IMPROVING AND TEACHING
POPULATION HEALTH
June 19, 2014 webinar
AAMC / CDC / Duke collaboration
J. Lloyd Michener, MD
Professor and Chair
Department of Community and Family Medicine
Director, Duke Center for Community Research
Mina Silberberg, Ph.D.
Associate Professor
Vice-Chief for Research and Evaluation
Division of Community Health
Alisa Nagler, JD, EdD
Assistant Dean, Graduate Medical Education
Assistant Professor, Practice of Medical Education
Gwen Murphy, RD, MS, PhD
Assistant Consulting Professor
Division of Community Health
Department of Community and Family Medicine
Population Health: the health outcomes of a
group of individuals, including the distribution of
such outcomes within the group.
Source: Kindig D, Stoddart G. What is Population Health?
Am J of Public Health. 2003; 93(3): 380-383.
The Goal: “from Health Care to Health”
IMPROVING POPULATION HEALTH –
In one sentence:
Know the burden of preventable illness in your
community, and partner with community practices
and agencies to prevent these illnesses
Disease Burden / Practice Patterns Vary
Source: The Quality of Medical Care in the United States: A Report on the Medicare Program. The Dartmouth
Atlas of Health Care 1999. The Center for the Evaluative Clinical Sciences Dartmouth Medical School
Change In Female Mortality Rates From 1992–96 To 2002–06 In US Counties.
Kindig D A , and Cheng E R Health Aff 2013;32:451-458
©2013 by Project HOPE - The People-to-People Health Foundation, Inc.
Durham residents with diabetes
(2007-2009)
14,345 unique patients
8.7% of all patients >20 yo
14.3% of all patients >40 yo
Durham County Stats (per CDC):
2008 ~ 10% of adults diagnosed
with diabetes
North Carolina (CDC):
2008 ~ 9% of adults diagnosed
with diabetes
By Race:
8.4% White
15.6% AA
12.4% NA
4.5% Hispanic
4.3% Other
www.iom.edu/primarycarepublichealth
Degrees of Integration:
What is integration?
The Institute of Medicine defines integration as ‘the linkage of
programs and activities to promote overall efficiency and
effectiveness and to achieve gains in population health.’
 Principles of Integration:
 Shared goal of population health
 Aligned leadership
 Community engagement
 Sustainability
 Collaborative use of data
Why integrate now?
• Call to Action
– IOM Report
– Affordable Care Act
– New Funding Opportunities
• Changes in Health Care
–
–
–
–
–
–
Rise in Health Care Costs
Disturbing Health Trends
Increase in Health Research and Data
Impact of Social Determinants of Health
Drive to PCMHs and ACOs
Availability of Electronic Health Records
What can integration do?
Just For Us
Just For Us
Percent Difference Between Medicaid Recipients Enrolled in CCNC
and Those Not Enrolled in CCNC, for Rates of Asthma-Related
Emergency Department Visits and Inpatient Admissions, 2008–2012
Note. CCNC, Community Care of North Carolina. NCMJ
September/October 2013, Volume 74, Number 5
What is the Practical Playbook?
A cornerstone of the next transformation of health,
in which primary care and public health groups work
collaboratively to achieve population health improvement.
www.practicalplaybook.org
National Advisory Committee
American Academy of Family Physicians
Centers for Medicare & Medicaid Services
American Academy of Pediatrics
Council of State and Territorial Epidemiologists
American Association of Colleges of Osteopathic Medicine
Eastern Virginia Medical School
American Board of Family Medicine
Geisinger Health System
American College of Physicians
Health Resources and Services Administration
American College of Preventive Medicine
Kaiser Permanente
American Heart Association
Los Angeles County Health Department
Association of Academic Health Centers
Multnomah County Health Department, Oregon
Association of American Medical Colleges
New York City Health Department
Association of Public Health Nurses
Pennsylvania Health Department
Association of State and Territorial Health Officials
University of California San Francisco
Centers for Disease Control & Prevention
University of Utah
Practical Playbook Overview
Massachusetts Improves Quality of Life for Children with Asthma
The Community Asthma Initiative works to improve the
health and quality of life for children with asthma.
Boston Children’s Hospital designed the program to focus
on medical interventions rather than environmental
influences.
Since its establishment, the program has worked in
tandem with partners at every level, including the
individual, family, and larger community.
As a result, the Community Asthma Initiative helped
reduce the percent of emergency department visits by 58
percent, the number of asthma-related hospitalizations,
CAI helped reduce the number of the number of school absences for children, and the
asthma-related hospitalizations number of work absences for their parents.
by 80 percent.
Maryland Prevents One Million Heart Attacks and Strokes
The Maryland Million Hearts Initiative is part of a
national campaign to prevent one million heart
attacks and strokes by 2017.
The statewide initiative is a partnership between
the Department of Health and Mental Hygiene and
local communities, health systems, nonprofit
organizations, federal agencies and private-sector
businesses.
Since the program began, the state has seen an
increase in blood pressure control at participating
centers.
The program has seen a 27 percent increase in
blood pressure control at participating
centers.
Next steps – define what clinicians need to know
and do in and with the community
The Population Health Competency Map
Training Levels:
1. Foundational — Basic awareness of the principles and
appreciation for their impact and importance in community health.
2. Applied — An intermediate level of learning, enabling skilled
participation in community-engaged population health activities.
3. Proficient — Advanced learners who achieve competence for
independent practice or leadership of the design and
implementation of community-engaged health improvement activities.
