Perspectives from the Field: Integration of primary care and public health toward population health improvement

Perspectives from the Field: Integration of primary care and public health toward population health improvement Health Resources and Services Administration Region V Great Lakes Public Health Training Collaborative Draft Summary Report: Inquiry Toward Communities of Practice February, 2016

Acknowledgements Funding Acknowledgment: This project was supported by the Health Resources and Services Administration (HRSA) Regional Public Health Training Center Grant (RPHTC). The purpose of the RPHTC Program is to improve our Nation s public health system by strengthening the technical, scientific, managerial, and leadership competence of the current and future public health workforce. Project Workgroup: The project workgroup includes the Region V Great Lakes Public Health Training Center Collaborative Central Office and Local Performance Sites including faculty and staff from the following Universities: University of Illinois at Chicago School of Public Health, Indiana University Richard M. Fairbanks School of Public Health, the University of Michigan School of Public Health, the University of Minnesota School of Public Health, The Ohio State University College of Public Health, and the University of Wisconsin School of Medicine and Public Health. The overall template and structure for the report was developed by Jessie Jones and Kim Abed at the Michigan Public Health Institute, in collaboration with the Michigan Public Health Training Center at the University of Michigan, School of Public Health. Specific questions about this report may be directed to: Christina Welter, DrPH, MPH Principal Investigator, Great Lake Public Health Training Collaborative Director, MidAmerica Center for Public Health Practice Associate Director, DrPH Program Clinical Assistant Professor, Community Health Sciences Email: cwelte2@uic.edu Phone: 312-355-5303 Working Draft Page 1

Table of Contents Executive Summary... 3 Introduction and Background... 4 Project and Report Purpose... 5 Methods... 6 The Sample... 7 Key Findings... 8 Perceptions and Experiences of Local Health Department Professionals... 8 Overall Summary... 8 Definition of Population Health... 8 Interface of Governmental Public Health and Primary Care... 9 Missed Opportunities for Partnership...10 Barriers to Improving Population Health...11 Future Possible Work, Given Barriers...12 Success Stories...12 Perceptions and Experiences of Health Care Providers...13 Overall Summary...13 Definition of Population Health...13 Interface of Governmental Public Health and Primary Care...14 Missed Opportunities for Partnership...15 Barriers to Improving Population Health...15 Future Possible Work, Given Barriers...16 Success Stories...17 Comparison of Discussions with Local Health Departments and Providers...17 Recommendations...18 Appendix...29 Working Draft Page 2

Executive Summary The Great Lakes Public Health Training Collaborative (GLPHTC) is a Health Resources and Services Administration (HRSA) funded grant to increase workforce and organizational capacity to improve health at the local, state and regional levels. GLPHTC undertook an initiative entitled Inquiry Toward Communities of Practice, starting in 2015, to explore how it might better support local integration of primary care and public health to improve population health. The purpose of the project was threefold: 1) Understand perceptions around population health from primary care and public health audiences; 2) Describe what was working and what needed improvement to promote integration; and, based on recommendations, 3) Develop training and resources to address the gaps. This report summarizes the project findings. Eleven facilitated discussions occurred throughout the six-state region with a total of 100 participants from either primary care or governmental public health communities. Results and recommendations were shared with key stakeholders within the region for further description and feedback. Findings from the conversations suggest that some differences remain between primary care and local public health perceptions of definitions, barriers and opportunities to collaboratively address population health improvement. When asked to define population health, local public health participants used terms such as the public, collective, community, and population, whereas providers used terms such as patient population and target population. When discussing barriers to integration, providers mentioned barriers that impact individuals (for example, transportation) while local public health professionals talked about larger systemic barriers. Finally, when asked to share ideas for future partnerships, providers mostly focused on specific health issues that could be addressed, while local public health professionals were more likely to note systems barriers that could be overcome through partnerships. Several success stories were provided and are highlighted in the document. Several recommendations emerged from the findings that include, but are not limited to, the following: 1) Continue to provide education and training toward a common definition of population health improvement; 2) Provide specific ways and projects to foster integration between governmental public health and clinical care (examples may include data sharing and use, health literacy, and resource and intervention coordination); 3) Provide examples of evidence-based or promising practice interventions that can be a vehicle of coordination; 4) Present case examples of successes, including how the partnership developed and lessons learned; and 5) Provide skills in leading change and partnerships to help overcome barriers. Working Draft Page 3

