Improving Population Health

What Does a Population Health Integrator Do?

Last week, Joanne Lynn addressed issues on population health for frail and disabled elders, and suggested the need for an integrator at this life stage. This week Debbie Chang Vice President of Policy and Prevention at Nemours, an integrated child health system, further discusses the integrator role, based on a paper she presented to the CMMI Population Health Models group earlier this month. Nemours has taken on the role of an integrator to improve child health and well-being in Delaware.

What Does a Population Health Integrator Do?

 By Debbie I. Chang, MPH

Achieving the Three-Part Aim – better quality of care, better health for populations, and lower costs – has become a critical area of focus for health care reform. One approach to meeting the Three-Part Aim is to work to improve population health with a place-based focus by seeding and funding integrators. Integrators operate at a population level in a geographical region. Working in a sustainable fashion with health care, public health and other community partners, integrators:

1. Promote prevention,
2. Improve health and well-being
3. Improve quality and reduce health care costs

An integrator is an entity that serves a convening role and works intentionally and systemically across various sectors to achieve improvements in health and well-being for an entire population in a specific geographic area. Examples of integrators range from integrated health systems and quasi-governmental agencies to community-based non-profits and coalitions. The integrator role is not one-size-fits-all, but rather must be flexible to adapt in response to the needs of the community or population it serves. Integrators, or a system of integrators, may take various forms, depending on available resources and on community strengths and needs.  An integrator need not perform all of the functions listed below at once; external forces and contexts may require certain functions to take precedence at certain times. 

Communities may have one or more integrators. In fact, large and/or complex communities may be most effective with multiple integrators. Integrators working within the same community may specialize. For example, one integrator may focus on children, to integrate key developmental aspects that address long-term needs and promote healthy development in the multiple sectors where children spend time such as schools, child care, primary care and neighborhoods. Another integrator in that same community may focus on another phase in the life course.

A wide array of organizations could assume an integrator role, depending on communities’ goals, contexts, leadership, and stakeholder capabilities and resources. Over time, there may be an evolution in the entity or entities serving in the integrator role. Ultimately, a successful integrator or system of integrators benefits the community and its population by transforming the system thereby making it transparent to those who pay for it and who use it and by catalyzing and facilitating the integrated systems-work necessary to address the upstream social determinants of health. 

Population Health Integrator Functions

Leadership and Partner Engagement

• Engage partners from multiple sectors and/or connect with other integrators to achieve the Three-Part Aim, with an emphasis on integrating services and mobilizing interventions to address upstream determinants of health. 

• Serve as a trusted leader in the community that accepts accountability for and strategically drives the integration functions.
  
  
• Facilitate agreement among multi-sector stakeholders on shared goals and metrics to improve the health outcomes of a population in a geographic area.

• Assess the community resources, including workforce capabilities, that are available to reach shared goal(s); determine what gaps need to be filled and what duplication needs to be reduced; and work with partners to make appropriate adjustments

Spread, Scale and Sustainability

• Work at the systems level to make policy and practice changes in both the public and private sectors that impact populations and/or support partners or connect with other integrators in making these changes to scale up what works so that the entire population can benefit. 
  
  
• Serve as a source for spreading what works at both the policy/systems level and at the practice level to reach sufficient scale. 

• Sustain change by impacting policies and practices in collaboration with institutions and community partners at the local, community and state levels.

• Pursue financial sustainability via various methods, including leveraging existing and new sources of funding, developing innovative uses of current sources, and testing payment reforms that promote value and incentivize disease prevention and healthy development.

Continuous Learning and Improvement to Promote Population-Level Solutions

• Gather, analyze, monitor, integrate and learn from data at the individual and population level.  Apply this knowledge to improve care and the patient experience at the individual level, improve systems at the population level, evaluate progress, and ensure that resources are targeted most efficiently, based on actual needs of communities and groups of patients. 

• Identify and connect with system navigators (those roles intended to help individuals coordinate, access and manage multiple services and supports) so the integrator can harvest and aggregate data from individual cases and use the data to promote population-level solutions.
  
  
• Develop a system of ongoing and intentional communication and feedback at multiple levels including with affected sectors, systems and communities. 

For an expanded discussion on this topic, please read Integrator Role and Functions in Population Health Improvement Initiatives.

Debbie I. Chang is Vice President of Policy and Prevention at Nemours.

Where I’d Put the Money: Quality of Life Investments for Frail and Disabled Elders

This week, we are very pleased to welcome guest blogger Joanne Lynn, M.D., who serves as Director for the Altarum Center for Eldercare and Advanced Illness. A few months ago, David Kindig asked readers, “Where Would You Put the Money?” Dr. Lynn responded with a provocative comment, which she expands on below (please note that this post is cross-posted on the Altarum Institute’s blog, Health Policy Forum).

