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SANDRA G HASSINK, MD, FAAPCHAIR, GOVERNOR’S COUNCIL
DIRECTOR NEMOURS OBESITY INITIATIVEA I DUPONT HOSPITAL FOR CHILDREN
WILMINGTON, DE
Governor’s Council on Health Promotion and Disease
Prevention
The Council’s Charge
“A Council on Health Promotion and Disease Prevention is hereby established and its members are charged to advise the Governor and executive branch state agencies on the development and coordination of strategies, policies, programs and other actions state-wide to promote healthy lifestyles and prevent chronic and lifestyle-related disease
Chronic Diseases and Related Risk Factors in the United States
* National Center for Health Statistics. Mortality Report. Hyattsville, MD: US Department of Health and Human Services; 2002† Adapted from McGinnis Foege, updated by Mokdad et. al.
Actual Causes of Death†
Tobacco
Poor diet/lack of exercise
Alcohol
Infectious agents
Pollutants/toxins
Firearms
Sexual behavior
Motor vehicles
Illicit drug use
Leading Causes of Death*
Percentage (of all deaths)
Heart Disease
Cancer
Unintentional Injuries
Pneumonia/influenza
Diabetes
Alzheimer’s disease
Kidney Disease
Stroke
Percentage (of all deaths)
0 5 10 15 20 25 30 35 0 5 10 15 20
Chronic lower respiratory disease
Costs to Delaware
Obesity The most recent estimates for Delaware show that
medical expenditures related to obesity in the state are more than $207 million a year.
Tobacco A CDC study on smoking-attributable costs estimates
that tobacco smoking in Delaware results in about $722 million a year in direct medical expenditures and indirect costs including lost productivity.
Delawareans
15.6 percent of adult Delawareans have never had a cholesteroltest ,18.7 percent have not had the test within the previous five years.
21.4 percent of Delaware adults report having limited activity dueto a disability; 8.3 percent report a disability that requires them to usespecial equipment.
70 % of adults are receiving treatment for their hypertension, ONLY 46%have their high blood pressure under control. African-American stroke survivors have greater limitations in activities than Caucasian stroke survivors,
The African-American prostate cancer mortality rate is 2.1 times greater than the Caucasian rate.
Chronic lower respiratory diseases are now the third-leading cause of death in Delaware. In the last 28 years, mortality rates have increased 12.1 % among African Americans and 6.6 % among Caucasians
Significant Racial Disparity Exits
Source: DHSS, Division of Public Health, Behavioral Risk Factor Survey (BRFS), 2009.
White and African American Adults, 2009: Significant Disparity for Obesity
36.8% 33.4%
26.1%41.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
By Race
Per
cent
of
Del
awar
e A
dults
18+
Obese 26.1% 41.1%
Overweight 36.8% 33.4%
White African American
Diabetes Prevalence
Mirrors Disparity in Obesity
Source: DHSS, Division of Public Health, Behavioral Risk Factor Survey (BRFS), 2009.
Delaware Adults With Diabetes: 2009
12.1%
7.2%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
White Black
Per
cent
of
Del
awar
e A
dults
Impact on Youth
“No longer considered to be a condition of primarily adult onset, type 2 diabetes has become increasingly common among children aged 6-11 years and adolescents aged 12-19 years.”
“The increase in type 2 diabetes among children and adolescents has emerged in parallel with an alarming rise in the number of young people who have become overweight or obese.”
Kenneth Copeland, M.D., et al, Clinical Diabetes October 2005; vol. 23 no. 4; 181-185
Disability
Prevalence of tobacco use, obesity and diabetes is significantly higher among people with disabilities. Obesity: 25.8% v. 42.2% Diabetes: 5.3% v. 15/5% Smoking: 17.1% v. 23.3%
18.3% of Delaware adults report a disability of some type, which limits their activities.
7.2% report a disability which requires special equipment.
Source: DHSS, Division of Public Health, Behavioral Risk Factor Survey, 2009; crosstabs from UD study, Disability and Health in Delaware, Delaware Behavioral Risk Factor Survey, 2006-2008.
