9th Annual Indiana Rural Public Policy Forum
January 17, 2012
Gregory N. Larkin, MD, FAAFP
State Health Commissioner

2010 national rankings:
38th in overall health
 41st in smoking adults
 37th in adult obesity
 36th in diabetes
 41st in cancer deaths
 48th in Public Health Funding/capita

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Tobacco Reduction Rates

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10 years, 27% to 21%
Increased funding in 2011
More “clean air work place policies” being adopted
or discussed
Obesity “stabilizing” (sort of).
Immunizations – novel approach, good start
Ellen Whitt
Asst. Commissioner
INShape
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Created by Governor Daniels to motivate, educate and
connect Hoosiers for healthier choices
Web-based program that connects credible resources
for interested individuals and businesses
59% of Hoosiers know of “InShape” with interactive
communication with 50,000 from all counties and 2,000
Twitter followers and growing

ISDH and ISP involved since 2006
 LHD, DNR, USDA APHIS and FSIS, FDA, BOAH

The 2011 statistics:
 Vehicles inspected – 94
 10 in violation
 Food destroyed – 4,020 lbs.
 57 trucks secured (61%)
 60 drivers educated on food safety/defense (64%)
5
Dr. James Howell
Asst. Commissioner
Dr. Duwve CMO
Pam Pontones
State Epidemiologist
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International traveling Hoosier- infected
Misdiagnosed for 2 weeks, family infected
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Emergency Intervention by ISDH:
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One family member quarantined by legal order
CDC, LHD, Indiana hospitals and providers alerted
Church members screened, vaccination
Bus of children- CHIRP
Entire workforce temporarily shut down,
screened and vaccinated
Over 700 people impacted, only 14 cases due to
response
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Indiana: 39th/50th in physician/capita access
Indiana remains a conservative policy state for
“physician extenders”
Physician distribution challenging
Having a lower access to either primary
care physicians or primary care
physician “extenders” reduces delivery
of the most cost effective method of
community health care: primary care.
Primary Care targets prevention and
chronic disease management
The greatest VALUE for health care
dollars is prevention and management
Source: Indiana 2006-2010 BRFSS
Source: Indiana 2010 BRFSS
Source: Indiana 2010 BRFSS
*BMI >= 30.0
Source: Indiana 2006-2010 BRFSS
*BMI >= 30.0
Source: Indiana 2010 BRFSS
(BMI=>30.0 - or a person 5 feet 6 inches tall weighing 186 or more pounds*)
No Data
<10%
*CDC Adult BMI Calculator
10%–14%
15%–19%
20%-24%
25-29%
Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2000.
(BMI=>30.0 - or a person 5 feet 6 inches tall weighing 186 or more pounds*)
No Data
<10%
*CDC Adult BMI Calculator
10%–14%
15%–19%
20%-24%
25-29%
Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2001.
(BMI=>30.0 - or a person 5 feet 6 inches tall weighing 186 or more pounds*)
No Data
<10%
*CDC Adult BMI Calculator
10%–14%
15%–19%
20%-24%
25-29%
Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2002.
(BMI=>30.0 - or a person 5 feet 6 inches tall weighing 186 or more pounds*)
No Data
<10%
*CDC Adult BMI Calculator
10%–14%
15%–19%
20%-24%
25-29%
Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2003.
(BMI=>30.0 - or a person 5 feet 6 inches tall weighing 186 or more pounds*)
No Data
<10%
*CDC Adult BMI Calculator
10%–14%
15%–19%
20%-24%
25-29%
Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2004.
Obesity Trends* Among U.S. Adults
BRFSS 2005
(BMI=>30.0 - or a person 5 feet 6 inches tall weighing 186 or more pounds*)
10%–14%
15%–19%
*CDC Adult BMI Calculator
20%-24%
25%-29%
30-34%
>=35%
Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.
Obesity Trends* Among U.S. Adults
BRFSS 2006
(BMI=>30.0 - or a person 5 feet 6 inches tall weighing 186 or more pounds*)
10%–14%
15%–19%
*CDC Adult BMI Calculator
20%-24%
25%-29%
30-34%
>=35%
Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2006.
Obesity Trends* Among U.S. Adults
BRFSS 2007
(BMI=>30.0 - or a person 5 feet 6 inches tall weighing 186 or more pounds*)
10%–14%
15%–19%
*CDC Adult BMI Calculator
20%-24%
25%-29%
30-34%
>=35%
Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2007.
Obesity Trends* Among U.S. Adults
BRFSS 2008
(BMI=>30.0 - or a person 5 feet 6 inches tall weighing 186 or more pounds*)
10%–14%
15%–19%
*CDC Adult BMI Calculator
20%-24%
25%-29%
30-34%
>=35%
Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008.
Obesity Trends* Among U.S. Adults
BRFSS 2009
(BMI=>30.0 - or a person 5 feet 6 inches tall weighing 186 or more pounds*)
10%–14%
15%–19%
*CDC Adult BMI Calculator
20%-24%
25%-29%
30-34%
>=35%
Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2009.
Obesity Trends* Among U.S. Adults
BRFSS 2010
(BMI=>30.0 - or a person 5 feet 6 inches tall weighing 186 or more pounds*)
10%–14%
15%–19%
*CDC Adult BMI Calculator
20%-24%
25%-29%
30-34%
>=35%
Source: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. Atlanta,
Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2010.
Source: Indiana State Department of Health
Terry Whitson
Asst. Commissioner
Optimal mental, physical, environmental, social, and
intellectual well-being for all Hoosiers, leading to a
healthy, productive, vibrant and prosperous state.
27
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Targets:
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Decrease Tobacco Usage
Reduce Prevalence of Obesity
Reduce Infant Mortality
Reduce HIV, STDs, and Viral Hepatitis
Assure Food Safety
Reduce Healthcare Associated Infections
Examines health promotion and access to care
based on primary, secondary and tertiary
prevention.
Everyone has a role!
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Butler University College of
Pharmacy and Health
Sciences
Council of Community
Mental Health
Indiana Dental Association
Association of School
Nurses
Indiana Primary Health
Care Association
Indiana State University
College of Nursing, Health
and Human Services
LHD (1)
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Indiana Rural Health
Association
I.U. School of Nursing
County Board of Health
LHOs (2)
Vincennes University
ISDH Minority Health
Indiana Public Health
Association
ISDH Programs (11)
IUPUI Chancellor for Public
Health
Indiana Hospital
Association
IU Dept. of Applied Health
Science
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Promote improvement of population health and
system capacity to perform essential services
Utilize strategic planning as the framework for
planning process
Serve as a guiding framework for Community
Health Improvement Plans across Indiana
Promote development of a process that is:
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Comprehensive and sustainable
Foundation for capacity building at state and local
levels
Of benefit to the state as a whole
Grounded in evidence-based data
30
Kristin Adams
Director OPHPM