Introduction and Background The Region V Great Lakes Public Health Training Collaborative (GLPHTC) is a part of a Health Resources and Services Administration-funded public health training program aimed at improving our Nation s public health by strengthening competencies of the current and future public health workforce through education and training services. GLPHTC consists of 6 universities within Region V, including the MidAmerica Center for Public Health Practice at the University of Illinois at Chicago School of Public Health ( UIC SPH, Illinois); the Indiana Public Health Training Center at the Indiana University Richard M. Fairbanks School of Public Health (Indiana); the Michigan Public Health Training Center at the University of Michigan School of Public Health (Michigan); the Midwest Center for Lifelong Learning in Public Health at the University of Minnesota School of Public Health (Minnesota); the Ohio Public Health Training Center at The Ohio State University College of Public Health (Ohio); and the Wisconsin Center for Public Health Education and Training at the University of Wisconsin School of Medicine and Public Health (Wisconsin). Each university is considered a local performance site, or LPS. GLPHTC is an unprecedented partnership to establish and implement a unified strategic approach to improving the workforce development infrastructure of the entire region. With a combined 47 years of public health workforce development experience, the GLPHTC has been formed to build and leverage strengths of the respective organizations toward a common workforce development agenda and maximize resources with the goal of efficiently and effectively addressing national, regional and state-specific public health workforce development needs in HRSA Region V. GLPHTC established a common workforce agenda by undertaking an environmental scan conducted in the Fall and Winter of 2014-2015. The scan included three components: 1) An analysis of the region s 245 trainings; 2) Interviews with regional and national partners for definitions, trends, gaps and opportunities; and 3) A review of published literature and resources for definitions and possible program elements. Findings from this process revealed a strategic theme for the region s focus- capacity building for population health improvement. Results of the environmental scan specifically pointed to: 1) A need for engaged, workforce development initiatives resulting in action or change in the public health system; and 2) Facilitated mutual understanding of and increased partnership between public health departments and the clinical care community toward population health initiatives and efforts at the local level. In response to these findings, GLPHTC designed an overall strategic approach with a bold vision to increase multisectoral, integrated action toward population health improvement across the spectrum of care. GLPHTC also developed three goals to reach its vision over the four years of funding which include the following: 1) Develop a leading change curriculum; 2) Create a Center for Population Health Improvement; and 3) Facilitate an Inquiry Toward Communities of Practice initiative. This report addresses the first steps taken to address Goal 3 - to assess perceptions and understand barriers and facilitate discussions to encourage integration of primary care and public health to promote communities of practice. Working Draft Page 4

Project and Report Purpose 21st century public health, as a discipline, is experiencing monumental change through the implementation of largescope public health initiatives, while profound health and healthcare disparities persist. Collective action with multiple partners is required to address these challenges from upstream, population-based and individual levels. The integration of primary care and public health can provide a powerful partnership to address complexity stemming from large-scale, systemic health and social issues. Efforts to promote collaborative primary care and public health initiatives have been underway for several years (e.g. IOM, 2012), however, opportunity remains for building capacity at the local level to foster integrated population health improvement. The purpose of this report is to summarize the results and recommendations for next steps in the Inquiry Toward Communities of Practice program. The Inquiry Toward Communities of Practice program activity was established using aspects of the pedagogical approach of action learning. Action learning (AI) focuses on the idea that learning occurs much more rapidly when people are put into action solving problems using an approach that integrates the learner s existing knowledge with inquiry and reflection about what is working, what actions can be improved and what can be done differently in the future (Marquardt, Leonard, Freedman, and Hill, 2009). AI is often undertaken in multiple iterative cycles to prompt systematic reflection of lessons learned from each cycle, with the first stage often focusing on problem definition. Using foundational principles of AI, GLPHTC s Year 1 focus was to better understand the current perceptions of population health improvement among public health practitioners and health care providers in the six-state region of the GLPHTC. Perceptions include, but are not limited to, definitions, success stories, needs and gaps, and opportunities toward shared collaboration and workforce development needs. This project represents the leading steps to the pre-action learning process. The objectives of this needs assessment program activity include: Assess the needs for capacity building toward population health; Understand and describe population health definitions, successes, strengths, needs and opportunities toward shared collaboration; Analyze the similarities and differences between clinical care and primary prevention perceptions, strengths and needs around the integration of clinical care and primary prevention initiatives in each state and the region; Increase knowledge and participant understanding of the spectrum of population health initiatives; and Increase agency (self-efficacy/engagement) to conduct joint capacity building activities toward the integration of population health improvement. Working Draft Page 5

Methods Inquiry Toward Communities of Practice, Year 1 activities, were launched following the Region s agreement on its vision, goals and projects that were developed following the environmental scan review. Each Local Performance Site (LPS) in the region hosted facilitated discussions regarding perceptions of population health improvement in July and August of 2015. A total of 11 discussions took place. 1 Results of the discussions were presented to GLPHTC partners, the GLPHTC Regional Advisory Council, and stakeholders in each state for validation of relevancy and discussion of recommendations for strategy developments. Steps of the overall Stage 1 process are outlined in Figure 1. Figure 1. Inquiry Toward Communities of Practice Process The 11 population health improvement discussions included questions regarding definitions, success stories, needs and gaps, and opportunities toward shared collaboration. The focus groups consisted of two distinct stakeholder groups; 1) local public health department (LHDs) health officers and 2) health care providers from Federally Qualified Heath Centers (FQHCs), Community Health Center (CHCs), and rural health centers (RHCs). A comprehensive document, Inquiry Toward Communities of Practice Guidance Document, outlined the protocol for scheduling, recruiting, conducting, recording the discussions, as well as summarizing their contents. This document is available in the Appendix. Discussion facilitators used the focused discussion questions, outlined in the Protocol, to guide each of the conversations. The questions used to guide the facilitated discussions are listed in Table 1. Table 1. Core Discussion Questions Thematic Area Definition of Population Health Interface of Governmental Public Health and Care Missed Opportunities Barriers Future Possible Work Given Barriers Questions and Probes Each discussion should begin with acknowledgement and thank you. What are your conceptualizations or operational definition of population health? (Use the question immediately below if there is need for clarification. As an alternative, you may begin the discussion with live polling about definitions and display the range of definitions as a beginning place for the discussion.) When you hear this term population health - what does it mean to you? How are you interfacing at present with? (Group not in the room: LHDs or FQHCs, CHCs, (RHCs) How are you interfacing at present with nonprofit hospitals? Can you think about and share some examples of partnerships you have made with? (Group not in the room: local health departments or FQHCs, CHCs, RHCs) Can you share an example or two of successful outcomes in your area resulting from these partnerships? Can you think about and share an example of an attempted but not executed partnership with? (Group not in the room: LHDs or FQHCs, CHCs, RHCs) (probe) What might it have taken to succeed with this partnership? What are the more general barriers to improving population health in your area? Given these barriers and constraints, what would you like to be doing to create better integration of primary care and public health practice? (probe) What resources (material and time) would it take to do this? 1 Each state completed 2 facilitated discussions with the exception of 1 state that completed 1. The other is pending completion. Working Draft Page 6

