Public Health-Primary Care Integration:

5/27/2016 Learning Objectives Public Health-Primary Care Integration: Working Together to Improve Health Outcomes Susan Myers, M.Ed., R.N. Provider ...
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5/27/2016

Learning Objectives

Public Health-Primary Care Integration: Working Together to Improve Health Outcomes Susan Myers, M.Ed., R.N. Provider Relations Manager Bureau of Infectious Disease Control NH Division of Public Health Services

Selected Definitions of Public Health • The science and art of preventing disease, prolonging life and promoting health and efficiency through organized community effort…” (C.E.A. Winslow, 1920) • “…fulfilling society’s interest in assuring conditions in which people can be healthy” (Institute of Medicine, 1988)

• Describe the evolution of public health in the United States. • Discuss the principles for the integration of public health and primary care. • Identify interventions to facilitate integration. • Discuss the essential components of Public Health Detailing, as a strategy on the path to improving population health. • Explain components of an evaluation plan for Public Health Detailing.

A Look Back in Time… • For many centuries disease was synonymous with epidemics – Plague – Cholera – Leprosy – Smallpox – TB • Age of Reason and Enlightenment: 1620’s-1780’s – Scholars began to challenge the long-accepted realities – Expansion of science

A Look Back in Time… • With the advent of industrialism, populations shifted to urban centers and public health conditions worsened – Dense populations – Unsanitary conditions – Long work hours in unsafe industries

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A Look Back in Time

A Public Health Milestone

• 1700s-1800s: – Philadelphia established a board of health – Edward Jenner successfully used vaccination for smallpox – John Snow traced a cholera outbreak to well water drawn from a specific water pump – Pasteur proposed The Germ Theory of Disease – The first live attenuated viral vaccine (rabies) was developed – Lemuel Shattuck’s “Report of the Sanitary Commission of Massachusetts became the blueprint for the U.S. public health system • Sanitary inspections/ Food Safety • Communicable disease control • Maternal/Child Health Services

The Roots of Public Health Nursing • Lillian Wald (1867-1940): – Coined the term “Public Health Nurse” – Founded the Visiting Nurse Service in 1893 – By 1913, she employed 92 nurses – Educated low-income NYC families on • Infection Control • Disease Transmission • Preventative Care

The Roots of Public Health Nursing

A Look Back in Time

• Lillian Wald: – PHNs must treat social and economic problems – Expansion of role beyond caring for the sick – PHN must address the health of the entire neighborhood – Cooperation with social agencies to improve living conditions – Early advocate for school nursing

• 1927-1932: Committee on the cost of Medical Care – Conducted the first comprehensive assessment of health and medical care – Summarized the recommendations for improving the organization, financing and delivery of medical services and the health of the American population

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A Look Back in Time “The outstanding need is for effective leadership…Obviously there must be continued study of the diseases and conditions which are responsible for sickness and disability, as well as a survey of all agencies, groups and individuals which provide services. Private medical services and public health work are so closely related that, in such a survey, it is folly to deal with them separately.” -Committee on the Cost of Medical Care

A Look Back in Time • 1930s-1980s – Evolving gap between public health and health care – Emergence of employer-sponsored insurance plans – Creation of Medicare and Medicaid – Stunning achievements in medical science – Asymmetry in funding, prestige and societal perceptions of private-sector medicine in relation to the public health sector

1927-1932

A Look Back in Time • 1980s-2000 – Fragmented/duplicative services – Emergence of local federally qualified community health centers – Well-child clinics being discontinued – Public health and primary care acted cooperatively, but independently – “Silo” model of service delivery – 1994: Medicine/Public Health Initiative established as a joint endeavor of the AMA and the American Public Health

From the Millennium to Present • May, 2009: HHS directed $ 1 billion toward the development of a vaccine for novel influenza A (H1N1) • August, 2010: WHO declared an end to the 2009 H1N1 influenza pandemic 2012: Institute of Medicine published “Primary Care and Public Health: Exploring Integration to Improve Population Health”. • 2014: WHO declares Ebola to be an international public health emergency

From the Millennium to Present • The events of 9/11/2001 highlighted the need for strengthening the development of collaborative models between public health, emergency responders and the medical community • December 13, 2002: President Bush announced a major smallpox vaccination program • 2004: Significant shortage of flu vaccine occurred in the U.S.

