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 Areas1. Communication

2. Epidemiology/Surveillance

3. Evaluation

4. Health Systems Improvements

5. Community Mobilization

6. Community Linkages

7. Health Disparities

8. Policy and Environmental Change

9. Partnerships

Strategic Planning Process

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 PlanAligns 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• 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

Efficient & Accountable Care

Coordinated SeamlessHealth Care System 2.0

• Patient/Person Centered• Transparent Cost and Quality Performance

o Results-orientedo Assures Access to Careo Improves Patient Experience

• Accountable provider networks designed around the patient, including LTC needs

• Shared Financial Risk

• HIT integrated

• Focus on care management and preventive careo Primary Care Medical Homeso Care management/ prevention focusedo Shared Decision-Making and Patient

Self-Management

CommunityIntegratedHealthcare

• Episodic Health Careo Sick care focuso Uncoordinated careo High use of Emergency Careo Multiple clinical recordso Fragmentation of care

• Lack integrated care networks

• Lack of integration between acute and long-term care settings

• Lack quality and cost performance transparency

• Poorly coordinated Chronic Care Management

Uncoordinated Health Care System 1.0

Innovation Driven US Health Care System Evolution Anthony Rodgers, CMMI

Community Integrated Health Care System 3.0

Episodic Non Integrated

Care

Health System Transformation and Evolution Critical Path

CommunityIntegratedHealthcare

• Patient, Population, and Community-Centeredo Community Health Resource Linkedo 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 Integratedo Community Healthy Living Orientedo Community Health Capacity Buildero Community based support developero Shared community health responsibility

• E-health and tele-health capableo Wide use of remote monitoring and tele-

health and e-health managemento Health E-Learning resources, social

networking, health literacy tools

Four Domains

• Epidemiology and Surveillance

• Environmental Approaches

• Health Systems Interventions

• Clinic-Community Linkages

MI Health & Wellness 4x4 Plan

Healthy Behaviors Health Measures

1) Maintain a healthy diet 1) Body mass index (BMI)

1) Engage in regular exercise 1) Blood pressure

1) Get an annual physical exam 1) Cholesterol level

1) Avoid all tobacco use 1) 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:– 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• 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 patient-centered 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?