LPS program staff members either facilitated the discussion or were present for each discussion and supported by consultants who served as discussion facilitators. LPS program staff managed the recruitment and registration of discussion participants with support from local partner organizations, provided introductory information to participants, and administered evaluation surveys immediately following the discussions. The majority of discussions were conducted on web-based platforms (such as Adobe Connect); a few of the discussions occurred face-to-face, capitalizing on already scheduled conferences or meetings of stakeholders groups. All discussions were audio-recorded, and a note taker was also present at each discussion. Facilitators were asked to review recordings and notes from each discussion in order to identify content themes that emerged during the conversations. The summary documents for each discussion were submitted to the GLPHTC central office at The UIC SPH. This report outlines a preliminary synthesis of the emerging population health improvement themes identified in the 11 discussions, with an emphasis on: definitions, success stories, needs and gaps, and opportunities toward shared collaboration. Deeper analysis of discussion recordings is underway. It is projected that the report detailing comprehensive findings and implications from this analysis will be available in early 2016. The Sample The Inquiry Discussions that took place across Region V during the time period of June 2015 September 2015 included a total of 100 participants. Participant data from each inquiry discussion was collected from the LPS s and is summarized in Table 2. The participants were from primary care settings, LHDs, and FQHCs. The positions with the highest representation were chief medical officers, nurse practitioners, and medical health officers, with an average of 4 years of experience. In the Health Administrator/Management sector there were a total of 52 representatives with the highest number of representatives working as health commissioners, public health directors, and chief executive officers with an average of 6 years of experience. Of the 25 individuals who identified themselves as a Public Health Professional, positions included public health administrators, health officers, and executive directors with an average of 7 years of experience. There were 9 individuals in the Public Health Nursing sector which had the highest representation from directors/health officers, public health nurses, and adult health supervisors with, on average, over 22 years of experience. There were 2 Health Planners in attendance with an average of 2 years of experience. The Marketing/Public Relations sector had 4 representatives working as marketing specialists, marketing coordinators, and directors of marketing with an average of 5 years of experience. Table 2. Participant title by state Participant Title Participant location Illinois (n=17) Indiana (n=16) Michigan (n=18) Minnesota (n=15) Ohio (n=11) Wisconsin (n=23) Total (n=100) Medical Office 3 2 3 8 Health 5 7 15 6 11 8 52 Administrator/Management Public Health Professional 9 7 5 4 25 Public Health Nurse 2 7 9 Health Planner 2 2 Marketing/Public Relations 4 4 Working Draft Page 7

Key Findings The findings from the Inquiry Discussions are organized into three sections. The first section provides an overview of the themes elicited from participants during the discussions with LHD professionals. The second section provides a summary of the findings, organized under the same thematic headings, which emerged from the conversations with health care providers. The thematic headings are as follows: definition of population health; interface of governmental public health and primary care; missed opportunities for partnership between LHDs and FQHCs, CHCs or RHCs; barriers to improving population health; future possible work, given barriers; and success stories. Finally, the third section provides an overview of the comparison between these two groups. Perceptions and Experiences of Local Health Department Professionals Overall Summary A number of common themes emerged from the discussions among LHD professionals throughout the region. A central theme related to the definition of population health was that most LHD professionals discussed population health as the collective well-being of the population and referenced the social determinants of health as important influences beyond health behaviors. Many brought up the perceived differences in how clinical providers and public health professional define the terms, population, outcomes, and prevention. They noted that their own definition of population health considers a broader population group, outside of just the clients seen in clinics or disease panels served by the provider. When asked about the interface between governmental public health and primary care, LHD participants described the importance of collaborative partnerships and broad coalition efforts that work together to fill service gaps. Many successful partnerships were referenced although many noted several instances in which a lack of partnership exists. They went on to note that this can lead to the duplication of services, competition, and increased service gaps in other areas. When asked about missed opportunities for partnership between LHDs and FQHCs, CHCs, or RHCs, LHD participants talked about how the idea for a partnership was at times easier than finding the capacity to actually initiate it. Others noted that failed attempts at partnership can lead to a perception that partnerships are too difficult or that some organizations don t want to partner. The primary barrier to improving population health, noted by participants, was that further education is needed for the public, health professionals, and partners alike, on how systems and policy change can contribute to population health. They noted that changes in health service systems have restricted funding opportunities and have created difficulty in coordinating resources and staff. Finally, success stories were shared, including accounts of a number of partnerships made with FQHCs that have led to successful outcomes. A more detailed overview of findings under each of the core thematic headings is provided below. Definition of Population Health Definitions of population health revealed several overarching similarities among LHD professionals. Population health is the collective well-being of a population. Participants described population health as addressing the health of the entire community, using datadriven, broad-based interventions. Population health interventions are designed to have the greatest impact on the population at large. Participants indicated that population health and interventions to improve population health are responsive to the needs of the population and environment. Working Draft Page 8

