibilities selected by each respondent. Respondents were allowed to select more than one responsibility. They were also asked to indicate which of the four Domains they worked in primarily, and were allowed to select more than one. roles that had 50% or more respondents working across all 4 domains were: Epidemiologist, Evaluator, Chronic Disease Director, and PI. No program roles reported having 50% or more respondents working only in one domain. 44.7% of respondents who classified themselves as program staff reported working in 2 domains; 39.5% of these respondents reported working in only 1 domain. Among program managers, 39.6% reported working in only 1 domain; 37.4% reported working in two domains NO PROGRAM ROLES REPORTED HAVING 50% OR MORE RESPONDENTS WORKING ONLY IN ONE DOMAIN. - MOST RESPONDENTS REPORTED ADDRESSING MULTIPLE HEALTH ISSUES THAT WERE PREVIOUSLY ADDRESSED THROUGH CATEGORICAL PROGRAMS. 5

7 Figure 4 below describes the responses regarding what chronic disease issue or risk factor in which respondents primarily work. Again, respondents were allowed to select more than one issue or risk factor. Most respondents reported addressing multiple health issues that were previously addressed through categorical programs. Figure 4. Chronic diseases / risk factors addressed by respondents. Diabetes Heart Disease Hypertension Nutrition Obesity Physical Activity School Health Stroke Other Number of Respondents Respondents who reported working on diabetes also reported working on Hypertension 71.3% Obesity 46.6% School Health 29.9% Respondents who reported working on hypertension also reported working on Diabetes 81.0% Obesity 45.1% School Health 28.8% Respondents who reported working on obesity also reported working on Diabetes 81.8% Hypertension 69.7% School Health 58.6% Respondents who reported working on school health also reported working on Diabetes 72.2% Hypertension 61.1% Obesity 80.6% 6

8 Top Training Needs Questions were designed as a list of KSAs needed for a specific 1305/SPHA strategy, intervention or focus area. For each KSA, respondents were asked to identify their level of training need. Based on responses indicating the need for a great deal or some training, the top five training needs are listed below KSA Knowledge of new and traditional health care payment mechanisms, (e.g. fee for service and managed care, Accountable Care Organizations, value-based payment, Patient Centered Medical Homes.) Ability to obtain data from the large health systems that have population level data Knowledge of current quality improvement efforts by each payer, including their reach. Ability to engage with other payers, (i.e. who to meet with, developing projects together, including payers on workgroups and coalitions.) Knowledge of how to influence the decisions among providers and payers to prioritize hypertension and diabetes for measurement, reporting and improvement (This was divided into 2 measures, hypertension and diabetes, which tied in training need.) % Reporting Rank Great Deal or Some training needed 90.6% % % % % 5 Top 5 Training Needs by Categorical Area Top 5 training needs for those who reported primarily addressing Diabetes in their everyday work: KSA % Reporting A Rank Great Deal of Training Knowledge of current quality improvement efforts by each payer, 45.8% 1 including their reach. Knowledge of Stark Laws and their impact on expansion of 42.7% 2 DSME in community settings. Knowledge of how to influence the decisions among providers 42.2% 3 and payers to prioritize diabetes for measurement, reporting and improvement Ability to engage with other payers, (i.e. who to meet with, developing 41.6% 4 projects together, including payers on workgroups and coalitions.) Ability to obtain data from the large health systems that have population-level data 39.1% 5 7

9 Top 5 training needs for those who reported primarily addressing Heart Disease & Stroke in their everyday work: KSA % Reporting A Rank Great Deal of Training Knowledge of current quality improvement efforts by each 46.4% 1 payer, including their reach. Knowledge of how to influence the decisions among providers and payers 38.8% 2 to prioritize hypertension for measurement, reporting and improvement Ability to engage with other payers, (i.e. who to meet with, developing pr 38.7% 3 ojects together, including payers on workgroups and coalitions.) Ability to define and quantify the number of patients in the state who hav 38.5% 4 e hypertension but are not yet diagnosed. Knowledge of Stark Laws and their impact on expansion of DSME in comm unity settings. 36.2% 5 Top 5 training needs for those who reported primarily addressing Physical Activity, Nutrition, and Obesity in their everyday work: KSA % Reporting A Rank Great Deal of Training Knowledge of current quality improvement efforts by each payer, includin 33.7% 1 g their reach. Ability to obtain data from the large health systems that have populationlevel 32.9% 2 data Knowledge of how to influence the decisions among providers and payers 31.3% 3 to prioritize diabetes for measurement, reporting and improvement Knowledge of how to influence the decisions among providers and payers 30.6% 4 to prioritize hypertension for measurement, reporting and improvement Knowledge of new and traditional health care payment mechanisms, (e.g. fee for service and managed care, Accountable Care Organizations, valuebased payment, Patient Centered Medical Homes.) 30.1% 5 8