Integrated approach to a complex problem
The Council finds that the problem is complex and influenced by the structure and quality of Delaware’s health care
system, the presence and strength of our health policy
framework, the extent to which our environment supports health and healthy decisions, and each individual’s capacity
to engage in healthy behaviors.
Building a healthier future, a life course app0roach
Goal is to make optimal health achievable for all Delawareans.
To realize this goal, we propose a path that encourages health at every step, that recognizes and rewards commitment to health at
all levels. From the individual to the community, from the
health care provider to the employer, from the business owner to the policy maker, we all have a stake in building a healthier future
How did we develop the recommendations?
13
Process: Overview of Concept Mapping Steps
© 2011 Concept Systems, Inc.
Idea Generation: Communities of interest and expertise were identified, and responded with brainstormed ideas
Structuring: Communities of interest and expertise sorted and rated the results of the idea development, authoring the structure and value domain of the issue
Representation: CSI computed the maps, pattern matches and “go zones,” and prepared them for interpretation
Interpretation and Use: Strategies and tactics for action will follow directly from the interpretation of the results. Pattern matches and go zones will help to build consensus on action.
Planning: Planners and key issue advisors developed a focus prompt and identified participants
14
Defining the Issue
© 2011 Concept Systems, Inc.
“To promote healthy lifestyles and prevent chronic and lifestyle-related disease in Delaware, a specific thing that needs to happen is…”
“To promote healthy lifestyles and prevent chronic and lifestyle-related disease in Delaware, a specific thing that needs to happen is…”
Specific Aim: • Use the concept mapping process to identify specific recommendations for the Governor and executive state agencies to promote health and to prevent chronic and lifestyle-related diseases statewide.
Specific Aim: • Use the concept mapping process to identify specific recommendations for the Governor and executive state agencies to promote health and to prevent chronic and lifestyle-related diseases statewide.
15
Identifying Key Informants
© 2011 Concept Systems, Inc.
•Over 650 participants were invited to brainstorm online, including:•Council members•Medical and healthcare professionals•State employees •Researchers and educators•Community advocates and outreach coordinators•Food and agriculture manufacturers •Public relations and media representatives
•A subset (73) of these individuals were later invited to sort the ideas.•All participants were later invited to rate the ideas on importance and feasibility.
•Over 650 participants were invited to brainstorm online, including:•Council members•Medical and healthcare professionals•State employees •Researchers and educators•Community advocates and outreach coordinators•Food and agriculture manufacturers •Public relations and media representatives
•A subset (73) of these individuals were later invited to sort the ideas.•All participants were later invited to rate the ideas on importance and feasibility.
16 © 2011 Concept Systems, Inc.
Eliciting Knowledge and Opinion•Council meeting brainstorming session: 2/15/11
•Online brainstorming session: 2/24/11-3/23/11 (264 website visits)
require nutritional labeling on menus at restaurants and fast food establishments. (3)
ensure early screening for early detection to prevent or delay chronic illnesses. (49)
promote better insurance coverage for evidence-based pharmacological interventions. (60)
encourage communities with “free spaces” to create community gardens. (85)
make assisted exercise programs available, at no cost or very low cost, to people with disabilities. (105)
require nutritional labeling on menus at restaurants and fast food establishments. (3)
ensure early screening for early detection to prevent or delay chronic illnesses. (49)
promote better insurance coverage for evidence-based pharmacological interventions. (60)
encourage communities with “free spaces” to create community gardens. (85)
make assisted exercise programs available, at no cost or very low cost, to people with disabilities. (105)
17 © 2011 Concept Systems, Inc.
Organizing Knowledge and Opinion
Each statement was rated twice
(Importance & Feasibility)
Each statement was rated twice
(Importance & Feasibility)
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34
5
12
34
5
3Scan a multit
ude of
information and decide
what is im
portant.12
34
5
12
34
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1Manage tim
e effectively
2Manage resources effectively.
3Scan a multitu
de of
information and decide
what is im
portant.
4Decide how to manage multip
le tasks.
5Organize the work when
directions are not specific.
