Issue Category: Health Equity/Social Determinants of Health

TFAH Applauds the Obama Administration for Showing Strong Support for Increased Collaboration between the Health and Education Sectors

Washington, D.C., January 15, 2016 – Trust for America’s Health (TFAH) applauds the Obama Administration for showing strong support for increased collaboration and coordination between the health and education sectors. The following is a statement from Richard Hamburg, interim president and CEO, TFAH and co-chair of the National Collaborative for Education and Health.

“The release of the Healthy Students, Promising Futures toolkit and joint letter from the U.S. Department of Health and Human Services and U.S. Department of Education is an important step in ensuring all of the nation’s children can succeed in school and life.

Healthy children are more prepared to learn, and academic success puts children on track for healthier and more productive lives.  The toolkit importantly recognizes the inextricable link between health and education — and provides communities with ways to take action to help this generation of children thrive.

TFAH, as a co-founder with Healthy Schools Campaign of the National Collaborative for Education and Health, is excited to see real, high-impact opportunities to improve joint outcomes – including through:

  • Ensuring children have health coverage;
  • Expanding reimbursable health services available in schools;
  • Supporting wrap-around case management for at-risk students–including addressing health conditions and exposure to violence or trauma and toxic stress–to remove barriers to learning;
  • Promoting nutrition, physical activity and health education; and
  • Improved assessments of local community needs and building of partnerships across schools, hospitals, public health departments and others to provide services and programs that can better meet those needs.

We look forward to working with the Administration and state and local communities to support greater adoption and implementation of the Healthy Students, Promising Futures opportunities – and continuing to build toward a vision of healthy schools and communities for our children.”

 

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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

Report Finds Major Gaps in Country’s Ability to Prevent and Control Infectious Disease Outbreaks

28 States and Washington, D.C. Reach Half or Fewer of Key Indicators

Washington, D.C., December 17, 2015 – A new report released today found that more than half (28) of states score a five or lower out of 10 key indicators related to preventing, detecting, diagnosing and responding to outbreaks. The report, from Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF), concluded that the United States must redouble efforts to better protect the country from new infectious disease threats, such as MERS-CoV and antibiotic-resistant superbugs, and resurging illnesses like whooping cough, tuberculosis and gonorrhea.

Five states—Delaware, Kentucky, Maine, New York and Virginia—tied for the top score, achieving eight out of 10 indicators. Seven states—Idaho, Kansas, Michigan, Ohio, Oklahoma, Oregon and Utah—tied for the lowest score at three out of 10.

“The overuse of antibiotics and underuse of vaccinations along with unstable and insufficient funding have left major gaps in our country’s ability to prepare for infectious disease threats,” said Jeffrey Levi, PhD, executive director of TFAH. “We cannot afford to continue to be complacent. Infectious diseases – which are largely preventable – disrupt the lives of millions of Americans and contribute to billions of dollars in unnecessary healthcare costs each year.”

Some key findings from the Outbreaks: Protecting Americans from Infectious Diseases report include:

  • Healthcare-associated Infections: Around one out of every 25 people who are hospitalized each year contracts a healthcare-associated infection, leading to some 75,000 deaths a year.
    • Only nine states reduced the standardized infection ratio (SIR) for central line-associated blood stream infections (CLABSI) between 2012 and 2013.
  • Childhood Vaccinations: In 2014, there were more than 600 cases of measles and nearly 33,000 cases of whooping cough reported. While more than 90 percent of all U.S. kindergarteners receive all recommended vaccinations, rates are lower in a number of communities and states. More than 28 percent of preschoolers do not receive all recommended vaccinations.
    • 20 states have laws that either exclude philosophical exemptions entirely or require a parental notarization or affidavit to achieve a religious or philosophical exemption for school attendance.
  • Flu Vaccinations: Based on the severity of the strain, the flu can cause 3,000 to 49,000 deaths a year, more than $10 billion in direct medical expenses and more than $16 billion in lost earnings.
    • 18 states vaccinated at least half of their population (ages 6 months and older) for the seasonal flu from Fall 2014 to Spring 2015. The national average is 47.1 percent. Rates are lowest among young and middle age adults (only 38 percent of 18- to 64-year-olds are vaccinated).
  • Hepatitis C and HIV/AIDS: Of the more than 1.2 million Americans living with HIV, almost one in eight do not know they are infected. Hepatitis C infections—related to a rise in heroin and injection drug use from people transitioning from prescription painkillers—increased more than 150 percent from 2010 to 2013.
    • 16 states and Washington, D.C. explicitly authorize syringe exchange programs.
    • 43 states and Washington, D.C. require reporting all (detectable and undetectable) CD4 cell count (a type of white blood cell) and HIV viral load data to their state HIV surveillance program, as of July 2013.
  • Food Safety: Around 48 million Americans get sick from a foodborne illness each year.
    • 39 states met the national performance target of testing 90 percent of E.coli O157 cases within four days (in 2013).
  • Preparing for Emerging Threats: Significant advances have been made in preparing for public health emergencies, including potential bioterror or natural disease outbreaks, since the September 11, 2001 and anthrax attacks. Gaps remain, however, and have been exacerbated as resources have been cut.
    • 36 states have a biosafety professional in their state public health laboratories – which are responsible for helping detect, diagnose and contain disease outbreaks.
    • 15 states have completed climate change adaption plans that include the impact on human health.
  • Superbugs: More than two million Americans contract antibiotic-resistant infections each year, leading in excess of 23,000 deaths, $20 billion in direct medical costs and more than $35 billion in lost productivity.

