Vermont Medical Society Third Thursday webinar series

1. Vermont Medical Society Third Thursday webinar series Date: January 17, 2019 Title of Talk: Integrating Public Health and Primary Care 134 Main Street • P.O. Box 1457 • Montpelier, Vermont 05601-1457 Tel.: 802-223-7898 • 800-640-8767 • Fax: 802-223-1201 www.vtmd.org Webinar Materials Archived at: http://www.vtmd.org/vms-announces-free-webinar-series-schedule-201819

2. CME Disclaimer • In support of improving patient care, this activity has been planned and implemented by the Robert Larner College of Medicine at the University of Vermont and the Vermont Medical Society. The University of Vermont is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.The University of Vermont designates this live activity for a maximum of 1 AMA PRA category 1 credit(s)tm. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Please watch your email for a link from the Vermont Medical Society to claim your CME credit. CME credit must be claimed within 30 days of participating in the event.

3. VMS Third Thursday Webinar SeriesIntegrating Public Health and Primary Care Speakers: Breena Holmes, M.D., Director, Maternal and Child Health, Vermont Department of Health Wendy Davis, M.D., Associate Director, National Improvement Partnership Network; Clinical Professor, Department of Pediatrics, UVM Planning Committee Members: Jessa Barnard, ESQ, Stephanie Winters, Deputy Executive Director & Dr. Carl Dobson, M.D., Southwestern Vermont Medical Center Purpose Statement/Goal of This Activity: Discussion on Integrating Public Health and Primary Care Learning Objectives: Demonstrate awareness of integration efforts between primary care and public health. Disclosures: Is there anything to Disclose? Yes No Did this activity receive any commercial support? Yes No In support of improving patient care, this activity has been planned and implemented by the Robert Larner College of Medicine at the University of Vermont and the Vermont Medical Society. The University of Vermont is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. The University of Vermont designates this live activity for a maximum of 1 AMA PRA category 1 credit(s)tm. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

4. Integrating Public Health and Primary Care: Collaborating to Improve Health Care Delivery and Outcomes in Vermont Wendy Davis, MD FAAP – Vermont Child Health Improvement Program Breena Holmes, MD FAAP – MCH Director, Vermont Department of Health Vermont Medical Society Webinar Series – January 17, 2019

5. Objectives • Understand Vermont’s approach to primary care and public health integration as a strategy to improve health care delivery and outcomes for Vermonters • Define integration • Define public health and population health • Describe building blocks for an integrated system of care • Review public and population health priorities • Identify opportunities to become involved in this work

6. Why integration?Institute of Medicine (IOM) 2012 Report • Primary Care and Public Health: Exploring Integration to Improve Population Health (National Academies of Science, Engineering, Medicine: Health and Medicine Division) • Charge to Committee: identifythebestexamplesofeffectiveprimarycareand publichealthintegrationandthefactorsthatpromoteand sustaintheseefforts. • Definition:thelinkageof programs&activitiestopromoteoverallefficiency& effectiveness& achievegainsin populationhealth. http://www.iom.edu/~/media/Files/Activity%20Files/PublicHealth/PrimCarePublicHealth/PCPH-Report-Release-Presentation-03-28-12.pdf

7. Why integration?IOM Report (cont’d) • Multiple public/private partners contribute to the health of populations • Achieving substantial and lasting improvements in population health will require a concerted effort aligned under a common goal • Integration of primary care and public health could enhance the capacity of both sectors to carry out their missions and link with other stakeholders to catalyze a collaborative, movement toward improved population health http://www.iom.edu/~/media/Files/Activity%20Files/PublicHealth/PrimCarePublicHealth/PCPH-Report-Release-Presentation-03-28-12.pdf

8. Principles forSuccessfulIntegration(IOM) • Shared goal of population health improvement • Community engagement in defining and addressing population health needs • Aligned leadership [State of VT, VMS, health systems]: • bridges disciplines, programs, and jurisdictions to reduce fragmentation and foster continuity • clarifies roles and ensures accountability • develops and supports appropriate incentives, and • has the capacity to manage change • Sustainability, key to which is the establishment of a shared infrastructure and building for enduring value and impact • Sharing and collaborative use of data and analysis http://www.iom.edu/~/media/Files/Activity%20Files/PublicHealth/PrimCarePublicHealth/PCPH-Report-Release-Presentation-03-28-12.pdf