Where I'd Put the Money: Quality of Life Investments for Frail and Disabled Elders

By Joanne Lynn, M.D.

Readers of this blog are familiar with—and mostly supportive of—these two claims: (1) that social and environmental factors are stronger than health care services in shaping the population’s health, but (2) those factors are weaker than health care services in securing funding and public attention. Most of us are convinced that sending more funds and public support toward healthy food and exercise would do more to improve health than sending those funds toward high-cost medications or surgeries.

My question here is whether we can usefully apply the same perspective to the care needed for frail and disabled elders. Some will want to stop and contend that prevention of disability would still be the priority, and that argument has merit, of course. But “prevention” of disability associated with aging is really mostly delay, and most of us will have a period of serious disability before dying, no matter how well we eat and exercise.

Master Planning for Youth Comes of Age

By Kirstin Q. Siemering, DrPH, RD

This week, we’re building on a recent post, continuing the theme of master planning – but with a more targeted approach.

The National League of Cities (NLC) has catalogued more than 30 comprehensive youth master plans throughout the U.S. These plans (sometimes referred to as youth agendas, city blueprints, or children’s bills of rights) are typically developed through approaches similar to those used to guide land use and infrastructure decisions, but with a focus on young people. According to the NLC, these plans allow “city officials, school leaders, community partners and youth to take stock of local programs and services for young people, identify cost savings, reduce duplication of services, and strategically address pressing needs.”

Really?? A Free Population Health Textbook from Preventing Chronic Disease??

By David A. Kindig, MD, PhD

Yes, the online CDC journal Preventing Chronic Disease (PCD) has just released a compilation of 23 essays on current population health practice and scholarship relating broadly to population health metrics, incentives, and partnerships.

These essays were an early part of our Robert Wood Johnson Foundation funded project called Mobilizing Action Toward Community Health (MATCH) at the University of Wisconsin Population Health Institute, which many readers know has evolved into County Health Rankings & Roadmaps efforts. In 2009, we commissioned essays to critique underlying assumptions about metrics, incentives, and partnerships and to suggest approaches for overcoming potential barriers to population health improvement.

Don Berwick: "Waste is Theft"

By David A. Kindig, MD, PhD

I often emphasize the potential for wasted resources in ineffective health care to fund population health investments. And I have praised Don Berwick for his lifelong and more recent leadership in health care improvement.

Both of these threads came together last month when I heard Don give the George W. Gay Lecture in Medical Ethics at Harvard. Always a compelling speaker, he riveted the audience with the very human story of a newborn exchange transfusion gone very wrong when he was a pediatric resident.  His immediate point was the lost opportunity then to confront the errors promptly and openly to prevent reoccurrence.  He asserted that this was an ethical responsibility of physicians and health care systems if quality is to be continuously improved.

Increased Public Health Investment Is Necessary But Not Sufficient

By David A. Kindig, MD, PhD

Last week I summarized the IOM’s new report on For the Public’s Health: Investing in a Healthier Future. The entire 3-part series is extremely important from a policy perspective and should be on every population health advocate’s reading list.

I praised the report as a whole but also promised a critique. The crux of my argument is that to achieve the Committee’s ambitious goals, we need to think beyond governmental public health. The suggested doubling of the budget for governmental public health, which seems reasonable for the set of minimum public health services, is necessary but not nearly sufficient to achieve their population health improvement goals.

The IOM Reports on Investing in a Healthier Future

By David A. Kindig, MD, PhD

I’ve been waiting with anticipation for last week’s IOM report on For the Public's Health: Investing in a Healthier Future, from the IOM Committee on Public Health Strategies to Improve Health. This is the third of three reports. The first report was released in December 2010 and focused on measurement of population health and related accountability at all levels of government. The second report was released in June 2011 and reflected the committee’s thinking about legal and public policy reform such as health departments’ powers, duties, and limitations as defined in enabling statutes and the use of legal and policy tools to improve the public’s health.

The third report addresses the critical issue, in a time of declining resources, of public health resource needs and approaches to addressing them in a “predictable and sustainable manner to ensure a robust population health system.” Given my many calls for dependable revenue streams for population health improvement, this clearly was a must-read for me.

The Link Between Income and Health

By David A. Kindig, MD, PhD

Listening to the national conference call for the release of the 2012 County Heath Rankings last week, I was struck by the number of questions regarding the socioeconomic factors in the model. It made me recall the early morning call from a small town reporter when we released the first Wisconsin County Rankings in 2003, saying “do you mean that county income levels might be as important as the number of uninsured or the smoking rates?”