1Manage tim
e effectively
Rating Sheet
120 statements were sorted into
groups
120 statements were sorted into
groups
Work quickly
and effectively under
pressure49
Organize the work when
directions are not specific.
39
Decide how to manage multiple
tasks.20
Manage resources effectively.4
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Of those who responded…
© 2011 Concept Systems, Inc.
Of the following, which professional category are you most closely affiliated with?
19
Building the Results
© 2011 Concept Systems, Inc.
• The Raw Materials:– Statements– Sort Input from each participant– Rate Input from each participant
• The Tools– Aggregation of Sort Data– Similarity Matrix– Multidimensional Scaling– Cluster Analysis
This point map shows all of the ideas in relation to one another…
© 2011 Concept Systems, Inc.
“To promote healthy lifestyles and prevent chronic and lifestyle-related disease in Delaware, a specific thing that needs to happen is…”
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Conceptually similar ideas appear closer together.
© 2011 Concept Systems, Inc.
partner with farming communities to establish more fresh fruit and vegetable stands. (36)
work with food manufacturers in Delaware to improve the nutritional quality of their products. (39)
make nutritious foods, especially fruits and vegetables, affordable and available to all residents. (107)
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make nutritious foods, especially fruits and vegetables, affordable and available to all residents. (107)make nutritious foods, especially fruits and vegetables, affordable and available to all residents. (107)
promote the understanding that oral health conditions require the same quality of care as other health conditions. (64)
promote the understanding that oral health conditions require the same quality of care as other health conditions. (64)
have employers as leaders in support of healthy work places and prevention efforts. (113)
have employers as leaders in support of healthy work places and prevention efforts. (113)
© 2011 Concept Systems, Inc.
23 © 2011 Concept Systems, Inc.
The Emerging Structure
…contains all of the details and provides a conceptual structure.
Evaluate Effective Outcomes
Develop Policy and FundingSupport Integrated Consistent Care
Increase Access to Coverage for Prevention and Care
Create an Environment that Supports Healthy Choices
Make Healthy Food AvailableFocus on Schools
Educate for Health
Take a Whole Person Health Approach
Build Individual Capacity to Achieve a Healthy Lifestyle
24 © 2011 Concept Systems, Inc.
Revisiting the Emerging Structure: A “Regions” Perspective
Evaluate Effective Outcomes
Develop Policy and Funding
Support Integrated Consistent Care
Increase Access to Coverage for Prevention and Care
Create an Environment that Supports Healthy Choices
Make Healthy Food AvailableFocus on Schools
Educate for Health
Take a Whole Person Health Approach
Build Individual Capacity to Achieve a Healthy Lifestyle
CREATE A MORE RESPONSIVE HEALTH CARE SYSTEM
IMPLEMENT POLICIES AND PROGRAMS THAT SUPPORT HEATLH
CREATE A HEALTHY AND SUPPORTIVE ENVIRONMENT
BUILD CAPACITY FOR INDIVIDUAL HEALTH
Implement Polices and Programs that Improve Health
Develop and implement policy and strategy that supports healthy communities in Delaware.
Develop and implement policy and strategy that decreases tobacco usage.
Incentivize businesses to provide a workplace that encourages healthy living.
Evaluate the effectiveness of current health promotion and disease prevention programs in Delaware.
CREATE A HEALTHY AND SUPPORTIVE ENVIRONMENT
Ensure that exercise/physical activity and healthy eating programs and services are high-quality, culturally appropriate, accessible, available and affordable.
Improve the physical environment, including public transportation, throughout Delaware to improve opportunities for safe physical activity.
Make nutritious foods affordable and available to all Delawareans.
Establish and ensure adherence to food and beverage standards in places where Delawareans spend their time.
Work with food industry, including food processors, distributors, growers and retailers in the state and region to improve the nutritional quality of commercially available foods and beverages.
CREATE A HEALTHY AND SUPPORTIVE ENVIRONMENT
Ensure children in schools have access to affordable and healthy foods and beverages.
Ensure children have access to physical activity opportunities in schools.
