Building Capacity to

Improve Population Health using a

Social Determinants of Health Framework

Yumi Shitama Jarris, MD

Denise Koo, MD, MPH

Sharon Moffatt, RN, BSN, MS

Virginia Watson, MA

Turn to your neighbors…

• Introduce yourself

• Answer one of the following, EITHER;

• Do you participate in collaborations that involve or should include training around the social determinants of health?

• What is your experience with teaching about SDOH?

• What do you hope to gain from this workshop?

3

Discussion of Map

What do you see in this map?

What factors not visible in the picture also affect

health?

What factor has greatest

impact on health of your

community?

Training the Health Care Workforce to Improve

Population Health: Collaborating with Public

Health Partners

Yumi Shitama Jarris, MD

Assistant Dean for Population Health & Prevention

Georgetown University School of Medicine

Sharon Moffatt, RN BSN MS

Interim Executive Director

Association of State and Territorial Health Officials

Objectives

1. Describe methods to integrate population health training into health professions curricula to gain appreciation for the broader context of what determines health.

2. Apply steps to create successful collaborations between health profession institutions and public health organizations for meaningful experiential learning.

7

• 2012 AAMC graduation questionnaire, % of students reporting “inadequate

instruction”:

• Health policy (40%)

• Occupational medicine (37%)

• Health care systems (35%)

• Environmental health (34%)

• Community health & social service agencies (24%)

Are we doing well enough in teaching

population health in medical school?

8

Healthy People Curriculum Task Force “Clinical

Prevention and Population Health Framework”

9

http://www.teachpopulationhealth.org/

Three Distinct and Integrated Levels of the Population Health and

Prevention Curriculum at the Georgetown University

School of Medicine

MD/MPH

Degree

Population Health Scholar Track

Longitudinal Integrated Population Health & Prevention Curriculum for all students

10

Determinants of Health –Proportional Contribution to Premature Death

Determinants of Health and their Contribution to Premature Death

(Adapted from McGinnis, et al., 2002) Genetic Predisposition30%

Medical Care10%

Social Circumstances15%

Environmental Conditions5%

Behavioral Patterns40%

Population Health Scholar Track

• Comprehensive, longitudinal curriculum in population health.

• Opportunities to apply population health concepts to clinical practice and use

data to improve the health of individuals, communities, and populations.

• Tools to thrive and lead change in a transformed health care system.

• Special distinction at graduation as a Population Health Scholar.

12

Collaborating with Public Health Partners

• Allows students to gain appreciation for the broader context

of what determines health.

• Learn how program and policy interventions can address the

social determinants of health and reduce disparities in

preventable chronic conditions.

• Teaches the value of the integration of primary care and

public health.

13

• Gain exposure to state public health via a “day in the life of a state health

official”

• Gain exposure to public health and health policies issues and programs

• Complete a defined work product (e.g. Issue brief, journal article, webinar,

learning module)

• Shadowing public health leaders to primary care/public health national

meetings, as appropriate

Primary Aims of ASTHO’s work with

Medical Students

14

• Patient-Centered Medical Home

• Reducing Preterm Births through a Health Policy Approach

• Identifying Common Language on Return on Investment

• Role of State Health Departments in Supporting Breastfeeding in the

Workplace

• Medication Adherence Interventions in Hypertensive Minority Populations

• Role of State Health Agency in Working with Hospitals on CHNAs

ASTHO Projects

15

What a Public Health Community Can Offer

16

• Gain appreciation for the role of policy in improving health

• Provides insight into state and local population health trends (emerging

infectious diseases and incidence of chronic disease).

• Allows opportunities for individual and group practice engagement and

influence in local and state health policy development through community health

impact and needs assessments.

• Provides experience in use of tools for health equity: Data for hot-spotting;

Health Impact Assessments.

• Establish bi-directional relationships with public health professionals to improve

individual and community health.

• Prevention Focus: integrate a holistic and interdisciplinary approach to treating

patients.

• Public Health Policy: provide leadership on areas impacting social determinants of

health; partner with local and/or state agencies, NGOs, private foundations, and

philanthropic organizations that have an interest in reducing health inequities.

• Data Collection: collect relevant data and measures impacting social determinants of

health and share with partners.