Population health is responsive to the needs of the population and addresses social determinants of health. Participants indicated that services provided to improve population health have been designed based on the needs of the community served, and population health is dependent on the environment of that community. Population health addresses the factors within the places where community members live, work, and play, and have an impact on health for the community as a whole. Population health goes beyond physical and mental health and considers how lifestyle choices, race, gender, socioeconomic status, and other factors work together to influence health. Activities designed to address population health are distinct from delivery of health care services and are aligned with the Institute of Medicine s definition of the Core Functions and the Ten Essential Services for Public Health. Needs Assessment and Health in All Policies were ideas discussed as fundamental elements of population health, specifically in addressing health disparities. Achieving population health requires collaboration. Population health interventions address health through multi-sector efforts. Members of this group indicated that public health leaders are often the connectors and collaborators that bring different sectors together to help them realize their influence on the community s health and well-being. There was not always widespread agreement among participants in each state s discussion groups. For example one discussion yielded differing views on whether or not social wellbeing should be explicitly included in the definition. However, many LHD participants across the state agreed that their own perceptions of population health differed from that of clinical providers. While they view population health as pertaining to the broader population, clinical audiences only focus on those that are in their specific patient population. In one discussion, participants added their belief that health care entities are more focused on increasing profits rather than the prevention of disease. Interface of Governmental Public Health and Primary Care Participants noted many positive experiences interfacing with FQHCs, CHCs, and/or RHCs, as well as more difficult interactions they had experienced. Partnership can increase collaboration around specific health issues. Participants in this discussion provided many examples of successful partnerships that have led to greater availability of services, increased funding, or increased communication around specific health issues or needs. One example included a health officer, who sits on the board of the local FQHC, engaging the two organizations in services aimed to navigate chronic disease patients with needed resources. Another noted a multi-sector partnership that included both the LHD and FQHC focused on improving maternal-child health outcomes in the community. Additionally, participants indicated that they have worked together with the FQHC and other providers in the community to secure grant funding for community efforts; coordinate community needs assessments; emergency preparedness (most recently, Ebola preparation of regional hospitals); delivery of WIC; an oral health referral system; early childhood screening; creation of a network to provide access to mental health services with additional partners beyond the hospital and LHD; and community education. Successful partnerships were often the result of open, ongoing dialogue, and collaboration on community workgroups. In detailing the interface in one rural county, a participant noted we do everything without necessarily calling it population health. Another participant added that working on a Health Improvement Alliance was important. Working Draft Page 9

Partnership can fill identified service gaps. Several participants indicated that they work together with the FQHCs, CHCs, and RHCs in order to complement each other s services, increase capacity in the community, and assure that needed services are provided. Participants shared examples of working together to fill gaps, including experiences where FQHCs were able to pick up a service when the LHD was no longer able to provide it. Others noted how agencies worked together to collaborate, to ensure that services offered previously, are ongoing. Examples addressed dental health, behavioral health, and translation services. In addition, a discussion group offered E-Health and Accountable Communities for Health (ACH) as having an emphasis on collaborative action. However, it was explained that ACH is a collaborative program, but where there is leadership from public health the clinical impact is weak, and where there is leadership from clinical practice the public health impact is weak. Partnerships can lead to a variety of successful outcomes. Examples of successful outcomes resulting from partnerships included programs addressing patient navigation and care coordination; data sharing for community needs assessment; telemedicine services with a focus on mental health; creation of dementia-friendly communities; free dental clinics; or improved referral systems and services to help uninsured and migrant populations. When asked about successful outcomes, one discussion focused more generally on the fact that leadership and access to organizational resources were identified as key - personnel time is necessary to build relationships, public health can bring tools and training, and hospitals have resources to look into data. Further, participants noted that partnerships generally resulted in deeper engagement of clinicians in community planning. There was widespread agreement among the discussion groups that partnerships have a tremendous potential and can be effective tools in population health promotion. However, many participants also noted the challenges associated with creating and sustaining partnerships. Where collaboration has not been successful or has not occurred, there is a perceived lack of engagement and follow-through from the health care providers. Often there is a partnership on paper that is not fully manifest in practice. Participants also noted tension in relationships between the public health department and FQHC caused by duplication of services and a feeling of competition. Several participants shared the perception that the quality and level of interaction was dependent on the FQHC, CHC, or RHC leadership, and that turnover in leadership often leads to gaps in true partnership. Missed Opportunities for Partnership Participants were asked to share examples of attempted but not executed partnerships with FQHCs, CHCs, or RHCs. A few different types of examples illustrating missed opportunities. Difficulty integrating or communicating between technological systems. Many participants from multiple discussion groups noted that some attempts at partnership or collaboration have not been effective due to differences in technology or electronic health records, which have prevented sharing of needed data. Attempts at engagement that fell through due to perceived lack of interest and time. Some participants noted examples where the health department had reached out to partner with the FQHC in their area, but efforts were met with resistance or a lack of interest in participating on the specific project. This led to disappointment and possibly a lack of attempts to partner in other ways. Others noted that the plans for services in partnership were developed but never actualized due to the significant amount of time required for start-up. Working Draft Page 10