This concept is better understood today than it was in 2003, but it is still hard to communicate. We accept the health-compromising effects of smoking and lack of health care access, but how education and income ‘get under the skin” to produce disease and death is less obvious. Yet a growing body of literature supports this finding, and is the reason why we give social factors a weighting of 40% in the County Health Rankings model.

This week we’re calling attention to a study I co-authored with one of our PhD candidates, Erika Cheng. The article, Disparities in premature mortality between high and low income U.S. counties, appears in the April 2012 issue of Preventing Chronic Disease.

Movin' Down the Road to Health

By Julie Willems Van Dijk, RN, PhD

On April 3^rd you received your annual check-up of your community’s health -- the 2012 County Health Rankings. You’ve had a chance to review what’s going well for your community and where you are lagging behind others. But now what? What can you do to make your community a healthier place?

Since the inaugural release of the County Health Rankings in 2010, hundreds of people have contacted us to ask these questions and we’ve directed them to our Take Action cycle. It’s a simple and straightforward process. Work with other key partners, because we know solving issues like poor high school graduation rates, unemployment, excessive drinking, unhealthy air, or inadequate health care require the wisdom and resources of people from all walks of life. Gather information. Set priorities. Find the most effective approaches to address your priorities and then just do it!

County health ranks -- Are they a'changin?

By Bridget Booske Catlin, PhD, MHSA

It’s ranking season again (and I’m not talking about NCAA basketball) – the 2012 County Health Rankings will be available tomorrow (April 3, 2012). Since this is our third year of releasing the Rankings for all 50 states, we are fielding questions such as what has changed since last year? If not much has changed, why should anyone pay attention? 

Coming Soon...The Roadmaps to Health Prize

By David A. Kindig MD, PhD and Kirstin Q. Siemering DrPH, RD

On April 3^rd 2012, the University of Wisconsin Population Health Institute will make applications available for the inaugural Roadmaps to Health Prize. The Prize is part of the Robert Wood Johnson Foundation-funded County Health Roadmaps project and will recognize communities across the U.S. that have successfully mobilized to improve population health.

Communities throughout the country are actively engaged in finding ways to increase the health and vitality of residents. The Roadmaps to Health Prize is rooted in the idea that every community is on a unique journey toward better health. The prize will honor the accomplishments of communities along the continuum of this journey, from those that have achieved tremendous success to those that have struggled against great odds and may just be beginning to see results.

The Roadmaps to Health Prize is a place-based prize that will honor whole communities (rather than individuals or individual organizations). All U.S. communities are eligible to apply. For the purposes of the prize, “communities” are defined as towns, cities, counties, regions (such as contiguous towns, cities, or counties), tribes, and tribal communities.

United Way as a Partner in Population Health Improvement

By Kitty Hsu Dana

United Way's mission is to advance the common good by mobilizing people and institutions to invest in Education, Financial Stability and Health, so that all people in all communities have the opportunity for a good quality of life.  With a network of more than 1,200 locally-based organizations in the United States and another 500 in other countries, United Way is transforming from its traditional fundraising role to work with diverse partners across the sectors to make sustainable change in communities through multiple roles, including:

1. Compiling and summarizing data and research
2. Engaging and convening stakeholders, community leaders, corporate partners, concerned individuals/organizations, and others
3. Clarifying and advancing specific policy initiatives, and
4. Realigning fundraising for specific community-identified initiatives, objectives and practices.

These roles are similar to the idea of a "backbone organization" and to David Kindig’s “Super Integrator” concept. This is not to say that United Way will always take the lead; we recognize that effective leadership can be at the front, in the middle, or from behind. Nor does it mean United Way acts alone. As a non-partisan convener, United Way ensures that all critical parties are engaged and play necessary roles to advance the common good.

A "Master Plan" for Population Health Improvement

By Kirstin Q. Siemering, DrPH, RD

Wikipedia defines "comprehensive planning" as:

 A term used in the United States by land use planners to describe a process that determines community goals and aspirations in terms of community development. The outcome of comprehensive planning is the Comprehensive Plan which dictates public policy in terms of transportation, utilities, land use, recreation, and housing. Comprehensive plans typically encompass large geographical areas, a broad range of topics, and cover a long-term time horizon.

Communities have been developing "Master Plans" to guide their long-range decision-making since the late 19^th century (notably, concern about sanitation and the spread of disease in urban areas was the major early impetus). Amherst, Massachusetts calls its new Master Plan -- its first in 40 years -- a "statement of community intent."