17

Expanding the Solution Set

Population Health Scholar Track Summer

Practicum Sites and Mentors

Scholar Research

Mentor

Practicum Site Capstone Projects

Meghan Davis Rachel Scott, MD, MPH MedStar Washington Hospital CenterPregnancy outcomes of women living with HIV: a retrospective cohort

study at MedStar Washington Hospital Center from 2004 to 2015

Yuchen (Jake) Liu Matthew Levy, MD, MPH MedStar Community PediatricsBaseline Assessment of Asthma Management Practices for Kids Mobile

Medical Clinic

Margaret McCarthy Steven Schwartz, MD Potomac Physician Associates (PPA) Strategies for Improving the CMS Quality Measure PREV-1

Katherine Mullins

Lacy Fehrenbach, MPH

Andria Cornell, MSPHAssociation of Maternal and Child Health Programs

(AMCHP)

Maternal Levels of Care: Highlights from a Systematic Analysis of State

Activities

Jack Penner Jeff Weinfeld, MD, MBI MedStar Spring Valley Family MedicineImproving PCV13 vaccination rates in the Medicare population at MedStar

Family Medicine Spring Valley

Brandon Quinn Larry Wolk, MD, MSPH Colorado Department of Public Health & EnvironmentPopulation Health Tiers: Opportunities for Reimbursement

of Colorado’s Local Public Health Agencies

Zachary Smith

Katie Sellers, DrPH

Lisa Waddell, MD, MPHAssociation of States and Territorial Health Officials

(ASTHO)

Medication Adherence Interventions in Hypertensive Minority Populations:

A Review

Christopher

Wynkoop

Christine Goeschel, ScD, MPA,

MPS, RNMedStar Pellegrini Quality Improvement

Improving HCV Recognition and Linkage to Care Among the Baby Boomer

Generation18

• Plan mutually beneficial projects that can be disseminated and published.

• Additional activities can include taking minutes at meetings, doing a literature

search, shadowing.

• Participate in projects already off the ground in which the student can “own” a

specific part.

• Decide on a clear deliverable to be completed by the end of the practicum

(webinar, issue brief, poster).

• Choose a mentor who is at a mid-level place in the organization who has the time

and passion to guide the student experience.

Summer Practicum: Lessons Learned

19

• “Most valuable part for me has been working with the faculty who

attend our meetings and provide feedback on our projects. It is

helpful to hear how these experts discuss issues in population health,

and to hear about the work that they have conducted in the field.”

• “I gained very practical experience in the public health field and

navigating the complexities of the health department, qualitative

interviewing, and an opportunity to present to a diverse group of

stakeholders.”

Student Feedback

20

• Health professions schools should partner with community organizations and public health agencies to engage in a win-win collaboration.

• Through these integrated population health initiatives, our hope is to educate physicians who are capable of bridging the gap between the health of individual patients and the health of their communities.

Improved Population Health

21

Health and Well-Being for All (HWFA)

Accelerating Learning About

Social Determinants of Health

Using a Meeting-in-a-Box Approach

Denise Koo, MD, MPH

Advisor to the Associate Director for Policy, CDC

Virginia Watson, MA

Instructional Designer

The CDCE Legacy Project

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

Health Workforce Needs

Critical thinking

Systems thinking/public health approaches

Team skills

Community engagement

Collective action

Background for HWFA Meeting-in-a-Box

Origin of case study: CDC Experience 1-year Applied

Epidemiology Fellowship for medical students

Purpose: empower graduates to participate

collaboratively in community health improvement

(not just within health care system)

Additional goal: skill-building in leadership and being

change agents

Critical need: persons with systems thinking and

approaches to solve complex problems that span the

health system

Goal for Health and Well-Being for AllMeeting-in-a-Box

Practitioners empowered to advocate for an

upstream approach to addressing root causes of

illness

Meeting-in-a-Box Learning Objectives

Discuss the determinants of health, including

socioeconomic, behavioral, environmental and other

factors

Compare and contrast the internal and external

issues faced by key stakeholders

Identify strategies for moving from group alignment

to collective action

Recognize that partnership with other sectors is the

best way to achieve Health and Well-being for All

Components of HWFA Meeting-in-a-Box

Box with handle to carry contents

Fabric poster/map, 3’ x 5’

3 Modules: asthma, gang violence, obesity

Dialogue guides for each module

A patient story to motivate change

Cards to educate and to stimulate discussion

Coming together with Others Who

Care (role play for gang violence,

shorter variation for the other 2)

All contents brightly colored,

appealing

Modeled after Promedica’s

Hunger as a Health Issue

(produced by same company)

Discussion of Social Determinants of Health

Cards to stimulate discussion

2 Definitions (WHO, Healthy People)

3 Brief Descriptions/phrases (Robert Wood Johnson Foundation)

Which of the 5 resonated the most and why?

