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  • Accountable Care Communities (p. 25-30)
  • 2-3 Pilots focused on cardiovascular disease

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  • “Health Extension System” – clinician technical assistance to support transformation and linkages to public health, linkages between providers and linkages to Community Health Improvement (CHI) initiatives.
  • Community health to connect with Health Information Exchange (HIE).
  • Need to strengthen and modernize Public Health workforce.

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  • Two initiatives to develop a “Community Integrated Health System:
    1. “Designated Prevention Service Centers (DPSC)”: Evidence-based primary and secondary prevention supporting Advanced Medical Homes. Initial focused of Designated Prevention Service Centers is on indoor environmental quality and healthy behaviors, staffed with certified Community Health Workers. Initial targets include: diabetes prevention program, asthma home assessment, and falls prevention.
    2. “Health Enhancement Communities (HEC)”: multi-sector coalitions to improve public health and reduce disparities of communities 10,000-80,000. Strong existing collaborations will be intensified, will be linked to local clinical reforms, will have common measures, and will have state leadership.
  • 3-5 Health Enhancement Community grants will be competitively awarded.
  • Each Health Enhancement Community will use evidence-based initiatives toward 4 priorities: tobacco, nutrition, physical activity and diabetes care. Interventions based on policy-, systems- and environmental-level change. (p.70-84)

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  • “Healthy Neighborhoods” (p. 82-87): Neighborhood Councils, led by a full-time ‘Champion” to develop shared database of resources, develop (with hospitals) common goals and scorecard, develop cross-trained Community Health Workers (CHWs) to eliminate barriers external to delivery system and care coordinators to eliminate barriers internal to healthcare system.

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  • No reference to broad, primary community health improvement beyond various types of care coordination with Patient Centered Medical Home (PCMH).

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  • No discussion of any SIM investments in social or environmental determinants or in stare or local public health/prevention infrastructures. The Plan calls for local health departments to share the findings of community health needs assessments with the Regional Collaboratives, who will integrate these needs/resources with those of local Patient Centered Medical Homes (PCMHs). Regional Collaboratives will also ‘recruit practitioners and medical neighborhood participation…” (pg. 34)

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  • Key goal #3 of the Plan is to enhance public health efforts to address social and environmental factors influencing the health of specific populations. (pg. 21)
  • Four key values underlying public health improvements:
    • health equity,
    • integration
    • continuous learning, and
    • sustainability.
  • Proposed public health innovations:
    • Regional public health hubs bring together state and local public health, communities and the Alliance (a government-appointed group of providers, public health, businesses, payers, community development advocates).
    • Community assessments will be aligned across local public health, hospitals and others, with shared metrics and data support from the Hubs.
    • Convening stakeholders will be a Hub activity, to shield hospitals from anti-trust as they collaborate on assessments, etc.
    • Planning interventions will be supported by the Hubs which will advise on evidence-based interventions and try to get communities to link interventions for maximum collective impact.
    • Hubs will also have roles in evaluation, data collection, dissemination, and capacity building.
  • Uses Asset-Based Community Development method and seeks to improve broad quality measures, including quality of life, community health, along with medical outcomes.

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  • Plan will establish patient-centered, value-based delivery system through Regionalized Accountable Care Organizations (ACOs) that will begin with a Accountable Care Organization with phasing in of behavioral health and long-term care services and supports. The proposal plans for 6 regions. (pgs. 22-23, 124)

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  • “Community Health Hubs” (CHHs) will cover a county or region and provide community-based care prevention and care coordination. CHHs will be selected on a competitive basis (may be hospitals, local health coalitions, LHDs, other non-profits) and will contract with Patient Centered Medical Homes (PCMHs) to define roles, data sharing, tracking, and performance monitoring. CHHs will deploy community health teams to provide non-medical community supports and to work closely with hospital discharge planners.
  • CHHs will have standard discharge measures
  • CHHs must focus on Medicare and Dual Eligibles and also may add another superutilizer group eg., HIV, children with rare conditions.
  • CHH services will be available to other payers.

