ACHIEVE Action Institute:
Clinical & Community Linkages for Chronic
Disease Prevention
Nicole Flowers MD, MPH
Medical Officer
Centers for Disease Control and Prevention
Division of Community Health
APRIL 25, 2012
Learning Objectives
 Describe the burden of chronic disease
and approaches to reducing the burden.
 Understand how community efforts can
work synergistically with clinical levers to
address chronic disease.
 Identify options for supporting
individuals with chronic disease in your
community.
Chronic Diseases
145 million Americans are affected
Responsible for 7 of every 10 U.S. deaths
Cause major limitations in daily living
for 1 of 10 Americans
Account for ~75% of U.S. medical costs
Are inequitably distributed
across the population
Chronic Diseases and Related Risk Factors
Leading Causes of Death*
United States, 2000
Actual Causes of Death†
United States, 2000
Heart Disease
Tobacco
Cancer
Poor diet/
Physical inactivity
Stroke
Alcohol consumption
Chronic lower
respiratory disease
Microbial agents
Unintentional Injuries
Toxic agents
Diabetes
Motor vehicles
Pneumonia/influenza
Firearms
Alzheimer’s disease
Sexual behavior
Kidney disease
Illicit drug use
0
5
10
15
20
25
Percentage (of all deaths)
30
35
0
5
10
15
Percentage (of all deaths)
* Miniño AM, Arias E, Kochanek KD, Murphy SL, Smith BL. Deaths: final data for 2000. National Vital Statistics Reports 2002; 50(15):1-120.
† Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-1246.
20
Factors that Affect Health
Examples
Smallest
Impact
Counseling
& Education
Clinical
Interventions
Long-lasting
Protective Interventions
Largest
Impact
Changing the Context
to make individuals’ default
decisions healthy
Socioeconomic Factors
Eat healthy, be
physically active
Rx for high blood
pressure, high
cholesterol, diabetes
Immunizations, brief
intervention, cessation
treatment, colonoscopy
Fluoridation, 0g trans
fat, iodization, smokefree laws, tobacco tax
Poverty, education,
housing, inequality
 Imagine a typical chronically ill patient who sees his
doctor half an hour every three months. These four
encounters each year—the physician’s opportunity to
counsel, diagnose, and treat—constitute only 0.02% of
this patient’s life. For all the rest—the 99.98% of the time
that the patient is elsewhere, making decisions about his
health in the context of his culture, family, and
community—
the doctor’s impact on the
patient’s choices is minimal….
That 99.98% belongs to community
medicine, to population health,
and to public health.
Jarris et al,
Acad Med. 2011;86:1347.
 Imagine a typical chronically ill patient who sees his
doctor half an hour every three months. These four
encounters each year—the physician’s opportunity to
counsel, diagnose, and treat—constitute only 0.02% of
this patient’s life. For all the rest—the 99.98% of the time
that the patient is elsewhere, making decisions about his
health in the context of his culture, family, and
community—
the doctor’s impact on the
patient’s choices is minimal….
That 99.98% belongs to community
medicine, to population health,
and to public health.
Jarris et al,
Acad Med. 2011;86:1347.
National Prevention Strategy
• Extensive stakeholder
and public input
• Aligns and focuses
prevention and health
promotion efforts with
existing evidence base
• Supports national
plans
8
National Prevention Strategy
9
Clinical and Community Linkages to
Address Chronic Disease
 Clinical Preventive Services Procedures, tests, counseling, or medications
 Aimed at preventing the onset or progression of a
health condition or illness
 Clinical and Community Preventive Services
 Linking clinical domain and community resources for
systems change to promote improved health
outcomes in the community.
Expanded Chronic Care Model
Medical
Management
SelfManagement
Ongoing
Support
Critical Elements of Disease Management
Pharmacists Can Improve Care
and Reduce Costs




Supporting medication adherence
Improving the use of medications
Improving treatment outcomes
Helping patients with self-management
Community Health Workers
• Liaison between health systems and communities
• Facilitate access to and improve quality and cultural
competence of medical care
• Build individual and community capacity for health by:
•
•
•
•
Increasing health knowledge and self-sufficiency of the patients
Serving as community health educators
Providing social support
Advocating for the health care needs of patients and communities
Sample community activities to support teambased care (TBC)





Influence coverage for TBC in private health plans, among
self-insurers or public health plans.
Ensure standardized curriculum or protocols for health
care extenders.
Support jurisdiction-wide defining of the scope of
practice for the health care extenders
Gather and disseminate information about the return on
investment for utilization of team-based care approaches
Increase awareness among patients with chronic disease
about the availability of CHWs or pharmacists as
healthcare extenders
State Example - Maryland
•
P3 (Patients, Pharmacists, Partnership) is a
program among worksites and community
pharmacies using pharmacists to provide
chronic disease self-management
•
Participants have seen a sustained reduction in
A1C , blood pressure, and lipids
State Examples
• Minnesota passed legislation in 2009 to
make CHW services reimbursable under
Medicaid and the state regulates CHW
training, supervision, enrollment criteria, and
billing
• Massachusetts’ broad-based policies,
consistent and powerful advocacy from the
CHW workforce, and partnership with state
public health partners secured the ongoing
integration of CHWs into health care systems
Chronic Disease Self-Management Program

Low-cost, community-based class for people with
chronic diseases developed at Stanford University

A CDC meta-analysis of CDSMP showed improvements
in fatigue, depression, health distress, etc.

CDC’s Arthritis Program funds 12 state arthritis
programs that can offer CDSMP as a proven
intervention

CDC’s Diabetes program and Heart Disease and Stroke
Prevention program have refunded programs for
CDSMP
Sample Activities of Community Organizations to
support CDSMP
Possible PSE activities:

Facilitate increased uptake of CDSMP sites. Sites should be
linked to a health care delivery system

Campaign to increase awareness about availability and
benefits of CDSMP

Support provider referrals to CDSMP

Facilitate development of infrastructure for better
communication and data sharing between CDSMP and
providers.

Engage populations with health disparities
State Example - Oregon



Worked with other state agencies, local health dept,
health care providers, social service agencies, and CBOs to
create a sustainable infrastructure for delivering CDSMP
Best estimates over four years show 557 emergency room
visits avoided, saving $634,980 and 2,783 avoided hospital
days, saving $6, 501,088
Currently engaged in discussions with public employees
and educators’ benefit boards on inclusion of CDSMP as a
covered benefit
Community – Clinic Partnership
Community
Insurers
Employers
}
Clinic
Partnership Zone
Reimbursement
Informed Population Screening for
High Risk
Strong Community
Organizations
Proactive Practice
Team
Diagnosis of
Prediabetes
Structured Lifestyle
Programs
Healthy Public
Policy
Supportive
Environments
Total Population
Prediabetes
Decision Support
Information
Systems
Regular
Glucose
Monitoring
Diabetes
Informed,
Activated
Patients
Complications
EnhanceFitness
•
Evidence based, community based exercise program
developed by the University of Washington PRC
• Increases strength, boosts activity, elevates mood
• One of six physical activity programs recommended
by CDC Arthritis Program
•
Offered by Group Health as a free benefit to all its
Medicare enrollees since 1998
•
In 2011 the YMCA began offering EF at Ys in 8 states
and will continue expansion efforts
Community-Clinical Linkages
How can you support chronic
disease prevention in your
community ?