“America’s investments in infectious disease prevention ebb and flow, leaving our nation challenged to sufficiently address persistent problems,” said Paul Kuehnert, a Robert Wood Johnson Foundation director. “We need to reboot our approach so we support the health of every community by being ready when new infectious threats emerge.”

The Outbreaks report features priority recommendations, including:

  • Increase resources to ensure every state can maintain and modernize basic capabilities – such as epidemiology and laboratory abilities – that are needed to respond to new and ongoing outbreaks;
  • Update disease surveillance to be real-time and interoperable across communities and health systems to better detect, track and contain disease threats;
  • Incentivize the development of new medicines and vaccines, and ensure systems are in place to effectively distribute them when needed;
  • Decrease antibiotic overuse and increase vaccination rates;
  • Improve and maintain the ability of the health system to be prepared for a range of potential threats – such as an influx of patients during a widespread outbreak or the containment of a novel, highly infectious organism that requires specialty care;
  • Strengthen efforts and policies to reduce healthcare-associated infections;
  • Take strong measures to contain the rising hepatitis C epidemic and other sexually transmitted infections, particularly among young adults; and
  • Adopt modern strategies to end AIDS in every state and city.

The indicators represent examples of important capabilities, policies and trends, and were selected in consultation with leading public health and healthcare officials.

Score Summary: 

A full list of all of the indicators and scores and the full report are available on TFAH’s website. For the state-by-state scoring, states received one point for achieving an indicator or zero points if they did not achieve the indicator, with zero the lowest possible overall score and 10 the highest. The data for the indicators are from publicly available sources or were provided from public officials.

8 out of 10: Delaware, Kentucky, Maine, New York and Virginia

7 out of 10: Alaska, California, Maryland, Massachusetts, Minnesota and Nebraska

6 out of 10: Arkansas, Illinois, Iowa, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Vermont, West Virginia and Wisconsin

5 out of 10: Arizona, Colorado, Connecticut, Georgia, Hawaii, Mississippi, Missouri, Montana, Pennsylvania, Rhode Island, Texas and Washington

4 out of 10: Alabama, District of Columbia, Florida, Indiana, Louisiana, Nevada, South Carolina, South Dakota, Tennessee and Wyoming

3 out of 10: Idaho, Kansas, Michigan, Ohio, Oklahoma, Oregon and Utah

 

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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are striving to build a national Culture of Health that will enable all to live longer, healthier lives now and for generations to come. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.

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How an Entire Community Can Come Together to Help Control Asthma

By Karen Meyerson, MSN, APRN, NP-C, AE-C, Manager, Asthma Network of West Michigan

In 1994, a group of concerned health professionals in West Michigan recognized the alarming rise in pediatric asthma morbidity and mortality, locally as well as nationally. Significant disparities are also associated with asthma. For example, asthma deaths in Michigan occur six times more frequently in Black children than in White children. In response, the Asthma Network of West Michigan (ANWM) was formed as a grass-roots coalition with initial funding from the (then) three acute care hospitals and two local foundations.

To reach and improve the lives of the nearly 100,000 people in Western Michigan—24 percent of whom are children—who have asthma, ANWM created a direct service arm of its coalition and implemented a home-based asthma case management program for school-aged children who had uncontrolled asthma. ANWM, believed to be the first grassroots asthma coalition in the nation to receive reimbursement for asthma education and case management services from health insurance plans,  has since expanded its services to adults as well as children under the age of 5.

Our model relies on a few core components: home visits, care conferences and school/daycare visits and social worker services.