Now Available: "Roadmaps to Health" Community Grants Opportunity

By Phillip O. González

 

Much of what influences our health happens outside of the doctor’s office—in our schools, workplaces and neighborhoods. The ability to find good jobs, to prepare children for college and career success, to establish financial security, and to live in safe communities that promote positive relationships among family and friends are not usually thought of as health interventions. However, these factors play an important role in our ability to lead long and healthy lives.

The County Health Rankings, released annually by the University of Wisconsin Population Health Institute (UWPHI) and the Robert Wood Johnson Foundation (RWJF), rank the health of counties throughout the nation and clearly show how social and economic factors impact health. They emphasize the role that key factors such as education, income and employment, family and social connectedness, and community safety play in building healthy communities.  However, efforts to address these factors often occur within individual sectors and focus on short-term goals like expanding effective programs.  But what if those efforts could be broadened?  How might the vision and impact be expanded if those efforts were organized to include participants from multiple sectors such as health, the business community, or policymakers?  Might they achieve meaningful, long-term policy change?  And what strategies and tactics would a coalition formed from a diverse group of organizations undertake?

Is Lower Health Care Spending Good for Our Health?

By David A. Kindig, MD, PhD

I believe the most important scholarly publication in January, 2012 was Health Affairs’ “Growth in U.S. Health Spending Remained Slow in 2010; Health Share of Domestic Product Was Unchanged From 2009.” This annual report from the Office of the Actuary and the National Health Expenditure Accounts Team of the federal Centers for Medicare & Medicaid Services (CMS) always gets substantial coverage in the mainstream press and this year was no exception.

Why are health expenditure trends so important to improving population health? Because the amount we spend on health care in the United States is the elephant in the room regarding aligning resources appropriately to make us healthier and reduce disparities.

La Crosse Medical Health Science Consortium Moves Toward “Super-Integration”

By David A. Kindig, MD, PhD

Last week, I addressed the issue of population health resource allocation. I asked, “Where would you put the money?” and mentioned (among other possible approaches) the concept of a multi-sector “super-integrator” to take the lead in identifying and harnessing resources for population health improvement. I was delighted to hear from reader Catherine Kolkmeier, who directs the La Crosse Medical Health Science Consortium here in Wisconsin. Catherine was intrigued by the super-integrator concept and curious as to my opinion of whether the consortium fits this model.

"Where Would You Put the Money?"

By David A. Kindig, MD, PhD

As regular readers know, I’ve been arguing consistently for the need for a regular, sustainable revenue stream to support population health improvement. However, I’ve not directly addressed the question of how these dollars should be allocated. As one of the authors of the important Evans-Stoddart population field model said in their 2003 AJPH article (Consuming Research, Producing Policy?), “redirecting resources means redirecting someone’s income…most students of population health cannot confidently answer the question…well, where would you put the money?” 

Population Health Financing: Beyond Grants

By David A. Kindig, MD, PhD

My professional coming of age took place the late 1960s, in one of the original Office of Economic Opportunity (OEO) neighborhood health centers in the South Bronx. Because the health centers were a part of the larger federal antipoverty strategy, they were founded on a broad view of health (we would call it a population health framework even though that terminology didn’t exist then). Health care innovation was the core, with community health workers, health care teams, and the understanding that the residents who didn’t use the clinic contributed to overall neighborhood heath as much as those who did.

But the OEO funding paid for much more than health care, including job training, legal advocacy, school health programs, neighborhood built environments – what we now see as the multiple determinants of health. But one of the main lessons of my entire career was the following: when the grant goes away, the programs or innovations which it supported dwindle too. Don’t get me wrong: federal and foundation grants are essential for innovation to occur, and I have served productively on both the giving and receiving ends of this equation. But initial funding almost always ends at some point (through change of political priorities or foundation leadership and priorities), and additional funds must be sought for sustainability or going to scale.

Make Way for Starbucks' Community Stores

By Kirstin Q. Siemering, DrPH, RD

Population health can be a hard sell for the business sector, where the nature of the work has historically meant a focus on profits to the exclusion of most if not all other priorities. Although we applaud the current expansion of worksite wellness programs, we recognize that these efforts represent only a fraction what is needed for broad and lasting change. For broad population health improvement, we need to get beyond individual knowledge and behavior to effect policy and environmental changes that make the healthy choice the easy choice.

As we consider tangible roles for businesses to play in population health improvement, it might be helpful to think of a continuum, with worksite wellness as a starting point. Many potential roles remain unexplored, but we should all take a vested interest in shaping how work on the other end of the spectrum might look.