Social, political and contextual factors can inhibit partnership. Still others commented that missed opportunities arise from social, political and contextual issues around disease. Participants referenced the Ryan White HIV/AIDS Program, specifically, as a missed opportunity for engagement. In the early days, healthcare providers were not ready for universal testing and it was easier to send the patients over to the public health clinic. Others also noted attempts to partner with academic institutions that did not actualize due to interest/time/resource constraints. Barriers to Improving Population Health When asked to identify the more general barriers to improving population health in their area, participants responses included a few core themes summarized below. Education and awareness among professionals and the public. The primary theme that emerged from the discussion focused on the need to educate the public, health professionals, and partners. Participants noted difficulty getting the community being served to understand the importance of population health. Health care and public health staff training needs and turnover were also issues brought up, that the increased need to provide more information on the collective impact and the level of influence that community groups and agencies have on people becoming healthier. Participants also stated that efforts were needed to help advance the understanding of the effect of actions and policies on population health. Some participants mentioned the tensions between current policies and requirements that constrain efforts to integrate services and develop capacity. Some noted the importance of raising awareness about advocating for needed policies, among the public and professionals. Funding limitations. Public health professionals stated that most of their funding is tied to mandated services which prevents them from using staff time for other purposes. Participants indicated that 501 (3) organizations are now able to apply to funding opportunities that were traditionally open to public health, which is further restricting funding available to health departments to address health needs in the community. In addition, sometimes the grant duration is so short that it can be impossible to do anything that will make any significant changes - We are throwing short-term money and hoping for long term results. Additionally, tensions in some states were noted regarding the lack of available resources for rural health initiatives and perhaps an inequitable distribution between resources for urban versus rural services. Others noted the need for their state to take on more of a leadership role in convening partnerships, identifying and mobilizing resources. The changing health system. Another a prominent theme addressed the difficulty in dealing with larger hospital systems that have absorbed the local community hospitals that LHDs had partnered with in the past. In some instances, the integration of local community hospitals into hospital systems has resulted in difficulty identifying the key personnel with whom to coordinate. Fragmentation, as well as the interests of larger health systems on drawing money out of the smaller communities to offset losses in larger urban communities, were also noted. One participant said that there is often disconnect if a patient moves outside of one system and the health department must take over referral and connectivity. Working Draft Page 11

Health defined as health care. Efforts to improve health largely address treating existing health concerns rather than focusing on primary prevention and collective impact. Participants shared the perspective that health care providers see health in isolation, focusing on the needs of individual patients and not seeing the health of the overall population as within their sphere of responsibility. This is seen as leading to a lack of engagement or interest in collaborative work. Additionally, the culture is reliant on accessing the health care system to treat needs that arise rather than individuals taking responsibility for their own health and health outcomes. Finally, health care reimbursement systems were noted as presenting a barrier to being able to focus on preventive activities. Future Possible Work, Given Barriers When asked to consider what they would like to do to create better integration of primary care and public health practice, given the barriers and constraints listed, some ideas from participants focused on work that is starting to redesign the health care system in their state. Participants stated that they want to work together with the state and primary care providers to create a plan and vision for how population health will be addressed in the future. This included policies and practices, such as a community health assessment, that lead to data-driven decision making to address the highest areas of need, and community linkages and navigation services. A few specific ideas are shared below to illustrate these ideas. Organize around commitment to improve data sharing. One discussion noted that there must be resources to help smaller counties and communities get access to meaningful data. Specifically, better sharing of data, especially around cost and quality; access to meaningful data for planning and execution for smaller clinics; and, incentives for long-term care providers and behavioral health providers to get electronic health records. Increased involvement and communication around needs and interventions. Involvement of local community members in decision-making was discussed, as was the idea of creating a dialogue with stakeholders - listen to what people need and find ways to support what each side needs. Also, including the developers of electronic medical records, in conversations, was suggested. Continue to provide training. Participants discussed the need for more information about the pressure points around ACA and how LHDs can support providers, as well as additional training on the CHNA interface. Participants also noted the need for more leadership training and for increased capacity around collaboration and strategy development. Develop more efficient coordination. Participants noted the large number of coalitions working on the same goals and the need for greater coordination. Success Stories LHD participants reported several successful outcomes resulting from partnerships made with FQHCs in their jurisdiction. One LHD established a unique partnership with their FQHC aimed at increasing healthy eating habits amongst those suffering from chronic disease in their community. As a result of this partnership, the LHD was able to offer primary care physicians an opportunity to provide chronic disease patients with farmers market tokens to be Working Draft Page 12