Home Visits

Research and common sense says that the environment around a child, particularly the home, is an important factor in preventing and controlling asthma. Consequently, a home visit provides the ideal setting to educate, review medication plans, and help families identify environmental factors that may contribute to the severity of asthma. If there are issues in the home that are triggering asthma attacks, we connect the family to our partner, the Healthy Homes Coalition, that provides environmental remediation.

To help educate families, we send a certified asthma educator—a nurse (at the RN level) or respiratory therapist (at the RRT level)—into the homes of patients for up to a year to perform environmental assessments and teach them about asthma attack trigger identification and avoidance/reduction, medications, proper use of devices and other self-management techniques. The asthma educator’s home visits are typically biweekly for the first three months and then monthly thereafter, as necessary, to provide a continuum of care.

Care Conferences and School/Daycare Visits

Care conferences—which are reimbursable visits—are held with the primary care physician and, if indicated, the asthma specialist soon after a new patient enters the program. These conferences tackle issues surrounding adherence, including psychosocial barriers to asthma management and access to care, and elicit a written asthma action plan, if none exists. If necessary, we provide spacers, a device to use with inhalers, to all patients who do not have them.

School/daycare visits – also reimbursable visits – are conducted in order to educate those caring for the children throughout the day about asthma and the child’s asthma in particular. We share the asthma action plan with staff and discuss asthma triggers in those settings.

Social Work Services

Lastly, we connect patients to our Licensed Masters-level Social Worker’s services (LMSW), which help families link the clinical recommendations they receive in the hospital or at the doctor’s office with the social services in their community. This is a vital service because many of our patients and families typically have multiple stressors, ranging from environmental to financial to socio-legal and LMSWs are uniquely capable of identifying and assisting with this range of problems. By blending social support with clinical support, ANWM makes the appropriate referrals or contacts to financial resources, mental health agencies, food banks, hospitals, landlords and others.

Successes

With this type of intensive, personal care, we have had demonstrated success in controlling asthma and reducing healthcare utilization (including emergency department visits and hospital admissions due to asthma).  Patients often “graduate” from our program after just 6 to 12 months when their asthma control has improved.

When reviewing data over the past 19 years, we find that there have been significant reductions (64 percent) in the number of hospitalizations, days hospitalized for children and emergency department visits (from 60 percent to 35 percent). And, for low-income children with moderate to severe asthma who remained in the original case management study for at least 1 year, we saw an estimated average savings of $1,625 in hospital charges per patient. In total, we estimate the program results in approximately $800 in net healthcare savings per child per year, with a return to society—over two years—of $1.53 for every $1 invested.

We also hear from those we serve. The mother of a 5-year old boy with asthma told us that, “working with the Asthma Network has really made a big difference – his asthma is controlled now.  They gave me education and made sure that I understood what asthma meant…they made me feel like no one was judging me.” Mom added, “I thought he had asthma ONLY when he got sick so I didn’t give him his inhaler until he had symptoms. If I had never had that education, who knows how many more asthma attacks or emergency room visits he would have?”

Another important, but perhaps overlooked success, is merely being paid for our services by health insurance plans. Most similar programs aren’t so lucky to receive reimbursement for their hard work. We get reimbursed by Medicaid managed care plans, Medicare and other commercial insurers. We have also been successful in raising grant funds and community benefit funds from local hospitals.  It takes a lot of different funding streams, braided and blended together, to support our program, even with the insurance reimbursement. The funding is out there, you just need to spend the time to find it and combine the various streams to succeed.

ANWM owes our success to intentional collaborations with local health insurance plans, hospitals and schools, the people and entities helping patients (public health nurses, physician practices, community clinics, and our local healthcare HUB, Health Net of West Michigan) and our unique ability to blend different funding sources

Because of our success, other Michigan coalitions have formed and begun replicating our model—and they have also been successful in securing payment for similar services in their respective communities.

For more than 20 years we’ve worked hard to prevent adverse asthma events among our most vulnerable populations. We wouldn’t have been successful without the network of community resources and funding we’ve been able to marshal – and the ability, through home visits and social work services, to connect families to those services. Asthma cannot be cured, but it can be controlled. Individuals with asthma should expect nothing less.

Improving Lives & Saving Money by Extending Care from the Clinic into the Community

By Brenda Rueda-Yamashita, Chronic Disease Program Director, Alameda County Public Health Department

Asthma Start, which delivers in-home case management services, began nearly 14 years ago, when our local health officer wanted to intentionally address and prevent asthma—at the time, Alameda had the third highest rate of asthma in the state.

At the same time, First Five/Every Child Counts grants became available to organizations that wanted to focus on preventing adverse asthma outcomes for 0- to 5-year-olds.