From the Millennium to Present • Emphasis on health at the neighborhood level • Improving health outcomes through home visiting • Increased focus on chronic disease prevention • Rising health care costs • Challenges with shrinking resources • The Affordable Care Act

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Where Do We Go From Here?

Core Public Health Functions • Assessment – Assessment, monitoring and surveillance

• Policy Development – “Being part of the solution”

• Assurance – Assuring that high-quality services, including personal health services, needed for the protection of public health are available and accessible to all

Ten Essential Public Health Services

Ten Essential Public Health Services

• Monitor health status to identify community health problems • Diagnose and investigate health problems and hazards within the community • Inform, educate and empower people about health issues • Mobilize community partnerships to identify and solve health problems • Develop policies and plans to support individual and community health efforts

• Enforce laws and regulations that protect health and ensure safety • Link people to needed personal health services and assure provision of health care when otherwise not available • Assure a competent public health and personal health care workforce • Evaluate effectiveness, accessibility and quality of personal and population-based health services • Research for new insights and innovative solutions to health problems

Partnering to Improve Health Outcomes

Degrees of Integration, Institute of Medicine, 2012

• Primary Care: Health care services directed to individuals • Public Health: Activities operating at the population level • Alignment of public health and primary care may improve health indicators within both sectors

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Principles for Integration • Shared goal of population health improvement • Community engagement in defining and addressing population health needs • Sustainability – Key to establishment of shared infrastructure

• Collaborative use of data points • Aligned leadership – Bridges disciplines and programs to reduce fragmentation and foster continuity – Clarifies roles – Has capacity to manage change

Principles for Integration The integration of primary care and public health could enhance the capacity of both sectors to carry out their respective missions and link with other stakeholders to catalyze a collaborative, intersectoral movement toward improved population health.” -National Research Council, 2012

Efforts to Promote Integration • Maternal, Infant and Early Childhood Home Visiting Programs • Cardiovascular Disease Prevention • Colorectal Cancer Screening

Principles for Integration • Essential to examine the components of success, but also the barriers • Models of integration should be replicable • Strong linkages between clinical settings and community assets

A Shifting Health Care System: A Convergence of Challenges and Opportunities • The status quo is unacceptable • Unsustainable rise in health care costs • Increasing emphasis on primary prevention and health promotion • Need for outreach campaigns to promote clinical preventive services • Significance of social and environmental determinants of health • The ACA • Health informatics

Public Health Detailing: Partnering with Primary Care to Improve Health Outcomes • Based on Academic Detailing Models – Promotes evidence-based recommendations through educational outreach to clinicians – Provides relevant data and clinical information – Provides the opportunity to influence provider practices to improve public health indicators – Increases the provider’s access to information by bringing services directly to them

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A Novel Role for the Public Health Nurse:

Successful Models

Influencing Physician Practices Through Detailing

• Rhode Island Department of Health – – – – – – – –

Successful Models • New York City – Modeled on pharmaceutical detailing – Topical campaigns (influenza, colon cancer screening and smoking cessation) – Six HD staff made unscheduled visits to practices – Distributed “action kits” containing practice tools, provider information, patient education materials – More than 2,500 interactions with practice staff at 200 sites – By provider self-report, use of office systems for prevention and adherence to recommended practices increased

Public Health Detailing in NH: Overarching Goals

• Improve prevention, screening and • management of infectious diseases • Expand the scope and reach of infectious disease prevention services within existing health care programs • Build partnerships with primary care

Developed an Academic Detailing Program Face-to-face office visits Initial visits to internists, family medicine Academic Detailing Visitation Record developed for data collection Reached 439 providers at 138 sites 27% of practices reported an increase in STD-related education to patients 30% of practices reported increased STD screening 40% identified improved disease reporting