Community Benefit in the Population Health Literature

By David A. Kindig, MD, PhD

We try to keep this blog accessible and policy relevant, and therefore carefully avoid being overly academic. However, we also regularly follow the literature, which is a challenge given the breadth of multidisciplinary scholarship underpinning the field. So periodically I will point to particularly recent and relevant articles that may be of interest to readers. The list of 11 journals we regularly scan is listed at the bottom of this post. I welcome your flagging for me other journals and articles you suggest we follow. I’m going to start this series by focusing on an article from the December 2011 issue of the American Journal of Public Health.

The Impact of the Individual Mandate and Internal Revenue Service Form 990 Schedule H on Community Benefits from Nonprofit Hospitals by Principe K, Adams EK, Maynard J, and Becker ER.

IPH Reader Craig Mosbaek Weighs in on 2012

We were delighted to have a few takers for our recent call for readers' ideas for what's on the population health radar in 2012. We thought many would appreciate reader Craig Mosbaek's perspective:

By Craig Mosbaek, MPH

Here are six trends I think will have big impacts on public health in the coming year.

The policy approach to public health. The understanding of how policies and environments shape health behaviors and health outcomes will continue to develop.  Elected officials are beginning to appreciate this more, as well as public health professionals and others. You can see this institutionalized in initiatives such as CDC’s Community Transformation Grants, APHA’s new policy contest, and the Public Health Accreditation standards.

Funding for public health departments.  There have already been big budget cuts at many local and state health departments.  With the poor economy, these cuts will persist and there may be major reductions in federal spending on the horizon.  With limited resources, health departments should focus their efforts on the most important public health issues.

Healthcare costs saved by public health efforts. Public health advocates are increasingly using the argument that policies to improve population health will reduce long-term healthcare costs.  More research will focus on the return on investment (ROI) of public health approaches. Effective use of this argument could help alleviate the upcoming budget cuts for health departments.

Broadening the definition of public health. When expanding the definition of public health, some people use terms such as the social determinants of health or health in all policies. We are still working on how to talk about this broadened definition in ways that engage the public and encourage collaboration with other sectors.

Health impact assessments.  A corollary to the above (broadening the definition of public health) is the growing use of health impact assessments  (HIAs).  The PEW site shows about 80 completed HIAs nationwide right now. I wouldn’t be surprised to see 80 more HIAs completed in 2012 alone.

New communications technology. New media (blogs, Facebook, Twitter, video over the Internet) will continue to transform the ways we communicate. This impacts how public health professionals collaborate with each other, as well as how we interact with the public.  

Craig Mosbaek, MPH, President of Mosbaek Consulting, focuses on improving public health policy through communications, research/evaluation, and strategic planning. In 2010, he worked for Congress as the American Public Health Association’s Public Health Fellow in Government.

Population Health Outlook for 2012

By David A. Kindig, MD, PhD

Last week I reflected on Improving Population Health in 2011; today I’m looking forward to the year ahead. So what are the opportunities and challenges that 2012 presents for us?

The fall elections. On the one hand this is a challenge, since health outcomes and health disparities rarely directly enter into the political discussion and debate. Health care costs do, from both political parties, but in a relatively confined way. Rarely do ideas extend beyond the cost savings to examine, for example, how waste could be directed towards non-health care investments. The overwhelming task of implementing the Affordable Care Act (ACA) and defending its legal challenges requires much time and energy and has led some to believe that the current situation necessitates focusing efforts. Perhaps we should work now to consolidate and strengthen health care access and cost issues and – at least for now – have other determinants take a back seat.

Given what we know produces health, such an approach may be appropriate and opportunistic. Access to affordable health care is an important determinant of health, but even with full ACA implementation will not reach everyone. Jobs and economic development are at the top of the political agenda, and many candidates appreciate the role of education in increasing opportunity and economic productivity. Many leading Republicans support such goals. In an unexpected twist the Occupy Wall Street movement has moved the issue of income inequality onto the front page. Influencing candidates of both parties to campaign on strong economic development and education agendas could be the most important thing population health advocates could do this year.

The science of early intervention. Nicholas Kristoff’s recent op-ed, A Poverty Solution that Starts with a Hug summarizes the findings from an American Academy of Pediatrics policy statement in this way: “Cues of a hostile or indifferent environment flood an infant, or even a fetus, with stress hormones like cortisol in ways that can disrupt the body’s metabolism or the architecture of the brains. The upshot is that children are sometimes permanently undermined. Even many years later, as adults, they are more likely to suffer heart disease, diabetes or other physical ailments. They are also more likely to struggle in school, have short tempers, and tangle with the law.” This science is not unknown to scholars, but it is beginning to diffuse into the policy arena (and Kristoff is hardly a science/policy columnist). We need to keep developing more robust findings and facilitate their understanding at all levels of private and public policy.