Ensure children receive quality health education, nutrition education and physical education in schools.
Ensure children in child care have access to healthy foods and beverages and opportunities for physical activity.
Ensure children receive quality health education, nutrition education and physical education in child care.
BUILD CAPACITY FOR INDIVIDUAL HEALTH
Under a unifying theme, develop, fund and implement statewide, targeted and culturally appropriate campaigns to promote healthy lifestyles and prevent lifestyle-related diseases.
Engage community-based organizations (schools, workplaces, health care, faith based organizations) to promote healthy lifestyles.
Improve health literacy, so Delawareans have the capacity to obtain, process, and understand basic health information and services needed to make appropriate healthy decisions.
Enhance individual capacity to engage in healthy behaviors.
Create a More Responsive Health Care System
Standardize and support evidence-based practice to lead to consistently delivered, high level of care.
Measurably improve the accessibility and promotion of integrated primary and preventive care for all residents, incorporating mental, oral and vision health.
Build a responsive and accessible system of care. Consider both existing systems and innovative approaches.
Establish universal use of Electronic Health Records for all Delaware residents.
Ensure that patients and the public at large are educated and empowered to use patient-managed technology and communication for prevention and care.
Establish and support health care workforce recruitment and retention strategy
Vision
WHEN CARE IS:• Patient centered• Evidence-based• Well coordinated
PATIENTS WILL GET:The right care at the right timeBetter health outcomesReduced health care costs
iIIndividual weight status
Family
State
Individual Characteristics and risk
Dietary Intake
Physical activity
GenderAge
Sedentary activity
Genetic susceptibility
Ethnicity
Types of food available In the home
Nutritional knowledge
Food preferences
Income
Family TV viewing
Activity patterns
School lunch
School
Phys Ed
Health Education
Child care Licensing
Physical environment
Workplace
Wellness programs
Hospital system
Coverage
Primary careEHR
Food supply Community
Neighborhood safety
Parks/recreation
Fast food Corner storeGrocery store
School nurse
Insurers
Benefits
Medical Home
All payor claims data base
Wellness Education and Care System
Sussex/Stockley
Employer groupUniversity of Delaware
Pay for prevention
Health professional Training
evidence-based practice
integrated primary/preventive care
responsive and accessible system of care
universal EHR
patient-managed technology and communication
health care workforce
Integrating Health Care Systems into Health Systems
By increasing access to integrated preventive, wellness and health care services—and making them more available in more places
—we will not only decrease the use of emergency facilities but we will be offering Delawareans the opportunity to get the help they need immediately to avoid long-term health problems.
By incorporating prevention into health care processes and by providing supportfor each patient—particularly those who are underserved, have special healthcare needs or mental health conditions
—every Delawarean will have the guidance and skills necessary to make choices that help prevent diseases.
By integrating healthcare, public health and community services -we will create a seamless system that supports health in Delaware.
Gathering data to understand how to achieve optimal results in both healthcare
quality and decision-making, - will help us learn the best approaches to help individuals and providers achieve healthy outcomes.
An integrated, evidence-based care approach - will ensure that each Delawarean knows what he or she should do to stay
healthy.
Objective; Standardize and support evidence based practice to lead to consistently delivered high level of
care.
