Скачать презентацию Improving health and healthcare at the population level Скачать презентацию Improving health and healthcare at the population level

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Improving health and healthcare at the population level SCHA Data Knowledge Academy Keynote Presentation Improving health and healthcare at the population level SCHA Data Knowledge Academy Keynote Presentation October 13, 2016 @Healthier. SC #Healthier. SC. org

The most important number for determining health status? • Genetic Code • BMI • The most important number for determining health status? • Genetic Code • BMI • Age • Zip Code @Healthier. SC #Healthier. SC. org

The Neighborhood and The Need The 5. 6 square mile area of CPN is The Neighborhood and The Need The 5. 6 square mile area of CPN is marked by undereducation, teenage pregnancy, poor healthcare, violent crime, unemployment, and intergenerational poverty. Note: 2016 Federal Poverty Line for a family of 4 (200% FPL) = $48, 500 3/18/2018 We aim to break that cycle. 3

population health big picture • The overall health of people and populations is determined population health big picture • The overall health of people and populations is determined by a continuous interplay of social, environmental, economic and clinical factors/drivers. • Certain populations are more adversely impacted by these factors resulting in inequitable differences in healthcare access and health outcomes. • Effective solutions to the greatest health challenges at a community/population level will require collective actions that address both the major drivers of health and healthcare for the population overall and the equity gaps for those subpopulations most at risk @Healthier. SC #Healthier. SC. org

Population Health Population Health "the health outcomes of a group of individuals, including the distribution of such outcomes within the group" @Healthier. SC #Healthier. SC. org

Population Health Management • The actions through which care providers can improve clinical and Population Health Management • The actions through which care providers can improve clinical and financial outcomes for a defined population • The aggregation of data to provide a comprehensive clinical and financial picture at the patient and population level • Built around an integrated clinical delivery network and intensive care management for high risk patients within the defined population @Healthier. SC #Healthier. SC. org

@Healthier. SC #Healthier. SC. org @Healthier. SC #Healthier. SC. org

Key Triple Aim Measurement Principles • The need for a defined population- measures of Key Triple Aim Measurement Principles • The need for a defined population- measures of population health require a population denominator • The need for data over time- to distinguish between common and special cause variation, and to better understand the relationship between cause and effect and impact of specific interventions • The need to distinguish between outcome and process measures, and between population and project-based measures • The value of benchmark or comparison data @Healthier. SC #Healthier. SC. org

social determinants of health • conditions in the environments in which people are born, social determinants of health • conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks @Healthier. SC #Healthier. SC. org

Understanding Health Equity @Healthier. SC #Healthier. SC. org Understanding Health Equity @Healthier. SC #Healthier. SC. org

the health equity challenge • Health equity is achieved when every person has the the health equity challenge • Health equity is achieved when every person has the opportunity to “attain his or her full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances. ” • Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment. @Healthier. SC #Healthier. SC. org

Health Equity Triad Location and Built Environment Race and Ethnicity Income and Assets @Healthier. Health Equity Triad Location and Built Environment Race and Ethnicity Income and Assets @Healthier. SC #Healthier. SC Education Level • Living in povertyamplified in early childhood • Lack of access to high quality education & jobs • Unstable/unhealthy housing options • Unfavorable work or neighborhood conditions • Exposure to neighborhood violence Healthier. SC. org

Disparities in Mortality Rates for Three Health Status Indicators: Black and White Americans (1990 Disparities in Mortality Rates for Three Health Status Indicators: Black and White Americans (1990 and 2005) Source: Orsi JM, Margellos-Anast H, Whitman S. Black-white health disparities in the United States and Chicago: A 15 -year progress analysis. American Journal of Public Health. 2010; 100(2): 349 -356. @Healthier. SC #Healthier. SC. org

Relative Risk of All-Cause Mortality by US Annual Household Income Level Sources: Mc. Donough Relative Risk of All-Cause Mortality by US Annual Household Income Level Sources: Mc. Donough P, Duncan GJ, Williams D, House J. Income dynamics and adult mortality in the United States, 1972 through 1989. American Journal of Public Health. 1997; 87(9): 1476 -1483. Williams D. “Race, Racism, and Racial Inequalities in Health. ” Presentation to Harvard Kennedy School Multidisciplinary Program in Inequality and Social Policy. February 8, 2016. http: //inequality. hks. harvard. edu/files/inequality/files/williams 16 slides. pptx? m=1455915158 @Healthier. SC #Healthier. SC. org

@Healthier. SC #Healthier. SC. org @Healthier. SC #Healthier. SC. org

South Carolina’s Health People in 41 other states have better health than people in South Carolina’s Health People in 41 other states have better health than people in South Carolina …people who live in low-income neighborhoods or rural areas, and people of color have even worse outcomes …our children are the first generation projected to live shorter lives than their parents @Healthier. SC #Healthier. SC Hundreds of people and organizations in our state are doing great work, . . but we have not been as coordinated and aligned as we should be. For the first time in our state’s history. We are working together to change this. Healthier. SC. org

The Alliance for a Healthier South Carolina Mission: Coordinating action on shared goals to The Alliance for a Healthier South Carolina Mission: Coordinating action on shared goals to improve the health of ALL people in South Carolina. @Healthier. SC #Healthier. SC. org

Alignment of goals and actions: our primary way of impacting health in SC @Healthier. Alignment of goals and actions: our primary way of impacting health in SC @Healthier. SC #Healthier. SC. org