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  • The major components of the Blue Print are: Patient Centered Medical Homes (PCMHs), Accountable Systems of Care, Community Health Innovation Regions, Payment Reforms, and Infrastructure (pg. 6)
  • Creates "Community Health Innovation Regions" where, "partners act cohesively with a broad-based vision for region-wide impact, to make the environment healthier and to connect health services with relevant community services." First steps are needs assessment and action plan (pgs. 93-95)

New Hampshire:
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  • Transform the Long Term Services and Support Systems of Care in the State. Focus will be to expand services to those that may be at risk for needing services, but also to really target care coordination to the "superutilizers", as well as another subset (just below superutilizers) in order to prevent or delay worsening of conditions and needed demand for additional supports or use of unneeded services. Plans align with other public health programs and goals to further address chronic conditions. (pg. 41)

New York:
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  • Plan uses State Health Department’s Prevention Agenda 2013 – 2017 as a guide for building healthy communities. Plan will work to strengthen links between primary care, hospitals, long-term care providers, local health departments, and a variety of community stakeholders.
  • Focus on the prevention of chronic illnesses – cancer, diabetes, heart disease, hypertension, smoking, and colorectal cancer. (pg. 17)
  • Promotion of healthy women, infants, and children.
  • Provision of effective mental health and substance use prevention and treatment services.
  • Prevention of HIV, sexually transmitted diseases, and vaccine-preventable diseases.
  • Link with “Regional Health Improvement Collaboratives” (RHICs) – promote regional health planning (11 RHICs).
  • Plan discusses the importance of care coordination. (pg. 65 and pg. 69)
  • Plan discusses the preventive care integration. (pg. 71)
  • Plan details its MCH focus. Providing and coordinating age and developmentally appropriate child care, including vaccinations, developmental screening, and preventive oral health practices, for all children, in accordance with AAP/Bright Futures guidelines. Integrating routine preconception and interconception care in routine primary care delivered to women of reproductive age (including screening and follow up for risk factors, management of chronic medical conditions, and use of contraception to plan pregnancies). (pg. 72)

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  • Integration between primary care and public health will connect clinicians with community services; build community health teams to empower patients to successfully manage illness and maximize resources.
  • Development of connections between community health and primary care - Ohio is working across public and private agencies and partners to implement a 28-point agenda for addressing the most common and preventable causes for infant mortality. These efforts tie in closely to the state’s efforts to improve care through the Patient Centered Medical Home (PCMH) model and increase efficiency through a perinatal episode of care model.
  • Approaches considered include the development of community health teams to connect patients with community resources to reduce risk and improve disease management for illnesses and injuries related to episodes of care. Expanding collaboration among providers, public health, community organizations, and health care insurers through the Ohio Patient-Centered Primary Care Collaborative (OPCPCC) was also discussed as a means to develop integrated community health approaches.

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Prevention & Population Health:
  • Development of a community health improvement plan and implementation of improvements through the state’s ten county and municipal-based health departments and local health improvement coalitions.
  • Supporting the Healthy Pennsylvania health literacy initiative through Pennsylvania’s Family Place Libraries.
  • Utilizing technology to map chronic disease incidence to improve prevention and self-management of chronic conditions.
  • Maximizing patient engagement in behavior change to better manage chronic conditions and adopting healthy behaviors through acceptance of shared decision-making processes and tools and through the application of skills such as motivational interviewing .
  • Transformation Support Center – population roadmap for improvement focusing on the below items at practice level– 1. planned care and risk assessment at every visit using proactive team-based care, 2. patient self-management support, education, and activation, and 3. care coordination (hospital-based networks).
  • “Strengthening Public Health” – section (pg. 138)
  • Increase health literacy through Pennsylvania libraries. (pg. 143)
  • Utilize technology to address public health needs. (pg. 146)

Rhode Island:
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  • 3 levels of measurement to improve the health of Rhode Islanders:
    1. Indicators of overall health – population-wide basis, years of potential life lost
    2. Prevalence of specific diseases & conditions that contribute to a population’s health
    3. Behavioral & lifestyle indicators that impact the health of the population
  • Focus on Population Health Management – 3 key strategies:
    1. Empowering and enabling primary care providers to be the central coordinator of care
    2. Supplementing primary care with robust, patient-centered care management tools & resources based on a modernized data infrastructure
    3. Leveraging those care management tools & resources to effectively engage people in their own health
  • (Pg. 79):
    1. Social and community service resource directory
    2. Through planning, encourage the state, cities and towns to understand social determinants of health
    3. Communication – Public Service Announcements (PSAs) & social media
    4. Create a sustainable, commonly available fund for prevention activities – could include vaccination, tobacco cessation, obesity prevention
    5. Targeted sustainable health promotion efforts:
      • Smoking
      • Obesity
      • Diabetes care management