9. Findingsand Conclusions • Aspirational yet actionable framework for accelerating progress toward achieving the nation’s population health objectives • Current primary care and public health infrastructure inadequate to attain this goal • No single best solution: requires community-level application of the framework with substantial local adaptation and development of specific structures, relationships, and processes http://www.iom.edu/~/media/Files/Activity%20Files/PublicHealth/PrimCarePublicHealth/PCPH-Report-Release-Presentation-03-28-12.pdf

10. IOM ReportRecommendations • Focus on roles of HRSA and CDC: e.g. link staff, funds, data at regional, state, local levels • Create common research and learning networks to foster and support integration • Develop workforce needed to support integration • HHS Secretary to develop nationalstrategyand investmentplanfor the creation ofa strong, appropriately integrated primarycareand publichealth infrastructure http://www.iom.edu/~/media/Files/Activity%20Files/PublicHealth/PrimCarePublicHealth/PCPH-Report-Release-Presentation-03-28-12.pdf

11. What is Public Health?10 Essential Public Health Services (CDC)

12. Monitorhealth status to identify & solve community health problems Diagnose and investigatehealth problems/hazards in the community Inform, educate and empower people about health issues Mobilize community partnerships/ action to identify and solve health problems Develop policies and plansthat support individual and community health efforts Enforce laws and regulations that protect health and ensure safety Linkpeople to needed health svcs. and assure provision of health care when otherwise unavailable Assure competent public and personal health care workforce Evaluateeffectiveness, accessibility, and quality of personal and population-based health services Research for new insights and innovative solutions to health problems 10 Essential Public Health Services (CDC)

13. What is Population Health? • Organized activities for assessing and improving the health and well-being of a defined population . . . practiced by both private and public organizations • Target population: specific geographic community/region or other denominator: e.g., enrollees of a health plan, persons residing in a provider’s catchment area, aggregation of individuals with special needs • Difference between population health and public health is subtle: • Public health services typically provided by government agencies – include “core” public health functions of health assessment, assurance, and policy-setting • Current U.S.: most actions of public health agencies represent population health, but a considerable proportion, if not the majority, of population health services are provided by private organizations. Hadi Kharrazi, Elyse C Lasser, William A Yasnoff, John Loonsk, AneelAdvani, Harold P Lehmann, David C Chin, Jonathan P Weiner. A proposed national research and development agenda for population health informatics: summary recommendations from a national expert workshop; Journal of the American Medical Informatics Association, Volume 24, Issue 1, 1 January 2017, Pages 2–12. https://doi.org/10.1093/jamia/ocv210

14. Public & Population Health in Vermont • Vermont Department of Health (VDH) integration with sister departments, Agency of Human Services • Recognition of role/importance of Social Determinants of Health • OneCare Vermont Population Health Strategy Committee, charged with: • Assure a reliable pop. health mgt. strategy in place • Oversee the clinical model • Guided by the Quadruple Aim: improve pop. health, improve experience of care, reducing per capita costs, maintain sustainable healthcare workforce

15. Vermont Agency of Human Services • Department for Children & Families (DCF) • Department of Corrections (DOC) • Department of Disabilities, Aging & Independent Living (DAIL) • Department of Health (VDH) • Department of Mental Health (DMH) • Department of Vermont Health Access (DVHA – State Medicaid Agency & health reform)

16. OCV Population Health Strategy Committee • Provide strategic input and monitoring in the following areas: • Network clinical priorities and strategies • Informing quality measure selection, monitoring and improvement • Regular review of utilization of services for which prior authorization is waivered • Annual review and approval of evidence-based guidelines for which prior authorization is waivered • Selecting initiatives to address SDoH and community/ patient needs

17. Collaboration: Setting Public Health Priorities • Public Health (SHA-SHIP) • State Health Assessment (SHA): completed 2018 • State Health Improvement Plan 2019-2023 (SHIP): combines data with strategies to improve health outcomes and reduce inequities in 5 priority areas: • Chronic disease • Early childhood • Mental health • Oral health • Substance use disorder • Designed for partners across agencies and in multiple sectors

18. Collaboration: Setting Population Health Priorities • Blueprint for Health • NCQA scoring • Quality measures • OneCare Vermont • Monitoring and payment quality measures (tied to payment reform) • Vermont Child Health Improvement Program (VCHIP) and Division of Maternal and Child Health, Vermont Department of Health

19. In the beginning . . . VT Dept. of Health • Mission: protect and promote the best health for all Vermonters • Vision: Healthy Vermonters living in healthy communities • Goals: • Effective, integrated PH programs • Communities w/capacity to respond to PH needs • Health equity for all Vermonters

20. Collaboration with Professional Organizations • Vermont Medical Society, Vermont chapters of the American Academy of Pediatrics and the American Academy of Family Physicians, etc.!