The Best of 2011 – and an Invitation to Help Shape IPH in 2012

By David A. Kindig, MD, PhD

I don’t usually make formal New Year’s resolutions, but I do think about the passing of the old year and the opportunities and responsibilities in the new one. In that spirit, I’m devoting this week’s post to some key pieces from our 2011 archives.  Next week, we’ll be looking forward to give a preview of possible topics for 2012. We welcome any and all ideas from readers – this is your chance to help shape Improving Population Health in the coming year! Please just use the comment box below or email me directly.

So whether it’s for the first time -- or for a second look -- I invite you to take a look at some of my favorite posts from 2011.

Population Health Eye on Pre-Kindergarten

By Kirstin Q. Siemering, DrPH, RD

Here on the Improving Population Health blog, we recognize the important role that education plays in health outcomes. Earlier this year, David Kindig encouraged business sector investments in early childhood education as a means for improving the health of tomorrow’s workforce. And back in September, our “Eye On Pop Health” series focused on higher education, paying special attention to the need for community college reform.

This month, we’re celebrating the end of one impressive early learning initiative and the start of another. The Pew Center on the States’ ambitious, 10-year Pre-K Now campaign will end on December 31, 2011. The campaign’s goal, which was to advance high quality, voluntary pre-kindergarten for all three- and four-year old, hit many milestones as it worked toward transforming U.S. education from a K-12 system to a Pre-K-12 system. And last Friday, Domestic Policy Council Director Melody Barnes joined Education Secretary Arne Duncan and Health and Human Services Secretary Kathleen Sebelius to announce $500 million in grants to nine state winners of the Race to the Top Early Learning Challenge to spur improvement in early childhood education programs.

Can Leadership Come from within Health Care? Comments on the Triple Aim Regional Strategy…and Mt. Sinai Academic Health Center

By David A. Kindig, MD, PhD

We don’t usually repost the formal comments we get in response to a given blog, but we had several particularly thoughtful ones in response to the Nov 16 Triple Aim: Accelerating and Sustaining Collective Regional Action by John Whittington and I that I wanted to call attention to…as well as a provocative essay from Mt. Sinai Medical Center.

From Pamela Russo: Thank you for the brief history and evolution of the Triple Aim with regards to population health - clarifies and offers great promise. It offers a good model for broader and more collaborative interpretation of how hospital community benefits activities could evolve under the new regulations.

From Mary Lou Andersaen:  At the end of the Clinton administration such a program was funded to provide $1M /year for 5 years to support the development of a small group of communities to develop such systems linking all important sectors. Lessons were learned and a continuing organization called Communities Joined in Action continue that mission struggling without the necessary support to achieve the spreading of the best results. That passion exists right now in this country. Tap into it!

From Robert Stone Newsom:  Interesting approach and glad to see they have the critical element of “funders” in the list. The question as always remains: who are these funders? Whose pocketbook (profits, wages, income) must ultimately be reduced for such population health improvement to occur? All available evidence strongly supports the supposition that neither providers nor private sector insurers have any incentive to reducing their own income and profits for such ‘public good’ funding. Consequently increased taxation is likely the only sustainable approach. However, recent history has demonstrated both the 1% and 99%’s inability and / or unwillingness to meaningfully address the moral hazard inherent in our current healthcare ‘market’ models. In healthcare markets rational self-interest may guarantee that population health continues to be the victim of the tragedy of the commons.

County Health Roadmaps

By Bridget Booske Catlin, PhD, MHSA

Hopefully, by now everyone who reads this blog has heard of the County Health Rankings but I suspect few of you have heard of the County Health Roadmaps. Ranking the health of nearly every county in the nation, the County Health Rankings illustrate what we know when it comes to what’s making people sick or healthy. The new County Health Roadmaps show what we can do to create healthier places to live, learn, work and play. The Robert Wood Johnson Foundation (RWJF) is collaborating with the University of Wisconsin Population Health Institute (UWPHI) to bring this program to cities, counties and states across the nation.

The County Health Roadmaps project includes several efforts to build connections with local communities, national partners and leaders across all sectors to improve health. The project includes grants to coalitions across the U.S. that are working to improve the health of people in their communities; grants to national organizations to mobilize local leaders and affiliates to improve health; a prize program to recognize communities taking action and whose promising efforts will likely lead to better health; and tools and resources to help groups working to improve the health of people in their communities. 