10 Top 5 training needs for those who reported primarily addressing School Health in their everyday work: KSA % Reporting A Rank Great Deal of Training Knowledge of current quality improvement efforts by each payer, including their reach. Knowledge of new and traditional health care payment mechanisms, (e.g fee for service and managed care, Accountable Care Organizations, valuebased payment, Patient Centered Medical Homes.) Knowledge of Stark Laws and their impact on expansion of DSME in community settings. Ability to engage with other payers, (i.e. who to meet with, developing pr ojects together, including payers on workgroups and coalitions.) Knowledge of the terminology needed when working with payers, such as payer, insurer, capitated payment, risk sharing, self-insured

11 Appendix A Priorities KSAs Identified as Top Priorities with Level of Training Need For each of the following questions, we report on the selected priorities by all respondents, except for Questions 17 and 18. For these school health related questions, we report only the priorities selected by those 72 respondents who reported working primarily in school health. For those respondents reporting that they addressed other primary issues on an everyday basis, we include information under each question. Question 7 * Basic Strategy 4: Promote reporting of blood pressure and A1C measures, and as able, initiate activities that promote clinical innovations, team-based care, and self-monitoring of blood pressure * Enhanced Domain 3, Strategy 1, Intervention: Increase electronic health records (EHR) adoption and the use of health information technology (HIT) to improve performance * Enhanced Domain 3, Strategy 1 Intervention: Increase the institutionalization and monitoring of aggregated/standardized quality measures at the provider and systems level. Question 7 Out of 14 KSAs, these were the top 3 priorities: 1. Ability to define and quantify the number of patients in the state who have hypertension but are not yet diagnosed (53 individuals out of 216 respondents selected this KSA) a. 35.2% (76) of respondents said they need a great deal of training; 39.8% (86) of 2. Ability to obtain data from the large health systems that have population level data (50 individuals out of 216 respondents selected this KSA) a. 36.6% (79) of respondents said they need a great deal of training; 44.0% (95) of 3. Ability to quantify the number of defined health care systems that have reported on National Quality Forum (NQF) Measure 18 or NQF Measure 59 in the past 12 months (45 individuals out of 214 respondents selected this KSA) a. 30.8% (66) of respondents said they need a great deal of training; 41.6% (89) of Because training may be targeted to a specific group or issue, the priorities selected by state staff with different program responsibilities may be relevant, and will be including for each question. PI Manager/ Domain Lead Staff Evaluator Epidemiologist CD Director Total Respondents selecting this KSA as a priority KSA KSA KSA

12 Questions 8, 9 and 10 * Basic Strategy 4: Promote reporting of activities that promote clinical innovations, team-based care, and self- monitoring of blood pressure * Enhanced Domain 3 Strategy 2: Increase use of team-based care in health systems * Enhanced Domain 3 Strategy 2 Intervention: Increase engagement of non-physician team members (i.e., nurses, pharmacists, and patient navigators) in hypertension (HTN) and diabetes management in health care systems Question 8 Care Delivery out of 9 KSAs, these are the top 3 priorities: 1. Knowledge of how to influence the decisions among providers and payers to prioritize hypertension for measurement, reporting and improvement (88 individuals out of 206 respondents selected this KSA) a. 35.4% (73) of respondents said they need a great deal of training; 45.6% (94) of 2. Knowledge of how to influence the decisions among providers and payers to prioritize diabetes for measurement, reporting and improvement (80 individuals out of 204 respondents selected this KSA) a. 38.2% (78) of respondents said they need a great deal of training; 43.6% (89) of 3. Ability to quantify the number of defined health care systems that use EHRs appropriate for treating patients with high blood pressure or diabetes (71 individuals out of 205 respondents selected this KSA) a. 26.8% (55) of respondents said they need a great deal of training; 46.3% (95) of PI Manager/Domain Lead Staff Evaluator Epidemiologist Chronic Disease Director Total Respondents selecting this KSA as a priority KSA KSA KSA Question 9 Working with Providers out of 9 KSAs, these are the top 3 priorities: 1. Ability to quantify the number of defined health care systems with existing policies encouraging multidisciplinary approach to blood pressure control or A1c control (95 individuals out of 204 respondents selected this KSA) a. 31.4% (64) of respondents said they need a great deal of training; 46.1% (94) of 2. Ability to quantify the number of patients in defined health care systems that have policies or systems to encourage a multidisciplinary team approach to blood pressure control or A1c control (76 individuals out of 205 respondents selected this KSA) 11