used for purchasing healthy foods at the local market. The participant noted significant outcomes seen with this initiative, including a decreased chronic disease burden amongst participating patients. Another participant stated that an FQHC in their jurisdiction provides meaningful assistance regarding tuberculosis and communicable diseases within their migrant population. The LHD often experienced barriers to contacting members of the migrant community possibly exposed to a communicable disease, such as tuberculosis. However, through partnering with the FQHC, the LHD has been able to build on the well-established trust and rapport that the FQHC staff have within the migrant population, resulting in an increased success rate in locating those suspected of exposure. Finally, while a specific outcome was not described, one LHD professional called the partnership with their FQHC a model relationship. Key factors contributing to the overall success of their partnership included their ability to complement one another s service offerings, increasing each other s capacity, and fostering an environment of open and ongoing dialogue. Perceptions and Experiences of Health Care Providers Overall Summary A number of common themes emerged from the discussions among health care providers across the states. Most providers defined population health as the health of the community as a whole or groups of patients with similar health concerns. It was also noted that evolving definitions have led to a stronger focus on the social determinants of health. When asked about the interface between governmental public health and primary care, providers stated that collaboration is most often done to serve a common target population. When asked about missed opportunities for partnership between LHDs and FQHCs, CHCs, or RHCs, providers stated they felt as though population health is not a funding priority and this decreases opportunities for partnerships. When asked about barriers, some provider participants noted social determinants such as poverty, as barriers. However, in other cases providers stated individual patient characteristics, such as a lack of knowledge or behavioral follow-through, as barriers in some cases. Participants stated that creating and maintaining partnerships with LHDs, by serving on each other s committees and workgroups, would be mutually beneficial. Open communication was also said to be beneficial. Finally, success stories were shared, including many examples of successful outcomes as a result of partnerships with LHDs, such as efforts to collaborate through WIC clinics or on specific vaccine campaigns. A more detailed overview of findings, under each of the core thematic headings, is provided below. Definition of Population Health A number of core themes emerged from the discussion when participants were asked to provide a definition of population health. Population health focuses on the needs of a community instead of an individual. This group s definition of population health considered the community as a whole, and groups of patients with similar health concerns, rather than individuals. Provider participants noted that a greater focus should be placed on quality indicators directed toward patient-centered medical homes, closing gaps in care, as well Working Draft Page 13

as using more evidence-based (sometimes referred to as data-driven ) clinical guidelines and the universal application of said guidelines. Community Health Assessment was mentioned as a mechanism for better comprehending the population health needs. The tension between focusing on group health status versus individual outcomes was noted in one discussion. A specific comment from a health systems representative was that the emphasis on individual outcomes is coming from payers. Population health focuses on addressing root causes rather than physiological/biological causes of diseases. Provider participants discussed the importance of focusing on social determinants of health and disease prevention. They discussed the need to further emphasize the contributing factors of disease and identifying and working on addressing emerging health concerns affecting the population and their communities. Some discussions noted that the definition evolves over time, going from a biological model and moving towards a more comprehensive psychosocial model. Broadly speaking, there was acknowledgement of the importance of social determinants and a broader focus on entire communities. Some participants referred back to very specific, targeted examples in their work. Such participants conceptualized population health as the population that is assigned as patients or part of a disease panel. One noted, In our area, it has to do with the demographic information; people that we re serving and the kind of health care issues we re seeing from our FQHCs. In this respect, the definition reflects a more narrow view of population health than was articulated by other health providers. Truly serving the community beyond an existing patient set was viewed as a challenge in practice. As one provider participant noted, The focus for our organization has been through the eyes of primary care: chronic disease management, behavioral health, etc. What we can do outside our clinics is a different issue. Interface of Governmental Public Health and Primary Care Provider participants were asked whether and how they are currently interfacing with LHDs and LHD professionals. Most participants noted at least some level of collaboration with LHDs in serving a common population. They indicated the following ways in which they work together: Collaboration on services Participants in the discussion indicated that they work with LHDs in a variety of ways, including: working together to coordinate services for community members, such as tracking vaccines and STI surveillance; setting up or maintaining needle exchange programs; prenatal initiatives; health screenings for young children; and dental care. Participants also noted that they work with LHDs through data sharing activities. Additionally, some participants said that when the LHD in their community is unable to continue a service, their organization has picked up the service so that it is still available. Additionally, a cooperative grant application between an FQHC and LHD was provided as an example of collaboration toward integrated service delivery. Collaboration through workgroups, task forces, coalitions, etc. Participants noted interfacing with LHDs through community workgroups, including groups such as an infant mortality task force; a rural health cooperative focused on the reduction of binge drinking; a wellness coalition partnered with schools, businesses, libraries and senior centers; and groups developing community health assessments and health improvement plans. In addition, the Statewide Health Improvement Program (SHIP) was discussed as an interfacing activity with promise. Working Draft Page 14

