Transcript Coordinated Chronic Disease and Health Promotion Program

CCDPHP Grant and State
Strategic Plan
Linda Scarpetta, MPH, DCDIC
Integration Coordinator
MCC Board of Directors Meeting
September 19, 2012
Overview of CCDPHP Grant
• CDC provided grants to all state health
departments in Sept 2011
• Purpose:
– Build and strengthen state health department
capacity and expertise to effectively prevent
chronic disease and promote health
– Maximize reach of categorical programs
– Provide leadership and expertise to work
collaboratively across conditions and risk
factors
Overarching Areas
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Communication
Epidemiology/Surveillance
Evaluation
Health Systems Improvements
Community Mobilization
Community Linkages
Health Disparities
Policy and Environmental Change
Partnerships
Strategic Planning Process
Futures
Planning
DCDIC Managers and
Staff
Cross-cutting Efforts
and Key Partners
MDCH PHA and CrossCutting Partners
State Plan Strategies and Objectives
Cross-Cutting and Categorical
Partners
State Plan Expansion
Expanded Agency/Organizational Partners and
Non-Traditional Partners
CDC Expectations for State CCDPHP Plans
• Reduce burden of chronic disease and
injuries/violence in the state as a whole
• Include strategies led by governmental
and non-governmental partners
• Address the four domains
• Address health disparities and achieve
health equity
• Living document
• Consistent with existing categorical plans
CDC State Plan Guidance
• Goals, strategies and objectives will achieve
major population-level change
• Reach large numbers of people in the state
• Strategies and objectives should be of interest to
multiple programs and partners, impact multiple
diseases, outcomes and/or risk factors
• A coordinated effort of multiple partnerships with
organizations that can achieve large-scale
systems changes affecting multiple diseases or
risk factors
Michigan’s CCDPHP State Plan
Aligns with 3 major initiatives:
• MI Health & Wellness 4x4 Plan
• MI Primary Care Transformation Project
• Community Linkages – Pathways/Community
HUB Project
Rationale for Selection of Initiatives
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Cross-cutting
Evidence-based
Broad reach
Mutually synergistic with CD and injury efforts
Systems level change
Diverse partners
Address social determinants of health/health
disparities
• Encompass 4 CDC domain areas
• Potential for greatest impact
Innovation Driven US Health Care System Evolution
Anthony Rodgers, CMMI
Health System Transformation and Evolution Critical Path
Uncoordinated Health
Care System 1.0
Efficient &
Accountable Care
Episodic
Non Integrated
Care
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Episodic Health Care
o Sick care focus
o Uncoordinated care
o High use of Emergency Care
o Multiple clinical records
o Fragmentation of care
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Lack integrated care networks
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Lack of integration between acute and
long-term care settings
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Lack quality and cost performance
transparency
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Poorly coordinated Chronic Care
Management
Community Integrated
Health Care System 3.0
Community
Community
Integrated
Integrated
Healthcare
Healthcare
Coordinated Seamless
Health Care System 2.0
Patient/Person Centered
Transparent Cost and Quality Performance
o Results-oriented
o Assures Access to Care
o Improves Patient Experience
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Accountable provider networks designed
around the patient, including LTC needs
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Shared Financial Risk
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HIT integrated
Focus on care management and preventive
care
o Primary Care Medical Homes
o Care management/ prevention focused
o Shared Decision-Making and Patient
Self-Management
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Patient, Population, and Community-Centered
o Community Health Resource Linked
o Cost, Quality, and Population Health
Outcome Transparency
o Community Healthy Living Choices
Community Health Integrated networks capable of
addressing psychosocial, economic and LTC needs
Right care, at right time, in right setting
Population-based reimbursement
Learning Organization: Capable of rapid
deployment of Best Practices
Community Health Integrated
o Community Healthy Living Oriented
o Community Health Capacity Builder
o Community based support developer
o Shared community health responsibility
E-health and tele-health capable
o Wide use of remote monitoring and telehealth and e-health management
o Health E-Learning resources, social
networking, health literacy tools
Four Domains
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Epidemiology and Surveillance