Berwick is Gone: The Collision of Candor and Politics

By David A. Kindig, MD, PhD

We knew it was coming, but I winced when I saw the headline: Medicare and Medicaid Chief, Never Confirmed by Senate, Is Stepping Down. The headline, of course, refers to Don Berwick, who has run this critical agency in the Obama administration since July 2010. He is a highly regarded pediatrician and heath policy expert, and the founder of the Institute for HealthCare Improvement (IHI), a nationally recognized organization that leads efforts to improve health care quality and contain costs. Under his leadership, CMS has released final rules for Accountable Care Organizations’ (ACOs) Medicare Shared Savings Program, developed the Comprehensive Primary Care Initiative, and launched the Health Care Innovation Challenge.

Berwick is resigning because his appointment is an Obama “recess” appointment not requiring Senate confirmation.

Triple Aim: Accelerating and Sustaining Collective Regional Action

By David A. Kindig, MD, PhD and John Whittington, MD

I’ve been following the Institute for Healthcare Improvement’s (IHI) Triple Aim for some time. The IHI was founded in 1991 by Don Berwick and a small group of colleagues who were committed to redesigning health care into a system no longer plagued by errors, waste, delay, and unsustainable social and economic costs. In 2005, IHI created a vision to work on three simultaneous aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. A year ago they embarked on a broader regional health improvement effort at the community level.

While openly enthusiastic about their work, I’ve also offered constrictive criticism -- especially regarding their concept of the Third Aim Population Health, and how robustly the non-health care determinants fit into their model and priorities.

Is There Synergy in Community Development Financing and Population Health?

By David A. Kindig, MD, PhD

It’s been more than a year since I first blogged – with some incredulity – on the first Federal Reserve Healthy Communities Conference.

The Healthy Communities Initiative was created by the Federal Reserve System and the Robert Wood Johnson Foundation to encourage stronger linkages between community development and health. That first meeting, in July 2010, was devoted to building bridges and understanding between two fields with potential for synergy in goals and resources but very little else in common (including language).

This week I attended a follow-up meeting called Healthy Communities: Building Systems to Integrate Community Development and Health. Sponsored by the Federal Reserve Bank of San Francisco, the Robert Wood Johnson Foundation, and the Pew Charitable Trusts, the meeting brought together about 120 leaders from academia, foundations, banking and finance, and the federal government (including the White House, HUD, DOE, DHHS, and EPA).

(How) Does Where You Live Get Under Your Skin?

By David A. Kindig, MD, PhD

Last week Kirstin blogged on an innovative housing project in the South Bronx that incorporated fitness promoting design principles. She cited the Robert Wood Johnson Foundation’s Commission to Build a Healthier America's Issue Brief on Housing and Health which identified three interrelated aspects of residential housing that influence health: (1) affordability, (2) the physical conditions within homes, and (3) neighborhood environments surrounding homes.

Last week there was significant media coverage (including the October 29 Economist!) of an article by Jens Ludwig and colleagues that was featured in the Oct 20 New England Journal of Medicine. The study reported that moving from a high poverty neighborhood to a lower poverty one showed substantial improvement in obesity rates and blood sugar levels. Why was this report deemed of such interest and importance, even by the mainstream press?

Population Health Eye on Affordable and Healthy Housing for All

By Kirstin Q. Siemering, DrPH

This past summer, several news articles called attention to the County Health Rankings’ finding that people who live in urban and suburban environments tend to be healthier than those living in rural areas. The Wall Street Journal and the CBS Early Show should be applauded for calling attention to the fact that of the more than 3,000 counties assessed in the 2011 Rankings, 84% of the unhealthiest were rural while 48% of the healthiest were either urban or suburban. But we need to keep in mind that cities are also home to populations facing enormous health challenges.

The ACA’s Essential Health Benefits: Start Simply, Learn over Time, Make it Better

By John R. Ball, MD, JD

On October 6, the Institute of Medicine released the report Essential Health Benefits: Balancing Coverage and Cost. The report was in response to a request from the Department of Health and Human Services to recommend “criteria and policy foundations” for the Secretary’s determination of the essential health benefits (EHB) required to be offered by qualified health plans participating in the new state health insurance exchanges established by the Patient Protection and Affordable Care Act (ACA).

Early press coverage, which is often the public’s only impression of such reports, pretty much got it right: the report called for a balancing of the comprehensiveness of coverage with the affordability of the benefit package. If cost were not taken into account in constructing benefits, the resulting package would rapidly become unaffordable, frustrating the central intent of the ACA, which was to make health insurance more available to more people. 