A number of successful outcomes resulting from partnerships with LHDs were noted by participants. When asked to describe examples, the core theme emerging from the discussion concerned working together on case management and care coordination, and directing individuals in need of care to appropriate services. Another example included the ways in which LHDs and nonprofit hospitals have collaborated, including aligning IT systems, collaborating on leadership teams, agreements for care, and hospital discharge follow-up activities. Missed Opportunities for Partnership Participants were asked to describe missed opportunities for partnership with LHDs as well. Participants described examples of both partnerships that failed to come to fruition, as well as those that were initiated yet failed in some way. Characteristics of unsuccessful partnerships and unsuccessful attempts at partnership included the following. Perceptions of competition. Some participants said that their organizations offered similar services to those offered by LHDs in their jurisdictions. This contributed to a perceived competition which prevented collaboration. Participants noted that it would be better if they could coordinate to fulfill health needs rather than compete to provide services. Differing priorities. Some participants noted that population health, or community wellness, was not prioritized by all parties and therefore collaboration was not possible. Although this idea may also be understood as a barrier to improving population health, discussion about limited interest in population level wellness surfaced during detail sharing about missed opportunities for partnership. Data-sharing challenges. Participants stated that in many jurisdictions data is not available, not accessible, and/or not shareable. Some also said that prohibitive costs may be associated with some kinds of data sharing or access. Examples of such data included recent hospitalization and discharge summaries to share statewide. This also may be understood as a barrier, but it did emerge during these discussions focused on opportunities missed. On a similar note, participants stated that in some cases university researchers want to use patient populations for their research. Providers said they feel that they have to say no, due to scarcity of resources. Lack of state level leadership and prioritization. A few participants noted that state level leaders, including governors, have not valued or prioritized public health, thereby creating an environment that is not conducive to collaboration. Participants stated this lack of leadership has caused public health to lose status as an issue of importance and has decreased funding opportunities. Barriers to Improving Population Health Several themes emerged from the conversation around barriers to improving population health in the areas served by the health care provider organizations Transportation barriers. Several participants noted lack of available transportation as a barrier to getting patients to come for appointments and needed care. This barrier was communicated as often being related to the provider s impoverished patient population and/or the rural nature of certain communities. Working Draft Page 15

Literacy and language barriers. Participants noted that low levels of literacy among the patient population, due to lack of education and language barriers, can often serve as a barrier to the provision of effective care. Participants stated that these barriers lead to patients having difficulty understanding and working through care plans. Many of the literacy and language barriers were attributed to the very diverse population served by the organizations that the participants represented. Awareness and education about the importance of prevention. Discussion participants noted that education levels and cultural differences led to difficulties in patients understanding the importance of prevention and adhering to positive health behaviors. Similarly, participants noted that in addition to public education, the provider population and health care administrator population need education around their role in population health. They reported a lack of clarity about the role of health care institutions in addressing social determinants of health. Additional barriers mentioned included limited technological resources and limited funding, in general, to address many of the above-mentioned barriers. Participants indicated that they are limited in what they are able to do to address the transportation, literacy, language, and education barriers, due to funding. Funding challenges are exacerbated by difficulties in sustaining grant programs and in the way payment systems are structured. An example provided is payers focus on acute rather than preventive care. An additional example is the lack of focus on sustainability planning. Participants talked about programs that are run by volunteers, and then programs/services tend to diminish after a couple years. Finally, participants reiterated the missed opportunity, noted above, regarding the lack of leadership and the failure to establish key strategic relationships. One of the advantages we have in our location is that we are one county with routine communication with our LHD. We know who to go to You need an ongoing relationship. We meet quarterly with the LHD with the Health Access project and others. We talk about what is happening and what the needs are. That trusting relationship helps. Future Possible Work, Given Barriers When asked what they would like to do to create better integration of primary care and public health practice, given the barriers they face, a number of themes emerged from discussions with participants. Create and participate in opportunities for partnership with LHDs. Participants indicated that they would look for additional ways to partner with LHDs in the future, including serving on each other s committees and workgroups. A potential outcome of collaborative efforts, noted, was identifying available resources and limitations and working with those to create mutual benefit while also meeting the needs of the community. Additionally, participants said that regular and open communication with LHDs, to discuss ways in which they can work together, would be beneficial to the population s health. Participants expressed that partnering with LHDs, and the initiatives on which they have worked collaboratively, have left them well-positioned to act within health care and payment reform. Training. Participants noted the need for leadership trainings. Participants also stated the need for support and capacity building around developing clear public health messaging and disseminating the message to the community. Participants said that current trainings are focused on the day-to-day operation of clinics, yet Working Draft Page 16

more is needed about working with LHDs and developing sustainable partnerships. Additional ideas for trainings included certification for medical directors; training for the ACA and how to meet the requirements that are being put into place; and the provision of CME for integration courses. Success Stories Participants were able to identify and share many examples of successful outcomes experienced in their area, resulting from partnerships made with local health departments. One FQHC provider reflected upon the success of their partnership with an LHD during the H1N1 outbreak in their community. By organizing a coordinated effort, the FQHC and LHD were able to bring the community together around this issue, and provide community members with important public health information. While successful outcomes were seen in time-limited initiatives, such as the H1N1 outbreak, other participants shared successful outcomes experienced as a result of ongoing partnership made with LHDs. For example, one FQHC provider noted that the decision to have a LHD WIC clinic located within their center has provided them with a unique opportunity to provide outreach to encourage the immigrant population within their community to participate in their health care. By having the WIC clinic on-site, the FQHC can ensure newborns are receiving appropriate care and vaccinations from the WIC staff before transfer to the medical staff at the Center, for ongoing or future health care needs. Comparison of LHD and Provider Discussions There were several areas of overlap between the two different participant groups. However, a few distinct areas of divergence including the following: When asked to define population health, LHD participants used terms such as the public, collective, community, and population, whereas providers used terms such as patient population and target population. Explanations of primary barriers differed. Providers see barriers that impact individuals (for example, transportation) and LHD professional articulate larger systemic barriers. When asked to share ideas for future partnerships, providers mostly focused on specific health issues that could be addressed, whereas LHD professionals were more likely to note systems barriers that could be overcome through partnerships. Table 3 shows a side by side comparison overview of the themes revealed by each participant group. Table 3. Comparison of LHD and Provider Discussions Topics Local Health Department Professionals Health Care Providers Definition of Population Health Collective well-being of the population The health of the community as a whole Social determinants of health Groups of patients with similar Differences in definitions of health concerns population, outcomes, and prevention Focus on the social determinants of health Interface of Collaborative partnerships Collaboration to serve a Governmental Public Duplication of services, competition common target population Health and Primary Care Increased service gaps in other areas Working Draft Page 17