Environmental Approaches
Health Systems Interventions
Clinic-Community Linkages
MI Health & Wellness 4x4 Plan
Healthy Behaviors
Health Measures
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Maintain a healthy diet
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Body mass index (BMI)
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Engage in regular exercise
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Blood pressure
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Get an annual physical exam
1)
Cholesterol level
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Avoid all tobacco use
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Blood sugar/glucose level
MI Health & Wellness 4x4 Plan
• Multimedia campaign
• Deployment of local coalitions
• Engagement of partners to support
implementation
• Formation of MDCH infrastructure
• Acquisition of funding
Michigan Primary Care Transformation
• 3-year (2012-2014) demonstration project
• MI is one of eight states
• 36 physician organizations, 410 primary care
practices, and 1,700 physicians are involved
• Reform primary care payment models
• Expanding capabilities of Patient-Centered
Medical Homes
Patient-Centered Medical Home (PCMH)
• Goal to improve overall population health via:
– Risk reduction for healthy individuals
– Self-management support to prevent patients
with moderate chronic disease levels from
progressing to the complex category
– Care coordination and case management
support for patients with complex chronic
diseases
– Appropriate, coordinated end-of-life care.
Community Linkages
• Holistically address factors that contribute to a
person’s overall health
• Integrate medical care system with community
resources
• Healthcare has a limited impact on a person’s
health
• Social and economic factors have a greater
impact
Pathways/Community HUB Model
• Uses Community Health Workers (CHW)to
address social and economic determinants of
health
• Incentivized by success in:
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Identifying individuals at greatest risk
Assessing needs and identifying barriers
Referring to evidence-based services
Documenting results of referrals, progess and final
outcomes
• Bridge between health and social systems
MI Pathways/Community HUB Pilot
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3-year cooperative agreement from CMMS
Started July 1, 2012
Co-directed by MPHI and MDCH
Pilot Counties: Ingham, Muskegon and Saginaw
Hire 90 CHW and other staff
Target population is Medicare and Medicaid
beneficiaries in pilot counties
Overview of Michigan’s CCDPHP Plan
• Goal: By 2020, all people living in
Michigan will have access to a
community integrated health care
system supporting the prevention and
control of chronic disease and
injuries.
Strategies
• Strategies
– Based on National Prevention Council’s
recommendations in the National Prevention Strategy
– Evidence-based
– Potential to significantly reduce disease and injury
burden
– Improve health equity
– Align with the three initiatives
– Address four domain areas
– Consistent with current work of statewide partners
– Opportunities to build upon these efforts
Long-Term Objectives
• Long-term 1 : By 2020, 10% improvement in the
following indicators from 2011 baseline:
– A: Percent of Michigan adults reporting all four
healthy behaviors
– B: Percent of Michigan adults with timely screening
for blood pressure, cholesterol and glucose level
– C: Percent of Michigan adults with timely age and
gender appropriate cancer screening
• Long-term 2: By 2020, reduction in disparity
(evidence of increased equity) in above
indicators among racial/ethnic, geographic, and
disability status populations
Epidemiology/Surveillance
• Strategy: Develop a chronic disease and
injury surveillance system (including use of
health information technology) with
analysis and dissemination capacity to
inform, prioritize and evaluate impact of
programs and policies as well as ensure
strategic focus on communities and
populations of greatest risk.
Environmental Approaches
• Strategy: Engage and empower
people and communities to plan and
implement prevention policies and
programs to promote tobacco-free
living, healthy eating and active living.
Health Systems Interventions
• Strategy: Enhance coordination and
integration of clinical, behavioral, and
complementary services through
support and enhancement of patientcentered medical homes and
coordinated care management.
Community Linkages
Strategies:
• a) Promote and support coordinated
implementation of chronic disease and injury
community-based preventive services and
enhance linkages with clinical care.
• b) Reduce barriers to accessing clinical and
community preventive services, especially
among populations at greatest risk.
Next Steps
• Implementation and evaluation planning
• Partner engagement
Questions?