Successful Models • Baltimore City – Project Baltimore Campaign • Campaign to increase routine HIV screening among primary care providers located in high transmission areas • Visited 100% (85) of eligible practices • Delivered over 350 HIV Testing Action Kits • 73% of providers increased screening • 96% reported satisfaction with the campaign

Public Health Detailing in the State of New Hampshire • 13 regional Public Health Networks in NH • Used for public health planning and select public health services • Largest regional Public Health Networks: • Greater Nashua: population 205,765 • Greater Manchester: population 180,333 • Seacoast: 140,210

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Improving Health Outcomes • Enhance TB testing and treatment for appropriate populations • Integrate HIV testing as a routine component of care • Improve STD testing and treatment • Promote HCV testing for appropriate populations • Build capacity to expand adult immunizations

Improving Health Outcomes

Public Health Detailing in NH • Detailing visits include:

• Promote efficient and timely reporting of notifiable diseases • Build partnerships – Hospitals – Primary care physicians – Community health centers – Contracted Agencies

NH STD/HIV Surveillance: 2010-2014 • Chlamydia – Increasing case counts within the last 5 years – Females and persons under age 30 most affected – Highest disease burden in Hillsborough County

– Face-to-face visits with practice staff – Data sharing – Assessment of practices and needs – Education/technical assistance – Identifying pilot projects and opportunities for collaboration

NH STD/HIV Surveillance: 2010-2014 • Primary, Secondary and Early Latent Syphilis – Higher case counts 2012-2014 – Highest numbers of HIV co-infection cases seen among those diagnosed with infectious syphilis

• Gonorrhea – Varying case counts over the past 5 years – Persons under age 30 most affected – Hillsborough County bears the highest burden of disease

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NH STD/HIV Surveillance: 2010-2014

Tuberculosis Cases in New Hampshire: 2005-2014

• HIV – Newly diagnosed infections have been relatively stable over the past 5 years – Male to male sexual contact is the most common risk factor – The majority of new cases in the southern tier of NH

NH Tuberculosis Cases by County, 2010-2014 U.S.-born

Foreign-born

• • • • • • • • • •

2005: 2006: 2007: 2008: 2009: 2010: 2011: 2012: 2013: 2014:

4 17 11 19 16 10 11 9 15 11

Standards for Adult Immunization Practice

Total

Belknap

0

0

0

Carroll

0

0

0

Cheshire

0

1

1

Coos

0

1

1

Grafton

0

0

0

Hillsborough

6

23

29

Merrimack

0

6

6

Rockingham

5

6

11

Strafford

0

8

8

Sullivan

0

0

0

Total

11

45

56

Vaccination Coverage Among Adults

• Behavioral Risk Factor Surveillance System (BRFSS)

– Tdap among persons > 18: 40% – Pneumococcal vaccination among high-risk persons 18-64 years of age: 31.4% – Pneumococcal vaccination among persons 65 years of age and older: 75% – Flu vaccine coverage, 18-64 years: 44% – Flu vaccine coverage, > 65 years: 67.8%

• ASSESS immunization status at every encounter • Strongly RECOMMEND vaccines needed • ADMINISTER vaccines or REFER to a vaccinating provider • DOCUMENT vaccines received

Assessment • Screening/treatment for STDs/HIV/HCV – Criteria for screening – Barriers to screening – Accessibility to the current STD Treatment Guidelines – Information on sex partners – Availability of STD treatment medication – Do they refer to another site for treatment? • TB Screening and Treatment – Availability of TB skin testing/IGRA testing – Proficiency in administering/interpreting skin tests – Need for technical assistance – Challenges with treatment recommendations

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Assessment •



Adult Vaccines – Availability of adult vaccines – Enrollment in the NH Adult Immunization Program – Assessment of vaccine status – Vaccine administration and documentation – Referral mechanisms Reportable Diseases – Accessibility of the NH Reportable Disease List/Guidelines – Reporting requirements – Barriers

Assessment • Do they receive DPHS Health Alerts and data reports? Are they helpful? • What additional information is needed? • Thoughts for future conferences/trainings? • How can DPHS be more helpful to the practice? • Opportunities for partnerships?