Missed Opportunities for Partnership Between LHDs and FQHCs, CHCs, or RHCs Barriers to Improving Population Health Future Possible Work, Given Barriers The idea for a partnership is greater than the capacity Difficulty in initiating partnerships and failed past attempts prevent future attempts Further education is needed about systems and policy change Restricted funding causes difficulty in coordinating resources and staff Redesign the health care system to address population health Inclusivity of community Population health is not a priority among funders Competing services prevents working together to improve health Social determinants Individual patient characteristics Population health improvement is not seen as a priority Creating and maintaining partnerships with LHDs around specific health issues Success Stories Partnerships made with FQHCs Partnerships with LHDs Recommendations The following recommendations emerged from presenting and discussing the results of the project within the GLPHTC workgroup and with key stakeholder engaged in the GLPHTC work. 1. Differences in the understanding of population health improvement remain. There appears to be a significant opportunity to provide awareness building around the importance of community-based population health across all sectors and including the public. More effort needs to be put into making sure everyone has the same (or at least similar) understanding of the work. 2. Foster opportunities for governmental public health to interface with clinical care including, but not limited to, community health clinics and FQHCs. Facilitate focused, targeted projects between clinical care and governmental public health. For example, continue to provide training on how to facilitate partnership in focused ways, such as on how clinical care communities and governmental public health can collaborate on community health assessments and implementation of shared priorities. 3. Explore barriers to clinical care and primary prevention partnerships even more deeply, specifically around data sharing. Data sharing and use was a predominate theme in the results that may inhibit partnerships and could facilitate coordination and opportunity to measure shared outcomes. 4. Training on health literacy is needed. Providers and professionals need support in developing health communications approaches that would raise the clients and community members awareness of community health needs, their own health needs and other issues, such as access to care, etc. 5. Provide workforce development, across all sectors that is focused on the awareness and implementation of evidence-based or promising practices, including policy and programming interventions. 6. Provide workforce development programming on both strategies that lead to collaboration and awareness around existing collaboration that highlight partnerships occurring. Facilitate understanding of ways to prevent duplication and share lessons learned to promote greater alignment and leveraging of existing partnerships across the region. 7. The need for leadership skills required to build collaboration and implementation of cross-cutting interventions, remains high. Working Draft Page 18

Appendix Inquiry Toward Communities of Practice Guidance Document Overview This document has been created to formalize the standardization process for the Region V GLPHTC Inquiry Toward Communities of Practice programming activity. Although we assume that there will be slight variation in the administration of this program from one Local Performance Site (LPS) to another, we aim to conduct the program in a uniform fashion, meaning that the general structure, content and procedures of each program (inquiry discussion) are similar in each state in the Region V Collaborative. This guidance is intended to clarify project elements so as to maximize the uniformity of the inquiry discussions. Project Background: From multiple sources of information collected during our Region V GLPHTC environmental scan on population health improvement, the following problem(s) were identified: Primary prevention funding is quite limited (and/or requires new skills to obtain) for governmental public health. Funding for population health improvement is largely directed to the clinical care sector. The definitions and processes to undertake population health improvement appear to be largely clinical in nature and may not represent a comprehensive community approach to public health improvement. There are many efforts to transform governmental public health and foster collaboration with clinical care at the national level. Reportedly there are few efforts driven at the local level and few efforts are in a coordinated, centralized location. Given these challenges, the GLPHTC is engaged in workforce capacity building and development activities focused on population health at the interface of health care delivery and public health practice, By using this approach, we see great opportunity to develop and maintain integrated action toward population health improvement across the spectrum of care. Working Draft Page 19

A starting place to attaining increased and integrated multi-sectoral action is to engage varied constituents in dialogue about population health. Specifically, the Inquiry Toward Communities of Practice program is a means to: 1) convene stakeholders; 2) begin a dialogue about experiences with the interface between health care delivery and public health practice; and 3) foster or extend relationships between and among public health clinicians and administrators in the process of forming communities of practice. Inquiry Toward Communities of Practice is one of three programming components in the Region V GLPHTC program conceptual model, the others being a Population Health Improvement Center and Leading Change Institute (see model below). Definition of inquiry-based learning to drive communities of practice Inquiry-based learning is an approach to document, understand, increase awareness, and raise consciousness about problems and opportunities in a community. If done well, the process culminates in multi-sectoral communities of practice addressing joint local integration projects to drive population health improvement. Generally, the procedures used in the Region V GLPHTC Inquiry Toward Communities of Practice included: The development of a standardized focused conversation guide that provides a list of questions about perceptions of population health improvement that inquire about definitions, success stories, needs and Working Draft Page 20