13 a. 28.8% (59) of respondents said they need a great deal of training; 44.9% (92) of 3. Ability to quantify the number of defined health care systems or the number of patients that are in defined health care systems with policies or systems to encourage patient self-management of high blood pressure (that include SMBP monitoring tied to clinical support as an activity) (76 individuals out of 204 respondents selected this KSA) a. 31.4% (64) of respondents said they need a great deal of training; 40.7% (83) of PI Manager/Domain Lead Staff Evaluator Epidemiologist Chronic Disease Director Total Respondents selecting this KSA as a priority KSA KSA KSA Question 10 Working with Payers out of 6 KSAs, these are the top 3 priorities: 1. Knowledge of new and traditional health care payment mechanisms, (e.g. fee for service and managed care, Accountable Care Organizations, value-based payment, Patient Centered Medical Homes.) (95 individuals out of 207 respondents selected this KSA) a. 37.7% (78) of respondents said they need a great deal of training; 49.8% (103) of 2. Ability to engage with other payers, (i.e. who to meet with, developing projects together, including payers on workgroups and coalitions.) (86 individuals out of 204 respondents selected this KSA) a. 40.7% (83) of respondents said they need a great deal of training; 41.2% (84) of 3. Knowledge of current quality improvement efforts by each payer, including their reach (81 individuals out of 205 respondents selected this KSA) a. 45.9% (94) of respondents said they need a great deal of training; 37.1% (76) of PI Manager/Domain Lead Staff Evaluator Epidemiologist Chronic Disease Director Total Respondents selecting this KSA as a priority KSA KSA KSA Questions 11 and 12 * Basic Strategy 5: Promote awareness of high blood pressure among patients 12

14 * Basic Strategy 6: Promote awareness of prediabetes among people at high risk for type 2 diabetes. * Enhanced Domain 4 Strategy 2 Question 11 - out of 6 KSAs, these are the top 3 priorities: 1. Ability to work with health care systems to quantify the number of patients with a documented diagnosis of high blood pressure in an EHR system (113 individuals out of 202 respondents selected this KSA) a. 29.7% (60) of respondents said they need a great deal of training; 44.6% (90) of 2. Knowledge of the use of hypertension protocols in primary care (91 individuals out of 202 respondents selected this KSA) a. 10.4% (21) of respondents said they need a great deal of training; 58.9% (119) of 3. Knowledge of the barriers to hypertension control, including patient adherence to treatment and clinical inertia (81 individuals out of 199 respondents selected this KSA) a. 18.6% (37) of respondents said they need a great deal of training; 50.3% (100) of PI Manager/Domain Lead Staff Evaluator Epidemiologist Chronic Disease Director Total Respondents selecting this KSA as a priority KSA KSA KSA Question 12 - out of 12 KSAs, these are the top 3 priorities: 1. Ability to develop a communications plan to promote prediabetes awareness messages for 4 key sectors (general public, health care providers and systems, employers and businesses, and payers) (71 individuals out of 200 respondents selected this KSA) a. 19.0% (38) of respondents said they need a great deal of training; 48.5% (97) of 2. Ability to evaluate the impact of prediabetes awareness campaigns (65 individuals out of 199 respondents selected this KSA) a. 19.6% (39) of respondents said they need a great deal of training; 53.3% (106) of 3. Skills in accessing and analyzing data for developing targeted health communication messages and campaigns for 4 key sectors (58 individuals out of 200 respondents selected this KSA) a. 19.5% (39) of respondents said they need a great deal of training; 53.5% (107) of PI Manager/Domain Lead Staff Evaluator Epidemiologist Chronic Disease Director Total Respondents selecting this KSA as a 13