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The measurement of health department performance
against a set of nationally recognized, practice-focused and
evidenced-based standards.
The issuance of recognition of achievement of accreditation
within a specified time frame by a nationally recognized
entity.
The continual development, revision, and distribution of
public health standards.
The result of many years of deliberate work!

Determined what the health department has in
place and where to focus future efforts.

Facilitated Assessment

It took approximately 2 hours for most Local
Health Departments
La Porte
Steuben
St. Joseph
La Grange
Elkhart
Lake
Porter
De Kalb
Noble
Marshall
Starke
Kosciusko
Whitley
Jasper
East
Chicago
City
Pulaski
Newton
Allen
Fulton
Wabash
Huntington
Miami
Wells
Cass
Adams
White
Carroll
Benton
Grant
Blackford
Howard
City of
Gary
Jay
Tippecanoe
Warren
Clinton
Tipton
Delaware
Madison
Montgomery
Randolph
Hamilton
Boone
Henry
Fountain
Lake
Wayne
Parke
Ver-
Hendricks
Marion
Hancock
Putnam
million
Rush
Fayette
Shelby
Vigo
Morgan
Clay
Union
Johnson
Franklin
Owen
Decatur
Monroe
Brown
Bartholomew
Dearborn
Sullivan
Ripley
Greene
Jennings
Jackson
Ohio
Lawrence
Knox
Daviess
Jefferson
Martin
Washington
Scott
Orange
Clark
Pike
Dubois
Gibson
Crawford
Perry
Warrick
Posey
Vanderburgh
Spencer
Harrison
Floyd
Switzerland

Historically, LHDs have evolved as a primary
provider of immunizations

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Access, cost
Private providers quit immunizing: reimbursement,
cost, schedule complexity
Most funding for LHDs immunizations is
solely intended for the “uninsured” (no
insurance) or “under insured” (insurance that
DOES NOT cover vaccines)
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CDC auditing usage to assure appropriateness
ISDH in compliance to restrict inappropriate usage

In most rural counties either local providers
“restart” immunizing or LHD develop
capabilities to immunize the “insured”

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LHDs do not have the funding for private stock nor
the administrative billing capabilities
ISDH to offer LHDs near seamless capabilities
to immunize both insured and uninsured

VAXCARE Pilot:
 Provides private stock at no cost to LHD, fully provides
billing needs, gives LHD for vaccine administration
fees
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ISDH was awarded $1 M to develop
bidirectional CHIRP data flow between 5
Indiana HIOs and major EMRs
Thousands of Indiana physicians and all major
hospital systems currently connected to a HIO
Once completed, CHIRP data will be readily
and immediately available for provider and
patient review

Indiana Tobacco Prevention and Cessation
(ITPC)
Independent agency created 10 years ago to
administer grants to county and statewide antitobacco coalitions
 Nationally recognized processes
 Every county has a different coalition profile
 Reduction impact paralleled national reduction
trends, but Indiana remains 46/50th