In short, there was funding and a will to improve lives—and it can be magical when those two factors match-up.

While the initial grant was incredibly important, we’ve been able to grow and continue to implement the program by blending and braiding funding streams. For instance, we are supported by reimbursements from managed care organizations and funding from the hospital community benefit programs, private grants, tobacco settlement funds and sales tax revenue. As can be the case, promising programs disappear when an initial grant runs out, which makes braiding all these funding sources—which can be difficult—absolutely necessary to sustain the program over time.

Creating our approach

To inform our approach, we worked closely with local hospitals. They were uniquely able to provide referrals but also educate us on what questions (e.g., do you have mold, vermin, cockroaches, etc.) we should be asking of patients.

We quickly learned that the biggest benefit we could provide would be an in-home approach – you can’t separate someone’s health from the health of the environment they live in. Also, at the time, we spoke with a local doctor who knew her patient’s family was following her recommendations, yet no one was getting better and there were more and more adverse asthma events. Finally, the patient’s mother asked if the attacks could be because of the mushrooms growing in her home. When you hear that story, clearly a light bulb goes off: health is just as much about outside the clinic as inside.

In essence, Asthma Start sends social workers to meet with individuals and families affected by asthma to determine why medication isn’t working. We use social workers because addressing asthma, often, is not just about the disease but is psychosocial as well.

During these home visits, we make sure they have medication and are taking it correctly and outline the most common asthma triggers and how to address them. If needed, we also supply cleaning supplies, ranging from vacuums to dust mite covers to non-bleach-based mold cleaners. We also ask if they have stable housing, jobs, food, a doctor and insurance.

If we identify that a patient requires additional interventions, we can make referrals to our partners at Alameda County’s Health Homes program or other appropriate community resources, programs and organizations. Throughout the years, we have formed deep partnership with many local landlords, our housing authority, the district attorney’s office, schools, the biggest local managed care organization and many others.

Landlords

Clearly, we knew home triggers and poor living conditions were driving asthma attacks. The trick then is to get these alleviated. So, we sent letters and helped tenants send letters and we got issues addressed, sometimes. Seems simple, but it worked.

Housing Authority

In those instances where we couldn’t get a landlord to take appropriate action, it was incredibly important to connect with Healthy Homes and our code enforcement.

Now, Asthma Start, Healthy Homes and code enforcement meet monthly to conference on the existing cases. We identify the housing issues that are affecting a patient’s health and refer those to Healthy Homes which can, if necessary, work with code enforcement to make sure the poor living conditions are addressed.

District Attorney and Truancy Court

Our local district attorney found that many parents were in truancy court for chronic absenteeism because they said their children were having asthma attacks and couldn’t make it to school. These weren’t delinquent parents or children—they had legitimate issues.

Once we identified this issue, the district attorney began to refer every family to us that had asthma issues and they would complete our program, and usually start going back to school and never see the truancy court again.

The district attorney also does a training once a year when school starts to help school officials understand chronic absenteeism and how to refer kids to appropriate health services.

Schools

A lot of school districts have a School Attendance Review Board, which is a board of people who review why folks aren’t making it to school. We sit on many of these boards and if any health issue—asthma or not—is identified, we handle it. We make sure the case follows a similar structure and we get kids back in school. Research indicates that schools/society save about $40 a day per child that attends. If you take the 30,000 children in the U.S. that are out of school every day due to asthma, you are talking huge cost savings.

Chronic absenteeism is silently crippling the country: missing 10 percent of the school year is a huge risk factor for academic failure and, nationwide, more than one out of 10 students miss that much school every year. Asthma alone accounts for around 14 million absences each year and children with persistent asthma are more than three times as likely to have 10 or more absences than their peers.

Managed Care Organization

In around 2003, Alameda Alliance of Health (our main Medicaid managed care organization) wanted to leverage our asthma program. First, they had to find a code to pay for our work and found one related to health and behavior assessment.

We signed a contract with a specific amount of money that we had to bill against. This modest, but successful model, worked well for several years. Alliance, about a year ago, decided it might be easier to expand the program and refer all children that are seen in the emergency room to us and the program on a regular basis receives 20 referrals a week—children with asthma-related conditions are referred to Asthma Start, children with other conditions are referred to public health.

In addition to this reimbursement, Asthma Start is supported with funding from hospital community benefit programs, private grants, tobacco settlement funds and sales tax revenue. Braiding all of these funding sources together to finance the program isn’t easy, but is necessary to sustain the program over time.