15 priority KSA KSA KSA Questions 13 and 14 * Basic Strategy 7: Promote participation in ADA-recognized, AADE-accredited, state-accredited/ certified, and/or Stanford licensed DSME programs * Enhanced Domain 4 Strategy 1: Increase use of diabetes self-management programs in community settings Question 13 - out of 20 KSAs, these are the top 3 priorities: 1. Ability to speak with payers/health professionals/employers about the return on investment from self-management programs and benefits from a business model of self-management programs (41 individuals out of 190 respondents selected this KSA) a. 34.2% (65) of respondents said they need a great deal of training; 38.9% (74) of 2. Knowledge of effective approaches for promoting provider referrals for DSME such as through the use of EHRs and other technologies (37 individuals out of 191 respondents selected this KSA) a. 32.5% (62) of respondents said they need a great deal of training; 38.7% (74) of 3. Ability to work with partners to get DSME reimbursed by Medicaid (28 individuals out of 191 respondents selected this KSA) a. 22.0% (42) of respondents said they need a great deal of training; 41.4% (79) of PI Manager/Domain Lead Staff Evaluator Epidemiologist Chronic Disease Director Total Respondents selecting this KSA as a priority KSA KSA KSA Question 14 - out of 8 KSAs, these are the top 3 priorities: 1. Ability to quantify the number of Medicaid eligible with diabetes 18 years or older with any coverage for diabetes education (67 individuals out of 189 respondents selected this KSA) a. 19.0% (36) of respondents said they need a great deal of training; 42.9% (81) of 2. Ability to quantify the number of people with diabetes encountering/engaged with a diabetes self-management education program (55 individuals out of 191 respondents selected this KSA) a. 14.7% (28) of respondents said they need a great deal of training; 42.4% (81) of 14

16 3. Ability to quantify the number of new DSME programs and satellite sites established (and associated with CDC funded grantees) (32 individuals out of 187 respondents selected this KSA) a. 9.1% (17) of respondents said they need a great deal of training; 36.9% (69) of PI Manager/Domain Lead Staff Evaluator Epidemiologist Chronic Disease Director Total Respondents selecting this KSA as a priority KSA KSA KSA Question 15 * Enhanced Domain 4 Strategy 3: Increase use of healthcare extenders in the community in support of self-management Question 15 - out of 12 KSAs, these are the top 3 priorities: 1. Knowledge of potential funding sources for sustainable use of healthcare extenders (53 individuals out of 186 respondents selected this KSA) a. 28.0% (52) of respondents said they need a great deal of training; 45.2% (84) of 2. Ability to quantify the number of community pharmacists that promote medication management or patient self-management of diabetes (47 individuals out of 186 respondents selected this KSA) a. 18.8% (35) of respondents said they need a great deal of training; 46.2% (86) of 3. Knowledge of the current regulations, certification and/or licensing requirements for community health workers (43 individuals out of 188 respondents selected this KSA) a. 21.3% (40) of respondents said they need a great deal of training; 40.4% (76) of 15

17 PI Manager/Domain Lead Staff Evaluator Epidemiologist Chronic Disease Director Total Respondents selecting this KSA as a priority KSA KSA KSA Question 16 * Enhanced Domain 4 Strategy 2: Increase use of lifestyle intervention programs in community settings for the primary prevention of type 2 diabetes Question 16 - out of 12 KSAs, these are the top 3 priorities: 1. Ability to work with health care providers/systems to identify/create policies or practices (e.g. EHR reminders/prompts, prescriptions) to refer patients with prediabetes to local CDCrecognized lifestyle change programs (e.g., NDPP/YDPP) (49 individuals out of 185 respondents selected this KSA) a. 25.9% (48) of respondents said they need a great deal of training; 38.9% (72) of 2. Ability to promote to payers/health professionals/employers the return on investment and benefits from a business model from CDC-recognized lifestyle change programs for diabetes prevention (47 individuals out of 184 respondents selected this KSA) a. 31.0% (57) of respondents said they need a great deal of training; 36.4% (67) of 3. Ability to quantify the number of healthcare delivery organizations/entities that have policies or practices to refer persons with prediabetes or at high risk to a CDC-recognized lifestyle change program (40 individuals out of 183 respondents selected this KSA) a. 26.2% (48) of respondents said they need a great deal of training; 40.4% (74) of PI Manager/Domain Lead Staff Evaluator Epidemiologist Chronic Disease Director Total Respondents selecting this KSA as a priority KSA KSA KSA