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  • Patient Centered Medical Home (PCMH) model focused on primary prevention for healthy or at-risk patients and coordination of care for chronically ill.
  • Monitor population health status through tracking process indicators and indicators on intermediate outcomes.
  • Population models that emphasize prevention and wellness by design. PCMH models that reward providers based on their patient’s total cost of care provide new incentives to providers to make changes to their practice to ensure more patients receive preventive care. PCMH models also promote and support providers to counsel individuals to adopt healthy behaviors, such as encouraging treatment adherence, physical activity, tobacco cessation, and healthy eating.
  • More details on pg. 56.

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Prevention & Population Health:
  • Community‐Based Public Health Innovations (Model 4): Public Health‐Medicaid Managed Care Diabetes Education Project, Scaling the National Diabetes Prevention Program in Texas (pg.166-172)
  • The Texas SIM initiative will expand the reach of these programs to more communities, while also promoting their sustainability where the evidence shows promising outcomes (pg. 133)
  • Programs to measure the quality of care delivered by physicians and clinicians to manage patients suffering from chronic conditions, e.g. Bridges to Excellence and Blue Cross Blue Shield of Texas programs (pg.74 & 75)
  • Department of State Health Services (DSHS) is supporting a reorientation of the service delivery models to focus on resiliency and disease management, behavioral and physical health integration of services and continuity of care (pg.70)

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  • The state’s goal for improving care, population health, and reducing health care cost were the drivers for the selection of the two aims being proposed in the area of community health. The two aims are: the use of Community Health Workers (CHWs) and the implementation of a common wellness agenda (CWA) at the community level.
  • The strategy to include CHWs in the health care work force will increase effectiveness, efficiency, and appropriate mix of the health care workforce. When CHWs work collaboratively with primary care physicians there is an increase in effectiveness and efficiency because there is a greater likelihood that the patient will take their medications as prescribed and follow the physician’s directions (e.g., adopt new health behaviors like eating more nutritious foods, obtaining and maintaining a healthful weight, getting regular physical activity, not consuming tobacco products). CHWs could tackle not only behavioral health but also substance abuse (which impacts the patient’s ability to implement behavioral health changes), children’s dental health (which is integral to healthful eating), and long term services and support (such as supporting older adults and people with disabilities to maintain independence and maximize self-determination).
  • If CHWs and primary care physicians work effectively together to optimize patient health then it might be easier to move away from health care provider payment based on volume and move towards a payment system based on outcomes. Use of CHWs allows for an increase in primary care capacity because the physician, nurse, and CHW can work at the top of their licensure thereby containing cost and increasing patient support simultaneously.
  • Optimally, health care organizations would have policies to integrate CHWs into their care mode thereby working towards a more effective and less expensive workforce.
  • The CWA was developed to engage communities in bringing together and better coordinating available resources and services. The CWA will address all sectors of the community where people learn, work, live, play, and pray. (pg. 66)

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  • One of the three key strategies in the overall plan includes, improving health overall by building healthy communities and people through prevention and early mitigation of disease throughout the life course. (pg. 49)
  • Leveraging community-based, public-private collaboratives to bring together key stakeholders to link, align, and act on achieving health improvement goals, support local innovation, and enable cross-sector resource sharing, development, and investment.
  • Amplifying a Health in All Policies approach across State agencies and within communities, with a focus on healthy behaviors, healthy starts for children, prevention and mitigation of adverse childhood experiences, clinical-community linkages, and social determinants of health. (pg. 29)
  • Using geographic information systems-mapping and hot-spotting resources to drive community decisions.
  • Designing a toolkit for communities seeking to finance innovative regional projects.
  • Create Accountable Communities of Health - leverages innovation and collaboration already occurring in local communities by formalizing regionally governed public-private collaboratives to address shared health goals. These new partnership organizations will support communities, sectors, and systems in their regional service areas, and implement health improvement plans primarily focused on prevention strategies. (pgs. 30 and more details on pg. 52)