Competencies
•
•
•
•
Public Health
Community Engagement
Critical Thinking
Team Skills
Competency Map:
Integrating Population Health into Clinician Education
Learners:
Competency:
Public Health
Community Engagement
Critical Thinking
Team Skills
medical PA,
FM
PT students residents
F
F
F
F
F = Foundational (Basic) Awareness
A = Applied (Intermediate) Skilled participation
P = Proficient (Advanced) Independent practice
nurse
leaders
FM
faculty
P
P
P
P
Population Health Curriculum
Training levels
Basic
Intermediate
Advanced
Learner types
•
•
•
•
All students &
residents
Primary care residents
CFM faculty
•
Apply strategies that
improve the health
of populations
• Discuss potential • Identify
populationappropriate
based
preventive
interventions to
strategies for a
improve health
population, based
upon literature,
data assessment
and stakeholder
input
Learning Method
•
Project: design an
intervention
Evaluation
•
Assess intervention

Population Health
Fellows & Faculty
CH faculty
Develop and
implement
populationbased prevention
strategies in
collaboration
with community
partners
CDC/AAMC/Duke
Project on Population Heath
• Convene primary care programs that are
interested in improving population health training
of residents.
• Identify training materials that are already
available for medical students and residents, and
develop a library of resources.
• Map training materials to the GME milestones
using current GME population health milestones
and program requirements for primary care.
IMPROVING AND TEACHING
POPULATION HEALTH…
Mina Silberberg, Ph.D.
Associate Professor
Vice-Chief for Research and Evaluation
Division of Community Health
• Readings or electronic modules followed by small group
discussions or group exercises
• Community site visits
• Community health education
• Participation in local Healthy Carolinians coalition
• Integrated psychosocial/clinical patient assessment
• Projects –QI, community engagement, written and oral
reports
• Participation in population health management innovations
• Work with data
• Shadowing care managers
Population Health Curriculum
evaluation methods
•
•
•
•
•
Discussion participation
Project completion
Final assessment
Post-graduation activity
Real test – health improvement in home communities
Population Health Curriculum –
Faculty Development
Population Health Curriculum
The result:
Clinicians who can care for their patients
in the context of their communities
IMPROVING AND TEACHING
POPULATION HEALTH…
Alisa Nagler, JD, EdD
Assistant Dean, Graduate Medical Education
Assistant Professor, Practice of Medical Education
ACGME Milestones
•
•
Component of Next Accreditation System
Organized under 6 domains of clinical competency
1. Patient Care
2. Medical Knowledge
3. Professionalism
4. Interpersonal Communication Skills
5. Systems Based Practice
6. Practice Based Learning
•
Provide framework and shared language to describe
learner expectations and progress
•
Population Health Milestones??
ACGME Milestones
Example
1. Review of published milestones for population health
related content
2. Development of generic Population Health Milestones
for GME Program adoption
3. Linking of existing resources to Population Health
Milestones to support Programs with teaching and
evaluation
ACGME Milestones
General
Competency
Sub-competency
Example
Developmental Progression not
linked to training level
“Aspiration” or last level may
NOT be achieved by
graduating residents OR
faculty!
Mid-range evaluation indicates
trainee has met some but NOT all
of the expectations of the more
advanced Milestone
Milestone
Documentation of evaluation of
resident performance
ACGME
Clinical Learning Environment (CLER) Review
• Component of Next Accreditation System
• 6 focus areas:
1.
2.
3.
4.
5.
6.
Patient Safety
Quality Improvement
Transitions of Care
Supervision
Duty Hours Oversight, Fatigue Management & Mitigation
Professionalism
ACGME
Clinical Learning Environment (CLER) Review
Component of Next Accreditation System
6 focus areas:
1.
2.
3.
4.
5.
6.
“Including how sponsoring
institutions engage residents in the
use of data to improve systems of
care, reduce health care disparities
and improve patient outcomes.”
Patient Safety
Quality Improvement
http://acgme.org/acgmeweb/tabid/436/ProgramandInstitutionalAc
Transitions of Care
creditation/NextAccreditationSystem/ClinicalLearningEnvironmentR
eviewProgram.aspx
Supervision
Duty Hours Oversight, Fatigue Management & Mitigation
Professionalism
BACK TO LLOYD FOR FINAL HOUSEKEEPING ITEMS
Next steps:
1)
Share contact info
2)
Volunteers for institutional presentations
3)
Program evaluation
4)
Other?
Email address: Gwen.murphy@duke.edu
Resources - Department of Community and Family Medicine
webinar and slides posted here:
http://cfm.mc.duke.edu/modules/cfm_resrc/index.php?id=1
Milestones webinar schedule
repeated
June 3rd Tuesday 2:30pm EST
June 19th Thursday 3:30pm EST
repeated
July 1st Tuesday 10am EST
July 15th Tuesday 9am EST
repeated
August 5th Tuesday 9am EST
August 12th Tuesday 9am EST
repeated
September 9th Tuesday 10am EST
September 16th Tuesday 3pm EST
repeated
October 8th Wednesday 3pm EST
October 14th Tuesday 9am EST
AAMC-CDC Cooperative Agreement Webinar Series
To promote increased public health awareness
and encourage inclusion of public health perspectives
throughout the AAMC community
Inclusion and Integration of Population Health into
Undergraduate Medical Curriculum
June 26, 2014, 1:00 p.m. - 2:00 p.m. ET
https://www.aamc.org/initiatives/diversity/portfolios/
cdc/362178/webinarseries.html