18 Question 17 and 18 * Enhanced Domain 4 Strategy 5: Implement policies, processes, and protocols in schools to meet the management and care needs of students with chronic conditions (e.g., asthma, food allergies, diabetes, and other chronic conditions related to activity, diet, and weight) Question 17 - out of 9 KSAs, these are the top 3 priorities: 1. Ability to assist school districts in linking student health and educational data to facilitate identification, tracking and referral of students with chronic conditions (18 individuals out of 53 respondents selected this KSA) a. 28.3% (15) of respondents said they need a great deal of training; 34.0% (18) of 2. Ability to assist school districts in creating systems of referrals to community providers for students who fall outside of the healthy weight range or are identified as having a weightrelated chronic condition (13 individuals out of 54 respondents selected this KSA) a. 22.2% (12) of respondents said they need a great deal of training; 34.0% (18) of 3. Knowledge of recommended protocols and procedures for identifying and tracking students with chronic conditions that may require daily or emergency management (12 individuals out of 52 respondents selected this KSA) a. 19.2% (10) of respondents said they need a great deal of training; 46.2% (24) of Unlike the description above, the table below includes all respondents, not just those reporting primary responsibility in school health. PI Manager/Domain Lead Staff Evaluator Epidemiologist Chronic Disease Director Total Respondents selecting this KSA as a priority KSA KSA KSA Question 18 - out of 8 KSAs, these are the top 3 priorities: 1. Ability to persuade schools to collect data on absenteeism (18 individuals out of 52 respondents selected this KSA) a. 26.9% (14) of respondents said they need a great deal of training; 36.5% (19) of 2. Knowledge of reimbursement strategies for enrollment of students in Medicaid and/or management of a condition at a school based health center(17 individuals out of 54 respondents selected this KSA) a. 13.0% (7) of respondents said they need a great deal of training; 51.9% (28) of 17

19 3. (tied with 4) Knowledge of the requirements and use of Individual Health Plan (IHP), Emergency Action Plan (EAP) and 504 Plan in the management of students identified with chronic conditions (14 individuals out of 54 respondents selected this KSA) a. 14.8% (8) of respondents said they need a great deal of training; 51.9% (28) of 4. (tied with 3) Knowledge of eligibility criteria and enrollment processes for Medicaid for students identified with a chronic condition (14 individuals out of 54 respondents selected this KSA) a. 11.1% (6) of respondents said they need a great deal of training; 48.1% (26) of Unlike the description above, the table below includes all respondents, not just those reporting primary responsibility in school health. PI Manager/Domain Lead Staff Evaluator Epidemiologist Chronic Disease Director Total Respondents selecting this KSA as a priority KSA KSA KSA KSA

20 Appendix B Survey 19

21 NACDD Training Needs Assessment Copy Introduction The National Association of Chronic Disease Directors (NACDD) is conducting a survey to assess the training needs of state staff working in Domains 3 and 4 in the State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health (CDC-RFA-DP ) program. (We will refer to this program as 1305/SPHA from this point forward.) The NACDD s CVH, Diabetes and School Health initiatives collaborated to develop this Needs Assessment and used information collected from previous NACDD surveys to inform this one. The purpose of this survey is to identify states' top training needs and the level of training needed. This survey is organized around the primary knowledge, skills and abilities (KSAs) needed to implement 1305/SPHA strategies in both Domains 3 and 4. We would like you to answer the questions in the survey about your own needs, not those of your colleagues or your program. Respondents to this survey should be state health department managers or staff working in any capacity on Domains 3 or 4 in the 1305/SPHA program. In the 1305/SPHA Funding Opportunity Announcement, CDC has defined the Domains in this way: * Domain 1: Epidemiology and surveillance * Domain 2: Environmental approaches that promote health and support and reinforce healthful behaviors * Domain 3: Health system interventions to improve the effective delivery and use of clinical and other preventive services * Domain 4: Community-clinical linkages to support cardiovascular disease (CVD) and diabetes prevention and control efforts and the management of chronic diseases. Aggregated results will be shared with CDC and other partners to plan future trainings. Individual responses will remain confidential. The survey should take no more than 20 minutes of your time. Participation in the survey is voluntary. You may choose to end the survey at any time for any reason without penalty and may choose not to answer any questions at any time for any reason. If you have any questions about this survey, please contact Margaret Casey at mcasey@chronicdisease.org. By clicking Next you give your consent to participate in this survey. * State: 1. What state are you from? 2. Did your state receive Enhanced funding for 1305/SPHA? Yes No 3. How long have you worked in public health? Less than 2 years 2 4 years 5 9 years years More than 15 years