Results

I think we’ve been so successful because we were the missing link in the continuum of care from the doctor’s office into the home and community. One recent Alliance patient was referred to us – we saw her at 5 and helped address her asthma. Now, she is 12 and her asthma is a problem again. They were referred to us and immediately the family felt at ease and a conversation started. The problem? Her new allergy medication pill was too big to swallow, so she couldn’t take it. In that one example, we realized part of what we do is just make it okay to talk.

We’ve also saved money, reduced symptoms and improved lives. Our interventions return about $5.00 to $7.00 for each dollar invested. The program has greatly reduced emergency department visits and hospitalizations with 95 percent of children maintaining/reducing their symptoms. And, through these reductions the program has been able to measure a cost savings of up to 50 percent for Alliance.

The bottom line: kids are getting to school and living healthier, happier lives due to Asthma Start. And this work is possible and sustainable because we did the difficult work of blending all the diverse funding sources available to us.

Western North Carolina (WNC) Healthy Impact

WNC Healthy Impact is a partnership between hospitals, health departments, and key regional partners working together to improve community health in western North Carolina. The initiative began with investments by hospitals and health departments in 16 western North Carolina counties. It brings together local health care partners in the health improvement process to jointly assess health needs, develop collaborative Community Health Improvement plans, take coordinated action, and evaluate progress and impact. Since 2012, WNC Health Impact has led efforts to standardize and collect data, create reporting and communication templates and tools, encourage collaboration, and provide training and technical assistance across the western North Carolina community. To read more about this innovative program, see this brief summary [link].

West Baltimore Primary Care Access Collaboration

The West Baltimore Primary Care Access Collaboration (WBPCAC) is a group of sixteen organizations that aim to improve the overall health of the residents of west Baltimore. The mission of the Collaborative is to create a sustainable, replicable system of care, reduce costs and expand the primary care and community health workforce. In January 2013, the WBPCAC was awarded a five million dollar grant from the Maryland Community Health Resources Commission to reduce cardiovascular disease in west Baltimore in the four zip codes with the highest disease burden and most intense social needs of any other community in Maryland. To date, this is being accomplished by improving access to and the quality of healthcare by hiring 23 health care providers and providing training to many others. The WBPCAC has also deployed 11 Community Health Workers into these neighborhoods to partner with 172 community members to maximize their utilization of health and social services. To read more about this innovative program, see this brief summary [link]

Wake Forest Baptist Health’s Supporters of Health

Wake Forest Baptist Health is working in Forsyth County, N.C. to improve health and reduce re-admissions and charity care costs for the hospital. In 2014, the hospital trained former environmental service workers as community health workers. The community health workers receive referrals from hospital staff when patients are discharged and from agencies outside the hospital, and then work with the referred patients, connecting them to community resources. Partners include faith communities, social services agencies, safety-net clinics, and the hospital’s care transitions and pastoral care staff. The program has reduced hospital re-admissions. Wake Forest is funding this work through its foundation. To read more about this innovative program, see this brief summary [link].

Visiting Nurse Service of New York Population Health Management

The Visiting Nurse Service of New York (VNSNY) is the largest free-standing home and community-based nonprofit health system in the country. VNSNY has established a population health division to provide care coordination to at-risk populations, employing strategies such as transitions of care, health coaching, caregiver support, community-based peer workers, hot-spotting, motivational interviewing, and behavior activation. The Institute for Healthcare Improvement (IHI)/Rockaways Wellness Partnership with VNSNY is an innovative, community-based intervention for improving the health of “at-risk” populations through proactive client engagement and self-empowerment. To read more about this innovative program, see this brief summary [link].

University Hospitals as an Anchor Institution

Teaming with community partners over the past decade, University Hospitals of Cleveland (UH) created its “Anchor Institution” strategy aimed at addressing core city needs by creating jobs, stimulating the economy, and empowering urban residents to take ownership of their communities and futures. UH has committed to historically excluded minorities and diverse contractors in construction opportunities; to buy local and support diverse suppliers; and create and nurture innovative nonprofits to boost educational and economic activity. For example, through this effort, the Evergreen Cooperatives established four worker-owned companies, resulting in nearly 100 living-wage jobs with full benefits for inner-city residents; UH’s Buy Local vendor preference encouraged their largest supplier to open a distribution center in Cleveland; and NewBridge Cleveland, a dual-mission nonprofit, trains underemployed adults for high-demand health care jobs and engages at-risk youth in after-school arts curricula to kindle a love for learning and education. UH partners include Living Cities and The Cleveland Foundation for support. To read more about this innovative program, see this brief summary [link].