Karla Sneegas
Asst Commissioner

Indiana State Department of Health becomes lead
agency for anti-tobacco efforts

ITPC defunded and merged into ISDH
 Eliminates redundancy of administrative support
 Leverages existing ISDH health promotion/programs with
those of ITPC
 Chronic Disease
 Respiratory Disease
 Cancer
 Non redundant elements of ITPC remains fully intact
 ITPC executive director now Assistant Commissioner
 Separate ISDH commission, Tobacco Prevention/Cessation,
established
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All 2011 ITPC Grant awards to remain fully
intact (2 years)
Additionally, INCREASED funding
Elimination of redundant administration
 Dissemination of significant “reserve” ITPC monies
 Estimated $2M MORE funding in 2011, 2012, 2013

 Solicit more community/state grants for tobacco
cessation
 Seek INNOVATION
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What is a statewide trauma care system?
Why should Indiana develop one?
History of Indiana’s path towards development
Logical next steps

Evolution of “Trauma Care”
Captain Leo Larkin, MD, 1952
WWII Surgeon
Purple Heart, Wake Island, Pacific warfront
“Commish” Larkin, MD, age 3 years
Vietnam medical lessons:
•“Golden Hour” from injury to care crucial!
•Field and hospital coordination and
integration is vital
•Airlift medical services introduced
Field doctors in WWII learned:
•Importance of close coordination
•Importance of rapid stabilization
and transport of severe trauma
injured soldiers
•Importance of “intense (trauma)
care” centers
•Thousands of lives saved vs. WWI
care practices
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Trauma injuries, battlefield or highway, require rapid
evaluation by skilled personnel and immediately
transported to a qualified care center
Trauma care centers are unique in capabilities and are
NOT the typical community “emergency room”
When trauma patients are transported, ground or air, to
trauma centers, the preventable death rates DROP by 1530% and significant reduction of chronic disabilities and
overall community care costs.

Consistent, expert initial injury evaluation

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Consistent transportation protocols
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Assures each trauma care center is staffed and equipped
appropriately
Performance improvement systems
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National expert guidelines determines when and how a patient is
transported to a trauma care center vs. “ER”
Certification of trauma care centers

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Determines who should be immediately referred to a Trauma Care
system
Dynamic data registries to assess system improvement and
outcomes
Education and policy development of injury
prevention
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2004- ISDH Trauma System Advisory Task Force
- ~ 50 members
2006- IC 16-19-3-28 (Public Law 155)- ISDH as
the lead agency for statewide trauma system,
with rule-making authority
2008, December- ACS trauma system
consultation
2010, Gov. Daniels by Executive Order creates
the Indiana State Trauma Care Committee, ISDH
State Health Commissioner, Chair

Indiana State Department of Health

Trauma care system development (IC 16-19-3-28, PL 155)
 Rule authority for TCC designation and system development
Hospital, long term care and ambulatory clinic regulation
 Director of Trauma Care and Injury Prevention

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Indiana Department of Homeland Security

Emergency Medical Services (ambulances)
 Emergency Medical Commission governance

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41 states combine EMS and Trauma Care in 1 state agency, most
often the state public health department
80% of motor vehicle accident deaths occur in rural Indiana where 25%
of the population lives.
La Porte
Lake
Elkhart
St. Joseph
La Grange
Steuben
Noble
De Kalb
Porter
Marshall
Kosciusko
Starke
Allen
Whitley
Jasper
Pulaski
Newton
Fulton
Wabash
Miami
Huntington
Wells
Cass
Adams
White
Benton
Carroll
Grant
Tippecanoe
Howard
Blackford Jay
Warren
Clinton
Tipton
Madison
Delaware
Randolph
Montgomery
Boone
Hamilton
Henry
Fountain
Vermil-
Wayne
Parke
Hendricks
Marion
Hancock
Putnam
Rush
lio
n
Fayette
Shelby
Vigo
Clay
Morgan
Union
Johnson
9 trauma centers
1 South Bend
2 Fort Wayne
4 Indianapolis
2 Evansville
Franklin
Owen
Decatur
Monroe
Brown
Bartholomew
Sullivan
Ripley
Greene
Jackson
Ohio
Lawrence
Knox
Jefferson
Daviess Martin
Switzerla
nd
Washington
Scott
Orange
Clark
Pike
Dubois
Gibson
Crawford
Perry
Warrick
Posey
Vanderburgh
Spencer
Dearbor
n
Jennings
Harrison
Floyd
(Ohio has 38 trauma centers)
Ground
transportation
(46% of Hoosiers)
Helicopter
(91% Hoosiers)
(50% Availability)

Integrate KEY trauma care system components
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ISDH: Trauma care system ownership, injury/illness data bases
(registries), health care facility regulation
IDHS: Emergency care transportation
Better State integration of Emergency Care Components (require
legislative actions)
 National expert evaluation of Indiana, American College of Surgeons
(ACS), recommended in 2008 that EMS and trauma care should be in
the same state agency for improved integration and coordination of
trauma patient care. ISDH develops a Trauma Care and Injury
Prevention division
 Redefine the EMS governance commission and Trauma Care
Committee to include all components of state emergency care (e.g.
now primarily ambulance representation vs. adding more hospital
and trauma care center representation)
Gregory Larkin MD
State Health Commissioner
Sean Keefer
ISDH Chief of
Staff
Protecting our best natural resources!