@Healthier. SC #Healthier. SC. org @Healthier. SC #Healthier. SC. org

Our Common Agenda for Health Improvement @Healthier. SC #Healthier. SC. org Our Common Agenda for Health Improvement @Healthier. SC #Healthier. SC. org

Key Alliance metrics Metrics for overall improvement and disparity reduction: • Infant mortality and Key Alliance metrics Metrics for overall improvement and disparity reduction: • Infant mortality and low-birthweight • Reading at grade level and well-child visits • Primary-care-preventable utilization of acute care hospitals by people with and without behavioral health conditions • Appropriate management of asthma, diabetes, hypertension, and depression • Self-rated mental health status @Healthier. SC #Healthier. SC 21 Healthier. SC. org

Recent South Carolina Wins (2014 data) Healthy Babies 58 Fewer baby deaths 12% 338 Recent South Carolina Wins (2014 data) Healthy Babies 58 Fewer baby deaths 12% 338 Fewer babies born Reduction in Infant with Low-Birthweight Mortality Rate. Met 2020 Alliance Goal. 5% Reduction in Low. Birthweight Rate Healthy Children 17 7. 1% Position improvement in Improvement in Asthma America’s Health Rankings Medication Ratio for Childhood Immunizations 2, 372 Fewer Pediatric ED visits due to Primary Care Preventable Conditions.

Recent South Carolina Wins (2014 data) Healthy Minds People with existing behavioral health conditions Recent South Carolina Wins (2014 data) Healthy Minds People with existing behavioral health conditions spent 4, 272 fewer days hospitalized due to primary care preventable conditions. We consolidated in a public, online map, all statewide drop-boxes for prescription drugs. Healthy Bodies 12% Reduction in proportion of people who needed a doctor but couldn’t see one due to cost. Met 2020 Alliance Goal. 136, 624 Fewer uninsured 4, 276 Fewer hospitalizations due to Primary Care Preventable Conditions.

SC Call to Action for Health Equity @Healthier. SC #Healthier. SC. org SC Call to Action for Health Equity @Healthier. SC #Healthier. SC. org

Alliance equity metrics @Healthier. SC #Healthier. SC. org Alliance equity metrics @Healthier. SC #Healthier. SC. org

Equity Call to Action- Obesity 1: Stratify data to identify what populations to target. Equity Call to Action- Obesity 1: Stratify data to identify what populations to target. 2: Maximize the potential of diversity in your organization to develop culturally sensitive solutions WITH the community. Healthier. SC. org @Healthier. SC #Healthier. SC

The health equity ripple effect Obesity/Chronic Disease of the mom prior to conception is The health equity ripple effect Obesity/Chronic Disease of the mom prior to conception is a risk-factor for Low-birthweight is a risk factor for Infant Mortality and for difficulty to learn. Difficulty to learn is a risk factor for high-school graduation. High-school graduation is a major socioeconomic determinant of health. @Healthier. SC #Healthier. SC. org

Guide to Preventing Readmissions among Racially & Ethnically Diverse Medicare Beneficiaries Prepared for CMS Guide to Preventing Readmissions among Racially & Ethnically Diverse Medicare Beneficiaries Prepared for CMS OMH by the Disparities Solutions Center at Massachusetts General Hospital in collaboration with the National Opinion Research Center at the University of Chicago @Healthier. SC #Healthier. SC. org

key differentiating factors between hospital systems with lower and higher Medicare readmission rates • key differentiating factors between hospital systems with lower and higher Medicare readmission rates • Higher minority population • Higher unmarried population • Lower education level • Higher proportion not in labor force • Lower total financial assets @Healthier. SC #Healthier. SC • Lower household income • Lower supplemental health insurance • Higher depression scores • Lower cognition scores • Worse self rated health • Higher difficulty with ADLs Healthier. SC. org

All Payor Readmission Rates by Diagnosis @Healthier. SC #Healthier. SC. org All Payor Readmission Rates by Diagnosis @Healthier. SC #Healthier. SC. org

Racial Readmission Disparity Gap @Healthier. SC #Healthier. SC. org Racial Readmission Disparity Gap @Healthier. SC #Healthier. SC. org

1. Stratify the data @Healthier. SC #Healthier. SC. org 1. Stratify the data @Healthier. SC #Healthier. SC. org

2. Maximize the potential of diversity in your organization to develop culturally humble solutions 2. Maximize the potential of diversity in your organization to develop culturally humble solutions WITH the community. And you would move your Overall Readmission Rate from Orange to Yellow in the comparative dashboard @Healthier. SC #Healthier. SC. org

Centering Pregnancy Results P=0. 01 @Healthier. SC #Healthier. SC P=0. 50 Healthier. SC. org Centering Pregnancy Results P=0. 01 @Healthier. SC #Healthier. SC P=0. 50 Healthier. SC. org

Achieving population health equity- key collective upstream solutions • Collect and analyze all health Achieving population health equity- key collective upstream solutions • Collect and analyze all health data through an equity lens • Build a culture of diversity and inclusiveness that reduces the negative impact of implicit bias • Adopt a life course perspective to education and early childhood development (from cradle to career) • Deliver culturally and linguistically tailored health and social programs for specific at risk populations • Target urban planning and community development to healthy food access, safe spaces for physical activity, safe and affordable housing, public transportation and safety • Invest in community-based programs and resources @Healthier. SC #Healthier. SC. org

Healthier. SC. org @Healthier. SC #Healthier. SC. org Healthier. SC. org @Healthier. SC #Healthier. SC. org