Additional Education • • • • • • • • • • • • •

TB screening recommendations TST administration/interpretation Mantoux TB Skin Test DVD STD/HIV screening recommendations Tips on taking a sexual history STD treatment guidelines Hepatitis C Screening Recommendations PrEP for HIV Prevention Standards for Adult Immunization Practice NH Reportable Disease List NH Confidential STD Reporting Form NH Communicable Disease Report Form Links to websites and other resources

Evaluation • Provider Feedback Tool – One week post-visit • Has the knowledge of the staff increased as a result of the PHD visit? • Is there intention to change any practices in the future as a result of the visit?

– Three months post-visit • What changes, if any, have been made in practices as a result of the visit?

Evaluation • Percentage of providers with a specific knowledge shift • Percentage of providers with specified intention to adjust protocols or practices • Type of providers that have implemented actual change as a result of the detailing visit • Type of changes implemented • Barriers to implementation that are identified by the providers

Year One • • • • •

PHD in NH began in late 2014 Funding identified and 1FTE staff hired Protocols, data collection forms and evaluation process developed Data housed in Epi-Info Electronic surveys created for evaluation process

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PHD Visits by Facility Type

Year One • 82 Visits – 46 (56%) Face-to-Face – 36 (44%) Attempted

• 20 Follow-up Trainings – 9 (45%) related to TB

Lessons Learned • Detailing can be conceptualized to virtually any topic • Scheduled visits prove to be more fruitful • Regional efforts work well, but not always realistic • Patience and persistence • Be flexible when arriving at the practice • Highlight partnerships and collaboration • You can’t do it all…choose carefully!

References • • • • • • • • • • •

Centers for Disease Control and Prevention. (2011) Core Curriculum on Tuberculosis: what the Clinician Should Know 5th Ed. National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. Centers for Disease Control and Prevention. (2015) Epidemiology and Prevention of Vaccine-Preventable Diseases. Washington, D.C.: Public Health Foundation. Committee on Integrating Primary Care and Public Health; Board on Population Health and Public Health Practice; Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health, 2012. Community Preventive Services Task Force. The Guide to Community Preventive Services. Retrieved from http://www.thecommunityguide.org/ (2015). Immunization Action Coalition. Retrieved from http://www.immunize.org/timeline/ (2015) Larson, K. and Levy, J., et. al.. (2006) Public Health Detailing: A Strategy to Improve the Delivery of Clinical Preventive Services in New York City. Public Health Reports, 121 (3): 228-234. Montero, J and Moffat, S, et. al. (2015) Opportunities to Improve Population Health by Integrating Governmental Public Health and Health Care Delivery. Institute of Medicine Discussion Paper, 2015. National Resource Center for Academic Detailing. Retrieved from http://www.narcad.org/ (2015). New Hampshire Division of Public Health Services. (2013) New Hampshire State Health Improvement Plan: 2013-2020. Prybil, L., Jarris, P and Montero, J. (2015) A Perspective on Public-Private Collaboration in the Health Sector. National Academy of Medicine, 2015. Turncock, Bernard J. (2012) Public Health: What It Is and How It Works. Burlington, MA: Jones and Bartlett Learning, LLC.

Next Steps of Public Health Detailing in New Hampshire • Continue with expansion of PHD Program • Modify tools, as needed • Monitor evaluation results which will guide the next phase of PHD

Acknowledgments • Lindsay Pierce, M.Ed. • Kirsten Durzy, M.P.H.

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For Additional Information Susan Myers, R.N., M.Ed. Provider Relations Manager Bureau of Infectious Disease Control NH Division of Public Health Services (603) 271-5289 [email protected] http://www.dhhs.nh.gov

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