Enhancing the Medical Home: Opportunities and Challenges Lauren A. Smith, MD, MPH Medical Director Department of Publ

1. Enhancing the Medical Home: Opportunities and ChallengesLauren A. Smith, MD, MPHMedical DirectorDepartment of Public Health Medical Home Conference Office of Community Programs UMass Medical School May, 2008

2. Birth Outcomes

3. Number of Births 77,670 -5%* Teen Birth Rate (births/1000 ages 15-19) 21.3 -18%* % Smoking during pregnancy 7.4 -24%* % Low Birthweight 7.9 +11%* % C-Section 33.4 +43%* % Multiple Births 4.5 +5% % Births to foreign-born mothers 26.9 +30% Infant Mortality Rate 4.8 +4% (deaths per 1,000 live births) - White Non-Hispanic IMR 4.2 +11% - Black Non-Hispanic IMR 11.1 -13% - Hispanic IMR 5.8 +12%

5.

6. Gestational Diabetes Mellitus Massachusetts Births 2000-2006

7. GDM by Race/EthnicityMassachusetts: 2000 vs. 2006

9. Infants Delivered by C-Section Massachusetts and the U.S. : 1990-2006

10. C-section by Maternal Ethnicity1 Massachusetts Births 2006

11. Obesity and Overweight

15. Percent of Overweight/Obese Students Identified in BMI Screening, 2006-2007

16. Diabetes

17. ~330,000 diagnosed people with diabetes 100,000-140,000 are undiagnosed Even more with pre-diabetes #9 leading cause of death New severe complications per year 675 cases of blindness 1,150 cases of renal failure 2,300 lower extremity amputations 6,000 deaths with diabetes as major contributor

18. Increasing Prevalence of Diabetes

22. Substantial Variation in Diabetes Rates by Household Income

24. Diabetes Hospital Discharges, 2003-2005

25. Diabetes Mortality Rates, 2003-2005

26. Mortality Rates are Much Higher for Blacks and Hispanics

28. Opportunities for Improvement in Comprehensive Diabetes Care

29. Primary Care Workforce

30. Where are the clinicians to care for the the newly insured?

31. Focusing Attention on Physician Shortages in Western Massachusetts Joint Legislative and DPH Hearing in Western Mass. held in early 2008 – highlights: 16% loss of obstetricians in the region from 2002 to 2004 – versus 8% loss Statewide Difficulties recruiting new physicians due to higher salaries in other locations, coverage demands, high cost of living and perceived isolation Rural areas particularly hard hit by shortages although impact felt throughout the region Numerous action steps needed to address

32. Addressing clinician shortages DPH prepares full report to the legislature due in summer 2008 with list of recommendations Collaborates with Senate President on initiatives to address shortages Tuition remission Linkage with UMass Provides special funding to increase pipeline programs Proposes protections for community hospitals

34. Achieving the Balance Nutritional Risks Large portion sizes Inexpensive high-calorie food Fast food restaurant density Protective Factors Availability of healthy options Exercise options Nutrition knowledge

35. Expanding Portions, Growing Appetites

36. Living in Fast Food Nation Fast food restaurant density related to income and % black residents A 4% increase in black residents associated with 10% increase in fast food density Predominantly black neighborhoods 6 times more fast food restaurants 2.4 fast food restaurants/sq mile

37. Where are the healthy options? Supermarkets have more “heart healthy” food vs. grocery & convenience stores Low income & minority neighborhoods Less likely to have supermarket More likely to have small grocery stores

38. Influence of Supermarkets on Meeting Dietary Guidelines

39. Nutritional Challenges – The Real Cost of Healthy Diet

40. Missing Food Items By Store Size

42. Avoid unhealthy behaviors? Targeted marketing to minority & low income communities More tobacco billboards Disproportionately concentrated alcohol ads Increased number of liquor stores and underage sales Specific targeting of alcohol & tobacco ads using cultural references, ethnic-specific characters

43. Moving Beyond Documenting to Moving the Dial HOW can we make a difference as a Department of Public Health?

45. Eliminate racial/ethnic disparities in health Release of $1M dollars for innovative efforts throughout the state 42 grantees across the state Workforce development, QI, social determinants Create Office of Health Equity Expand collection and use of data on race/ ethnicity by health programs Increase programming for health issues disproportionately affecting communities of color - $2 million in violence prevention Adapt existing DPH programs to reflect focus on racial and ethnic disparities Issue new specialized data report

46. New Opportunities to Understand the Issue Copies will be available at regional resource librariesCopies will be available at regional resource libraries

48. Promoting wellness in Workplace, Schools, Communities, and Home Released $1M to support innovative efforts throughout the state Develop workplace wellness initiative with toolkit, media, and mini-grants Convene cross-sector statewide task force to eliminate obesity Expand tobacco control efforts Highlight best practices such as Tri-Town retailer certification Smoking cessation targeted in Berkshires with June launch of NRT

49. New Targeted Campaigns

51. Manage chronic disease: Action Steps Release of $1M to support innovative efforts throughout the state Grantees: 11 community health centers, 2 CBOs Improve chronic disease management among diverse populations Blacks: Brockton Latinos: Brookside, Great Brook Valley, Holyoke, Lynn, Lowell Cape Verdeans: Brockton Asians: Lowell, Lynn Focus on comprehensive approaches to asthma, diabetes, cardiovascular, substance abuse Promote Community Health Workers to bridge cultural gaps in self management Support efforts outside the health care facility to improve chronic disease management

53. The Case for Regionalization: Massachusetts Population: 6.3 million 351 towns and cities 13th in nation for population 44th in nation for land area 1st in nation for number of local public health depts. (351) No county system No statewide public health mutual aid system Points to Emphasize: Description of Massachusetts; there is limited connections between communities in all governmental work sectors. Home rule is guiding principle Points to Emphasize: Description of Massachusetts; there is limited connections between communities in all governmental work sectors. Home rule is guiding principle