Each discusses an example of a personal, social,

economic, or environmental factor that impacted

them, a patient, or someone they know

Module Focus

Patient story to motivate change (patient impacted by

recurrent asthma, gang violence, or obesity)

SDOH Examples relevant to each story

Graphics, data, maps

Discussion, including whose problem is it?, role of

health professionals and impact on society

Set up for 6 steps

Six Steps to Health and Well-being for All

(1) Seeing the Bigger Picture Begin to see interrelationships of parts of a whole

(2) Focusing on What’s Important Determine and communicate the magnitude of the problem

(3) Finding Others Who Care Harness the power of champions and recognize impacted groups

(4) Walking a Mile in Someone Else’s Shoes

Empower a coalition of the willing

(5) Acting on What’s Important Develop and document a future vision that’s desired and then

implement your plan

(6) Communicating Your Vision and Mission Sell it, sell it, sell it!

1: Seeing the Bigger Picture

Begin to see the interrelationships of

parts of a whole

• Discuss examples of SDOH from

the scenario (start with how they

might have impacted the

individual in the story)

• Do they affect the

whole community?

• Are they preventable?

from Obesity module

2: Focus on What’s Important

Determine and communicate the

magnitude of problem

• Know What Affects

Health – modifiable risk

factors

• Finding data to support

your case

• Discuss need for

community-wide

agreement for change

3: Finding Others Who Care

Harness the power of champions and

recognize impacted groups…

• Brainstorming a list of possible stakeholders,

supportive and reluctant

4: Walking a Mile in Someone Else’s Shoes

Empower a coalition of the willing

• The purpose of this step is for participants to

consider perspectives of other stakeholders

• Take turns sharing the perspectives that need to

be considered as you continue through the rest

of the steps of the case study

• Each module offers a different way to “walk in

someone else’s shoes”

Walking a Mile in Someone Else’s Shoes

Gang violence (60+ minutes): full role play with

motivation, “friends/foes,” hidden agendas

ROLES (STAKEHOLDERS)

• Clinician

• Public health representative

• Former gang member

• City Council member

• Police officer

• School counselor

• Hospital administrator

Walking a Mile in Someone Else’s Shoes

Obesity (20-30 minutes): discussion of strengths,

points of agreement, sources of conflict, obstacles

ROLES (STAKEHOLDERS)

• Clinic receptionist

• Clinic director

• Public health representative

• City manager

• Parks & recreation director

• Business owner

• Religious leader

Walking a Mile in Someone Else’s Shoes

Asthma (20-30 minutes): discussion of how a group

might come together (forming, storming, norming)

ROLES (STAKEHOLDERS)

• Parent

• Parent representative

• Clinician

• Public health representative

• School system representative

• Hospital administrator

• City Housing Authority

representative

5: Acting on What’s Important

Develop and document a future vision

that’s desired and then implement your

plan…

• Given the points of agreement from prior step,

choose an action the group could pursue

together

• Use PDSA as model for

change/improvement

6: Communicating Your Vision and Mission

Sell it, sell it, sell it!

• Tailor communications based on the audience

• Overcoming barriers

Coming Together for Sustainable Change

• Reflection / Take-aways

• My Commitment

Supplemental Resources

Available Soon on CDC Foundation website:

Extra copies of dialogue guides, cards, poster image

Video about San Francisco Wraparound project (gang violence)

Facilitator guide and additional tips

Resources for how to find data, evidence-based interventions

Support for each of the 6 steps

Webinar links

Video of teaching in

Action (possible)

Possible Audiences?

Who do you see as possible audiences for this tool?

Health professionals in training (students, residents)

Undergraduates or younger students

Interdisciplinary orientation

Community coalition—early meeting

Faculty Development

Public health department staff

Boards or senior leaders of health systems

Community developers

Urban planners

Other disciplines

Possible Uses

Map as standalone, with initial discussion questions

Gang violence module with role play (3 hours)

Asthma module (2+ hours)

Obesity module (2+ hours)

Foundational: beginning of education (any module)

or community engagement process

Problem-based learning: explore any aspect in more detail

Investigate data about the issue and its determinants

Create role plays

One step/lesson, with homework before next lesson

Health and Well-Being for All Meeting-in-a-Box available

via this link to the Public Health Foundation:

http://bitly.com/PurchaseHWFA

Code DRKOO gives you $20 off your purchase through end of

August

• In groups of two or three, discuss your approaches to training

the public health and primary care workforce to collaborate to

address the social determinants of health

• How might you use or have you used methods similar to what

was presented here?

• Report to the larger group what you plan to do as a result of

this workshop

46

Group discussion