Identify, adopt, implement and evaluate models for use of evidence basedpractice standards. Professional societies, DHSA Year 1 &ongoing
Align licensing requirements with the use of evidence-based practices. State licensing boards Year 2
Eliminate the disparity between payment for prevention and medical treatment. (Note: Use new CMS guidelines as basis.) DHCC, private and public insurers(including Medicaid),legislature Year 2 & ongoing
Train providers about mental health screening and treatment. DHSA Year 1 & ongoing
Identify training needs for health professionals who serve the at-risk populations (for example, adolescents, seniors, ethnic/racial minorities). DHSA Year 1 &ongoing
Incorporate an emphasis on health promotion, including communications skills, in health professions training. DHSA, University of Delaware, Wesley institutions of higher learning Year 2 & ongoing
Integrate professional education efforts across professional organizations. Delaware academies and medical societies, DHSA Year 1 &ongoing
Objective; Measurably improve the accessibility and promotion of integrated primary and preventive care for all residents,
incorporating mental, oral and vision health
Use assessment of gaps in primary care in the state to guide development of nontraditional methods of health care delivery. DHCC, DPH Year 1
Conduct causal analysis of underserved areas/populations. DPH Year 1
Include people with disabilities and special needs in the analysis of underserved or inadequately integrated service. DHCC, DPH Office of Primary Care, University of Delaware Center for Disabilities Studies Year 1
Ensure coverage for PCMH for all, beginning with state employees. CHPDP, OMB, HCC Year 2
Integrate mental health screening and referral into primary care and wellness support. MSD, insurers, DHSS,DHCC, professional societies Year 2 & ongoing
Promote early and adequate transition of care for all, including those with disabilities or special health care needs. CHPDP Year 2 & ongoing
Train providers to help individuals with disabilities identify what is necessary to protect their health, including prevention of
secondary conditions. University of Delaware Center for Disabilities Studies, DHSS, professional societies Year 3 &
ongoing Ensure that adult dental care is included in Medicaid coverage.
DHSS Year 2 & ongoing
Objective; Build a responsive and accessible system of care (Consider both existing systems and innovative
approaches)
Establish and ensure reimbursement for an integrated program of health coordinators to connect patients with care and information, breaking down barriers and encouraging prevention. Institutions of higher learning, DHSS, professional societies, health providers Year 2
&ongoing Expand the definition of primary care provider and develop a
credentialing model to ensure quality. Legislature, DHSS Board of Professional Registration, insurance companies,
professional societies Year 2 Develop and support community health and wellness centers in
nontraditional locations, e.g. schools and businesses. School districts ,DHSS, professional societies, legislature Year 2
Develop and fund an innovative screening, wellness education and care system in each county, capable of meeting people where they are.
Insurance companies, payers, DHSS, professional societies, legislature Year 1
Co-locate medical and mental health services. Payers, DHSS, DPH, professional societies, legislature, health providers, FQHCs
Year 1
Objective; Establish universal use of Electronic Health Records for all Delaware residents.
Use DHIN as the foundation for integrated state health data, to promote sustainable interoperability and access to data among providers. DHIN, providers ,insurance companies ,Quality Insights of
Delaware, DHCC, DHSS Year 1Develop and implement a strategy for universal
use of EHR statewide. Quality Insights of Delaware, DHCC, DHIN,CHPDP,
professional societies Years 2–5Implement an all-payer claims database in
Delaware, and ensure that it is interoperable with other health data.
Insurance companies, DHCC, DHIN, DHSS Year 1 & ongoing
Objective; Ensure that patients and the public at large are educated and empowered to use patient managed technology
and communication for prevention and care.
Develop an integrated system for patient-centered health data, including the use of personal technology, to provide patients’ connection to personal health data, monitoring and feedback. Consider use of systems such as Tele-health DHCC,
insurance companies, DHIN, private providers, DHSS,CHPDP
Objective; Establish and support health care workforce recruitment and retention strategies.
Develop long-term, community-specific recruitment strategies to attract health care providers. CHPDP Year 1
Develop an integrated licensing and credentialing system. DIMER/DIDER, DHSA,Residency Program,DHCCYear 2
Develop definitions and reimbursement structure for non-physician health promotion services provided to individuals. Coalition of insurers and health stakeholders to adopt standard definitions,
insurance companies, Board ofMedical Practice, Office of Insurance, hospital credentialing, payers, Board of Licensure Year 2
Offer incentives for early-career health care professionals to practice in Delaware. DHSS, DHCC Year 3
Establish community health rotation programs in Delaware for medical and dental residents. DHCC, DE Health Sciences Alliance
FIRST STEPS
Implement and sustain an all payer claims database in Delaware and ensure that it is inter-operable with EHR
Develop and fund a nontraditional wellness education and care system in each county capable of meeting people where they are
• Ensure coverage for patient centered medical homes for all Delawareans, beginning with State employees
