Advancing Health Equity and Improving Health for All through a Systems Approach Presentation to the Public Health Association of Nebraska

Advancing Health Equity and Improving Health for All through a Systems Approach Presentation to the Public Health Association of Nebraska Lisa F. Waddell, MD, MPH Chief Program Officer Association of State and Territorial Health Officials September 30, 2016

Objectives Provide a brief overview of the Association of State and Territorial Health Officials (ASTHO) Highlight the 2016 ASTHO Presidential Challenge: Advancing Health Equity and Optimal Health for All and Outline a Triple AIM for Health Equity Highlight a Systems Approach and the Use of Learning Collaboratives and Communities to Improve Health Stimulate thinking about the role of multi sectoral collaborations and partnerships as a necessary frame to advance health equity and improve health for all Lessons Learned and Keys for Success

Association of State and Territorial Health Officials (ASTHO) Represents U.S., U.S. Territories and Freely Associated States, and D.C. public health agencies Tracks, evaluates, provides TA, and advises on the impact and formation of public or private health policy Members: chief health officials of these jurisdictions Convene governmental and nongovernmental agencies Engage clinical and community partners Leverage and link data to collaborate with public and private payers to drive payment policy reforms Raise visibility among a broader community of policymakers, funders

Support S/T Health Officials as Successful Transformational Leaders Strengthen the Capacity of S/T Public Health Agencies Improve Health Equity and Population Health Outcomes Through Transformational Leadership Serve as the Collective Voice for S/T Public Health Promote a Culture of Health and Safety Across Sectors Increase ASTHO Organizational Effectiveness and Sustainability Association of State and Territorial Health Officials Provide Effective, Efficient and Sustainable SHO Onboarding Provide Ongoing Support Across the SHO Experience Enhance Peer Connections and Mentoring Improve Communication and Messaging Develop the Current and Future Public Health Workforce Develop Informatics Capability Build Consensus on Challenging Issues Develop and Implement a Focused Federal Advocacy Agenda Coordinate Rapid Response to Public Health Threats Provide Support for Implementation of Health in All Policies Harmonize Data and Expertise Across Sectors to Inform Approaches Foster the Coordination of Public Health and Health Care Implement an Enterprise-Wide Knowledge Management System Strengthen Board Governance Strengthen Workforce Development and Management Strategic Map: 2016-2018 Provide Expert Consultation and Technical Assistance Prioritize and Develop Evolving Capabilities and Skills Represent the Voice of Members with Governmental and Cross-Sector Partners Develop the S/T Role in the Interface of Human, Animal and Environmental Health Build a Sustainable Financial and Organizational Model Engage S/THOs With Other Leaders In Public Health and Across Sectors Cultivate Diversity, Inclusion and Cultural Competence Serve as a Thought Leader on S/T Public Health Practice, Policy, Research & Analytics Disseminate Innovative and Evidence-Based Approaches Strengthen and Expand Situational Awareness Increase Collaboration and Alignment with Affiliates Strengthen the Mechanisms to Amplify the Voice of ASTHO Strengthen Partnerships Across the Public Health Enterprise Expand the Understanding of What Creates Health and Engage with Key Partners Cultivate Continuous Quality Improvement

5 ASTHO 20 Affiliates Representing state and local public health expertise

Definitions - What is Health Equity Health Disparities Differences in health status among segments of the population including those due to gender, race/ethnicity, income, education, disability, geographic locations Health Inequity Differences in health/health care that are systemic or avoidable and therefore, considered unfair or unjust Health Equity Achieving the highest level of health for all people

Healthy People 2020 Nation s Health Promotion and Disease Prevention Agenda Builds on the vision outlined in HP 2010 with a vision of a society in which all people live long, healthy lives 4 Overarching Goals for the Country Attain high-quality, longer lives free of preventable disease, disability, injury and premature death Achieve health equity, eliminate disparities, and improve health of all groups Create social and physical environments that promote good health for all Promote quality of life, healthy development, and healthy behaviors across all life stages

When you are backed in a corner What do you do?

We need to move UPSTREAM Tackle the Social Determinants of Health Education, Housing, Public Transportation, Employment Opportunities, Pubic Safety and More

2016 ASTHO Presidential Challenge Advancing Health Equity and Achieving Optimal Health for All

We need a Triple Aim for Health Equity

Triple AIM of Health Equity Expand our Understanding of What Creates Health Implement a Health in All Policies (HiAP) with Health Equity as a Goal Strengthen the Capacity of Communities to Create Their Own Healthy Futures

ASTHO s 2016 President s Challenge Advance Health Equity and Optimal Health for All http://www.astho.org/health- Equity/2016-Challenge/

Why Does it Matter? Why Should we Care?

Infant Mortality 2013 Preterm Birth 2014 4.2-5.3 5.6-6.8 6.9-7.9 8.6-9.6 SOURCE: Kaiser Family Foundation (Map). Matthews, TJ, M.S., et. al. Infant Mortality Statistics from the 2013 Period Linked Birth/Infant Death Data Set. Division of Vital Statistics, CDC. National Vital Statistics Report 64 (9), August 6, 2015. SOURCE: CDC/NCHS, National Vital Statistics System, mortality data set.