21. Collaboration with Professional Organizations • Vermont Medical Society: a critical partner in Public and Population Health advocacy • Vermont Legislature, 2019 • Marijuana policy: limiting medical marijuana to evidence-based conditions and opposing commercial legal sales of non-medical marijuana • Tobacco Control • Supporting raising the age of legal purchase to 21 and regulation of e-cigarettes • Reproductive Rights • Firearm Purchase Waiting Period

22. VMS and Population Health Policy • Prescription drug pricing • Price transparency • Paid family leave • Percent of funding for primary care • VITL opt-out vs. opt-in • Health effects of climate change

23. Quality Improvement Infrastructure • Vermont Child Health Improvement Program

24. Collaboration with Vermont Hospitals

25. State Health Reform: Blueprint for Health

26. Hospitals • A foundation of medical homes and community health teams that can support coordinated care and linkages with a broad range of services • Multi-insurer payment reform that supports a foundation of medical homes and community health teams • Health information infrastructure that includes EMRs, hospital data sources, a health information exchange network, and a centralized registry • Evaluation infrastructure that uses routinely collected data to support services, guide quality improvement, and determine program impact Medical Home Specialty Care & Disease Management Programs Community Health Team Nurse Coordinator Social Workers Nutrition Specialists Community Health Workers MCAID Care Coordinators Public Health Specialist Medical Home Social, Economic, & Community Services Medical Home Mental Health & Substance Abuse Programs Medical Home Healthier Living Workshops Public Health Programs & Services Health IT Framework Evaluation Framework

27. Federal Health Reform: ACA

28. Children’s Health Insurance Reauthorization

29. Expansion to the Whole Population

30. Vermont Case Study: Child Health & Integration • Maternal & Child Health at the Vermont Department of Health and Vermont Chapter, American Academy of Pediatrics (AAPVT) • Annual grant funding from MCH/VDH to AAPVT • Supports attainment of mutual goals: child population health/health care delivery outcomes • System of care • Tools to support provision of care • Improve communication among key parties

31. Vermont: Child Health and Integration • Expansion to include multiple disciplines and community partners • Family Medicine, Obstetrics/GYN, mental health, public health programs, community partners • Annual planning to identify mutual population health goals and activities • Data: MCH, WIC, PRAMS, YRBS • Family engagement • Representation on committees, advisory boards • Vermont Family Network

32. Maternal and Child Health: Vermont Vision:Strong healthy families power our world. Mission: We invest in people, relationships, communities and policies to build a healthier Vermont for future generations. Principles: Strength-based│ Two-generation │ Partnerships Vermont Department of Health

33. Vermont MCH Priorities

34. Women’s/Maternal Health • Performance measures: • % of women who smoke during pregnancy • % of women advised by healthcare provider to abstain from alcohol in pregnancy • Key strategies: • Access to cessation resources • OB practice pilot Data Source: Behavior Risk Factor Surveillance System

35. Children with Special Needs: Transitions • Performance measures: • % of adolescents with and without special health care needs (ages 12-17 y.o.) who received services to make transitions to adult health care • Key strategies: • Partnership with OneCare Vermont to align care coordination services (including transition) • Partnership with VocRehab to provide access to full range of transition supports Data Source: National Survey of Children’s Health

36. School Age and Adolescent Health • Performance measures: • % of adolescents (ages 12-17 y.o.) with a preventive medical visit in the past year • % of adolescents that feel they matter to people in their community • Key strategies: • HS curriculum re: healthcare rights and responsibilities • Endorse annual well care visit • Meaningful youth engagement Data Source: National Survey of Children’s Health

37. Vermont Child Health IntegrationPublic Health – Primary Care Integration Work Group • Collaboration among VCHIP, VDH/MCH, AAP-VT, VAFP, and partners • Monthly meetings • Develop common agenda • Define objectives, activities, deliverables • Forum to rapidly address emerging issues, funding opportunities • Implementation infrastructure

38. Summary • Integrating the work of Public Health and Health Care professionals is necessary to effectively improve health care and population health outcomes for Vermonters. • Public-private collaborations impact care and outcomes as no single entity can. • Vermont’s track record of progressive health reform and physician leadership provides a unique context in which to successfully conduct these activities.

39. Questions/Comments • Join VMS for Advocacy Day, Feb. 14, 2019!