22 NACDD Training Needs Assessment Copy 4. How long have you worked in chronic disease prevention or control, in any capacity? Less than 2 years 2 4 years 5 9 years years More than 15 years 5. What is your role in your state's 1305/SPHA program? Please select all that apply. If none of the answers describes your role, please use the Comment box to describe it. Responsibilities in Domain Responsibilities in Domain Responsibilities in DomainResponsibilities in Domain /SPHA Principal Investigator Manager/Director/Coordinator/Domain Lead Staff Evaluator Epidemiologist/Data Manager Chronic Disease Director, or other supervisor of 1305/SPHA staff Other (Please specify below.) Please describe any other responsibilites/roles you have not covered above:

23 NACDD Training Needs Assessment Copy 6. What chronic disease issue or risk factor do you primarily address in your everyday work? Please select ALL that apply. Diabetes Heart Disease Hypertension Nutrition Obesity Physical activity School Health Stroke Other Other (please specify) Instructions The next sections contain a series of tables describing knowledge, skills and abilities (KSAs) related to 1305/SPHA. For each row within a table, please identify the level of training you need. Then, for each table, please identify the top 3 KSAs on which you would like training. For all the sections in this survey and the related KSAs, indicate the level of training you need by choosing ONLY ONE of the following: * Need a great deal of training (my skills are limited) * Need some training (I know the basics but need more in-depth) * Need no training * This KSA is not relevant to my usual work. For each question, please select THREE KSAs that are high priority for training. Access to Data/Using Data This question asks about your knowledge, skills and abilities (KSAs) to access and use the data required for these 1305/SPHA strategies: * Basic Strategy 4: Promote reporting of blood pressure and A1C measures; and as able, initiate activities that promote clinical innovations, team-based care, and self-monitoring of blood pressure * Enhanced Domain 3, Strategy 1, Intervention: Increase electronic health records (EHR) adoption and the use of health information technology (HIT) to improve performance * Enhanced Domain 3, Strategy 1, Intervention: Increase the institutionalization and monitoring of aggregated/ standardized quality measures at the provider and systems level.

24 NACDD Training Needs Assessment Copy 7. Please indicate the level of training you need for the following Knowledge, Skills and Abilities (KSAs). Please also select THREE KSAs that are high priority for training. Need a great Need some THREE high Need no training Not relevant deal of training training priority KSAs Knowledge of what data exist, who has the datasets and how public health can access the data Knowledge of the strengths and limitations of the datasets Knowledge of how electronic health records work Knowledge of the limitations in reporting high blood pressure in EHRs, (e.g. the need for structured data fields) Knowledge of who the other players are and their roles (RECs, QIOs, CMS, NCQA) Ability to learn which health systems have patient data at the population level Ability to obtain data from the large health systems that have population-level data Knowledge of how Meaningful Use will help promote reporting of BP and A1c measures Knowledge of how the full implementation of the ACA will help promote reporting of BP and A1c measures Ability to develop and implement a data sharing agreement Ability to quantify the number of defined health care systems that have reported on National Quality Forum (NQF) Measure 18 or NQF Measure 59 in the past 12 months Ability to quantify the total number of health care systems in the state (or at the highest level possible) Ability to quantify the total number of patients within healthcare systems in the state (or at the highest level possible) Ability to define and quantify the number of patients in the state who have hypertension but are not yet diagnosed. Please describe any specific training you need: Promoting Clinical Innovations The questions in this section ask about your knowledge, skills and abilities (KSAs) required for these 1305/SPHA strategies: * Basic Strategy 4: Promote reporting of blood pressure and A1C measures; and as able, initiate activities that promote clinical innovations, team-based care, and self-monitoring of blood pressure * Enhanced Domain 3 Strategy 2: Increase use of team-based care in health systems * Enhanced Domain 3 Strategy 2 Intervention: Increase engagement of non-physician team members (i.e., nurses,

25 NACDD Training Needs Assessment Copy pharmacists, and patient navigators) in hypertension (HTN) and diabetes management in health care systems Questions in this section are concerned with care delivery, working with providers, and working with payers. 8. For care delivery and quality improvement, please indicate the level of training you need for the following Knowledge, Skills and Abilities (KSAs). Please also select THREE KSAs that are high priority for training. Need a great Need some THREE high Need no training Not relevant deal of training training priority KSAs Knowledge of the terminology clinical innovations, team-based care, and self-monitoring of blood pressure Knowledge about Patient Centered Medical Homes Knowledge about team-based care Knowledge of the role of the payer in quality improvement, e.g. Medicaid, Medicare, private payers Knowledge of how to influence the decisions among providers and payers to prioritize hypertension for measurement, reporting and improvement Knowledge of how to influence the decisions among providers and payers to prioritize diabetes for measurement, reporting and improvement Knowledge of how registries, clinical decision supports and patient reminders work and the research on how they support chronic disease management Ability to quantify the number of defined health care systems that use EHRs appropriate for treating patients with high blood pressure or diabetes Ability to quantify the number of patients in defined health care systems that use EHRs appropriate for treating high blood pressure or diabetes Please describe any specific training you need:

26 NACDD Training Needs Assessment Copy 9. For working with providers, please indicate the level of training you need for the following Knowledge, Skills and Abilities (KSAs). Please also select THREE KSAs that are high priority for training. Need a great Need some THREE high Need no training Not relevant deal of training training priority KSAs Knowledge of and ability to engage statewide professional organizations that can influence clinical care and health outcomes, such as the use of selfmeasured blood pressure monitoring Knowledge of the role of the team members providing care including physician, nurse, pharmacist, community health worker Knowledge of medication therapy management and its role in hypertension and diabetes control Ability to engage Federally Qualified Community Health Centers (FQHCs) in data driven quality improvement Knowledge of each partner's role in quality improvement Ability to quantify the number of defined health care systems with existing policies encouraging multidisciplinary approach to blood pressure control or A1c control Ability to quantify the number of patients in defined health care systems that have policies or systems to encourage a multidisciplinary team approach to blood pressure control or A1c control Ability to quantify the number of defined health care systems or the number of patients that are in defined health care systems with policies or systems to encourage patient self-management of high blood pressure (that include SMBP monitoring tied to clinical support as an activity) Knowledge of and ability to locate resources related to heart disease and stroke prevention, e.g., Million Hearts; NACDD Domain 3 Resource Guide Please describe any specific training you need:

27 NACDD Training Needs Assessment Copy 10. For working with payers, please indicate the level of training you need for the following Knowledge, Skills and Abilities (KSAs). Please also select THREE KSAs that are high priority for training. Need a great Need some THREE high Need no training Not relevant deal of training training priority KSAs Knowledge of the terminology needed when working with payers, such as payer, insurer, capitated payment, risk sharing, self-insured Knowledge of new and traditional health care payment mechanisms, (e.g. fee for service and managed care, Accountable Care Organizations, value-based payment, Patient Centered Medical Homes.) Ability to engage with Medicaid (i.e. who to meet with, developing projects together, including Medicaid on workgroups and coalitions.) Ability to engage with other payers, (i.e. who to meet with, developing projects together, including payers on workgroups and coalitions.) Knowledge of current quality improvement efforts by each payer, including their reach. Knowledge of the insurers and their reach. Please describe any specific training you need : Community - Clinical Linkages: Awareness of Hypertension and Prediabetes This question asks about your knowledge, skills and abilities (KSAs) required for these 1305/SPHA strategies: * Basic Strategy 5: Promote awareness of high blood pressure among patients * Basic Strategy 6: Promote awareness of prediabetes among people at high risk for type 2 diabetes. * Enhanced Domain 4 Strategy 2

28 NACDD Training Needs Assessment Copy 11. Please indicate the level of training you need for the following Knowledge, Skills and Abilities (KSAs). Please also select THREE KSAs that are high priority for training. Need a great Need some THREE high Need no training Not relevant deal of training training priority KSAs Knowledge of the clinical aspects of hypertension including causes and treatments Knowledge of the current guidelines for hypertension diagnosis, treatment and control Ability to identify areas and populations at greatest risk for hypertension Knowledge of the use of hypertension protocols in primary care Knowledge of the barriers to hypertension control, including patient adherence to treatment and clinical inertia Ability to work with health care systems to quantify the number of patients with a documented diagnosis of high blood pressure in an EHR system Please describe any specific training you need:

29 NACDD Training Needs Assessment Copy 12. Please indicate the level of training you need for the following Knowledge, Skills and Abilities (KSAs). Please also select THREE KSAs that are high priority for training. Need a great Need some THREE high Need no training Not relevant deal of training training priority KSAs Knowledge about existing prediabetes marketing materials for 4 key sectors Ability to use health communication techniques to reach audiences (develop messages, use social and traditional media) Ability to evaluate the impact of prediabetes awareness campaigns Skills in accessing and analyzing data for developing targeted health communication messages and campaigns for 4 key sectors Knowledge about target audiences and the value they place on diabetes prevention Ability to identify the age-adjusted percentage of adults reporting prediabetes in BRFSS Knowledge of the use of diabetes protocols in primary care Knowledge of the clinical aspects of diabetes including causes and treatments Knowledge of the current guidelines for diabetes diagnosis, treatment and control Ability to identify areas and populations at greatest risk for type 2 diabetes Ability to develop a communications plan to promote prediabetes awareness messages for 4 key sectors (general public, health care providers and systems, employers and businesses, and payers) Ability to identify existing prevention/health promotion campaigns where prediabetes awareness can be included Please describe any specific training you need: Community - Clinical Linkages: DSME/DSMP This questions in this section ask about your knowledge, skills and abilities (KSAs) required for these 1305/SPHA strategies: * Basic Strategy 7: Promote participation in ADA-recognized, AADE-accredited, state-accredited/ certified, and/or Stanford licensed DSME programs * Enhanced Domain 4 Strategy 1: Increase use of diabetes self-management programs in community settings

30 NACDD Training Needs Assessment Copy 13. Please indicate the level of training you need for the following Knowledge, Skills and Abilities (KSAs). Please also select THREE KSAs that are high priority for training. Need a great Need some THREE high Need no training Not relevant deal of training training priority KSAs Knowledge of National Standards for Diabetes Self- Management Education (DSME) Knowledge of the content of traditional DSME, the content of the Stanford Diabetes Self-Management (DSMP) and the difference between DSME and Stanford DSMP Knowledge about where to find DSME resources (e.g., Diabetes Training and Technical Assistance Center e- pace training on DSME, NACDD s DSME Resource List, National Standards on DSME, etc.) Knowledge of the stakeholders of DSME/DSMP Knowledge of the barriers to acceptance of Stanford programming by CDEs (Certified Diabetes Knowledge of Stark Laws and their impact on expansion of DSME in community settings. Knowledge of the opportunities and details associated with the State Health Department serving as an umbrella organization for ADA recognition/aade accreditation Ability to work with programs to assist them in getting ADA/AADE recognition/accreditation Ability to work with DSME/DSMP programs to expand their reach Ability to identify areas of need/demand for DSME/DSMP and to work with partners to initiate programs Knowledge of available, reimbursable models of DSME Knowledge of the resistance or other priorities affecting DSME/DSMP reimbursement (e.g., ACA) Knowledge of integration of DSME/DSMP principles for purposes of seeking third-party reimbursement Ability to speak with payers/health professionals/employers about the return on investment from self-management programs and benefits from a business model of self-management programs Ability to work with partners to get DSME reimbursed by Medicaid Knowledge of effective infrastructure models that enhance DSME referrals to high-risk populations Knowledge of effective approaches for promoting provider referrals for DSME such as through the use of EHRs and other technologies Knowledge of how self-management programs interface with ACA 10 essential benefits Ability to speak to providers about referring to DSME programs based on evidence

31 NACDD Training Needs Assessment Copy Knowledge of/skill with social media in promotion of DSME Knowledge of approaches for sustaining DSME programs Please describe any specific training you need: 14. Please indicate the level of training you need for the following Knowledge, Skills and Abilities (KSAs). Please also select THREE KSAs that are high priority for training. Need a great Need some THREE high Need no training Not relevant deal of training training priority KSAs Ability to quantify the number of people with diabetes encountering/engaged with a diabetes self-management education program Ability to quantify the number of new DSME programs and satellite sites established (and associated with CDC funded grantees) Ability to quantify the number of counties with one or more new AADE-accredited, ADA-recognized, or stateaccredited/certified DSME programs established (and associated with CDC funded grantees) Ability to quantify the number of DSMP workshops offered over the funding year (and associated with CDC funded grantees) Ability to quantify the number of counties offering Stanford-licensed DSMP workshops over the funding period (and associated with CDC funded grantees) Ability to quantify the number of Medicaid eligible with diabetes 18 years or older with any coverage for diabetes education Ability to quantify the number of new DSMP workshops offered during the reporting period (and associated with CDC funded grantees) Ability to quantify the number of counties within the state offering one or more new CDSM workshops (and associated with CDC funded grantees) Please describe any specific training you need: Community - Clinical Linkages: Healthcare Extenders This question asks about your knowledge, skills and abilities (KSAs) required for this 1305/SPHA strategy: * Enhanced Domain 4 Strategy 3: Increase use of health-care extenders in the community in support of self-management