Selection of ASTHO Learning Collaboratives WA CA OR NV ID UT MT WY CO ND SD NE KS MN IA MO WI IL MI OH IN KY WV PA VA ME VT NH NY NJ MA CT RI DE AZ NM OK AR TN SC NC MD AK HI TX LA MS AL GA FL DC Healthy Aging Million Hearts AS FM GU MP PW PR VI LARC 2 or more

ASTHO Million Hearts Learning Collaborative The Million Hearts Initiative is focusing, coordinating and enhancing cardiovascular disease prevention activities across public and private sectors in an effort to prevent 1 million heart attacks and strokes by 2017 and demonstrate that improving the health system can save lives. ASTHO s Million Hearts Learning Collaborative aims to assist state health agencies in achieving the goal of Million Hearts by supporting them in integrating efforts with health care and other partners to control blood pressure. The states are using a quality improvement process to partner across sectors including clinical, community,public health and others to implement practices and policies to identity, control and improve blood pressure.

ASTHO Million Hearts State Learning Collaborative Goals Improve hypertension control and to achieve the national Million Hearts goal. Increase the percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose BP was adequately controlled during the measurement year Identify and build networks and cross-sector partnerships to control hypertension. Test models for collaboration between public health, health care, and community partners. Experience a QI process to affect practice and policy at all levels of the system.

Million Hearts Collaborative State Team Members State Health Agency lead Senior Deputy Public or Private Health Plan Local Health Department Clinical Provider Community Partner Health IT Expertise Regional Partners Health Equity/Diversity Expertise QIO or Community Health Center Networks National Partners American Heart Association Association of Health Insurance Plans Association of Public Health Nurses National Association of Community Health Centers National Association of Chronic Disease Directors National Association of County and City Health Officials National Forum for Heart Disease and Stroke National Association of Medicaid Directors YMCA of the USA

Comprehensive Systems Approach

ASTHO Systems Change Framework

New York: Strengthening Data Systems for Clinical and Population Health Goal: To leverage existing data systems to improve hypertension control within clinical settings and across populations in target communities. Strategy: Establish standardized methods of data surveillance and analysis to target clinical and population-level interventions Statewide standardized hypertension measures Regional Health Information Exchange and Medicaid data analysis Use EHR and public health data Outcomes: Improved hypertension control rates across FQHCs by 18.7% in roughly 18 months.

Data-Driven Action Illinois: Using hospital discharge data to inform standardized community wide BP screening and referral protocols S.Anton Slide

Oklahoma: Building Community-Clinical Linkages to Improve Hypertension Management Goal: To enhance the connection between patients clinical and community settings to create a supportive continuum of care for optimal hypertension management. Strategy: Heartland OK is a public health nurse-driven referral and care coordination system that connects patients with hypertension to community services through a public health nurse care coordinator. Outcomes: 25 percent of patients participating achieved blood pressure control within 90 days. Calculated ROI of $160:$1.

New Hampshire: Standardizing Protocols and Practices for Hypertension Detection and Management Goal: To streamline hypertension detection, referral, and management within and across clinical settings Strategy: Create standardized training, protocols, registries, and referral, and medication algorithms for high blood pressure detection, management and control. 10 Steps for Improving Hypertension Control in New Hampshire Outcomes: Hypertension control improved by an average of 11 percent in participating clinics.

Public Private Traditional and Non-Traditional Partners

Through this systems change model, the collaborative has:

ASTHO Long-Acting Reversible Contraception (LARC) Learning Community MT CO IA IN DE MD MA NM TX OK LA SC GA LARC Learning Community Cohort 1 States LARC Learning Community Cohort 2 States ASTHO, with support from the CDC s Division of Reproductive Health (DRH), formed the LARC Learning Community to focus on improving state capacity to successfully implement LARC immediately postpartum (IPP).

What is LARC? Long Acting Reversible Contraception (LARC) includes intrauterine devices (IUDs) and hormonal implants. IUDs and implants are the most effective form of reversible birth control available Failure rate is less than 1 percent LARC devices are safe and are recommended for most women and adolescents Despite a recent increase in use, fewer than nine percent of US women were using LARC in 2013

ASTHO LARC Immediately Postpartum (IPP) Learning Community Improve state capacity to improve access to voluntary IPP LARCs Facilitate state-to-state sharing Provide technical assistance Develop state stories, tools, and a toolkit on state solutions and materials Funder: CDC Division of Reproductive Health Partners: ACOG, AMCHP, CDC, CMS, NFPRHA, OPA

Systems Approach for Voluntary IPP LARC Labor & Delivery Policy Coding Training and Tools Billing Stocking & Supply Insurance Evaluation & QI Prenatal Service Location

Re-cap ASTHO is a key influential national organization representing the chief public health officials The Bar and Expectation to address health disparities has moved from reducing health disparities to eliminating health disparities, to achieving health equity ASTHO President is using his Presidential platform and national visibility to articulate and advance the work to Achieve Health Equity and Optional Health for All through the frame a Triple AIM for Health Equity We must move upstream to address the Social Determinants of Health and use Comprehensive Systems Approach to address the complex health issues facing our states and communities. Learning communities and collaboratives provide a facilitated and structured way to bring key partners and many voices together and share best practices

Dr W s - 4 S s for Success Science http://www.thecommunityguide.org/healthequity/index.html Systems Strategy Story

Leadership and Relationships Leadership Relationships Focus Winning Attitude Passion Team

TOGETHER We can Achieve Health Equity and Attain the Highest Level of Health for All

Thank You www.astho.org/programs/health-equity/ Lisa F. Waddell, MD, MPH Chief Program Officer Community Health and Prevention lwaddell@astho.org -