Ignoring Evidence and Economics at Our Peril

By David A. Kindig, MD, PhD

Two recent New York Times articles jumped off the page at me. The first, on the recommendation by the U.S. Preventive Services Task Force to forego routine screening for prostate cancer with the PSA test, received wide media coverage. The second, on an Institute of Medicine (IOM) panel recommendation that costs should explicitly be considered in deciding what benefits must be provided by insurance plans, received less attention. Both deserve attention from population health advocates and policy makers.

Do We Need Population Health Shock Therapy?

By David A. Kindig, MD, PhD

I just finished reading Thomas Friedman and Michael Mandelbaum’s new book That Used To Be Us: How America Fell Behind in the World It Invented and How We Can Come Back. It’s a sobering read as it assesses the U.S.’s position in the world and what we have to do to regain lost economic and social competitiveness.

Friedman and Mandelbaum focus on four areas we need to urgently address in order to avoid falling into second world status: globalization, the information technology revolution, deficits and debt, and energy demand and climate change. The authors express particular concern about our education performance, and argue that recent information about relative international test score performance should have prompted a response similar to the investments in science and technology spurred by Sputnik a generation ago. But that hasn’t happened.

HIA: A Practical Tool for Factoring Health into Decision Making Across Sectors

By Pamela Russo, MD, MPH

Staying healthy, whether we’re talking about individuals or populations, is influenced by people’s access to high quality health care and clinical prevention - but there is powerful evidence that staying healthy is more strongly influenced by people’s education, job opportunities, economic status, and the social and physical environmental conditions where they are born, grow, live work, and age. This understanding needs to be conveyed in a useful way to those making decisions on policies, programs and projects in non-health sectors such as transportation, energy production, labor, or education, who rarely consider the consequences of their decisions on factors that influence health. Absent the consideration of effects on human health, we have often unintentionally created conditions that are either hazardous to human health or create barriers for people to adopt and maintain healthy behaviors. How can we convert the evidence on the multiple factors that drive population health into something decision-makers can use to build health into their equations?

Will the Jobs Bill Impact Population Health?

By David A. Kindig, MD, PhD

The last week has seen much attention devoted to the issue of jobs and unemployment in our country. Presidential elections often hinge on the state of the economy and the persistence of high unemployment rates will likely play a greater role in 2012 than in previous periods. While a growing literature shows that displaced workers (defined as individuals who lose their jobs as part of plant closings, mass layoffs, and other firm-level employment reductions) tend to experience significant long-term earnings losses as well as decreased job stability, lower employment rates, earlier retirement, lower personal spending, and decreased health insurance coverage.

In addition to these primarily economic effects, there are likely to be health effects as well. Unemployment (measured as the percent of the population age 16 and over that is unemployed but seeking work) is one of seven key measures in the County Health Rankings’ Social and Economic Factors, but is only briefly mentioned in Healthy People 2020’s new section on the Social Determinants of Health.

Pop Health Twitter Roundup (9/22/11)

The latest and greatest from @PopHealth:

Not happy with the USDA's MyPlate guidelines, Harvard professors came up with their own

Global & Local: Designing Cities with Children in Mind

Michigan's Governor Rick Snyder: "Health is the foundation for Michigan's economic transformation"

Making it in the U.S. -- More than Just Hard Work

Employment prospects for low-qualified people are much dimmer than those for their more highly qualified counterparts

Nourishing NYC: working to eliminate the correlation between obesity and poverty

Claims data from 4 major insurers to become available to researchers through new Health Care Cost Institute

2011 MacArthur Fellow Roland Fryer examines causes and consequences of economic disparity due to race and inequality

Population Health Eye on Community Colleges

By Kirstin Q. Siemering, DrPH

We’ve often discussed the importance of education for population health. An individual’s level of educational attainment is important for ensuring both income and health. The level of education of the workforce in a community is also important for economic growth. In a 2010 Chronicle of Higher Education article, Chairman of the Salt Lake City Chamber of Commerce Mark Bouchard did a “then and now” comparison of how companies approach location decisions. Ten years ago, Bouchard said, the norm was for such efforts to be led by a firm’s real estate committee. These days, leadership is more often than not provided by human resource officials wanting to “know about the quality of the work force.” Since the article was published, this message has only become more relevant – and given the current 9% national unemployment rate, will likely remain so for some time.

While it may seem as if policymakers and advocates focus more on the importance of early childhood education and high school completion than on higher education, a recent and growing spotlight on community colleges has begun to draw attention to the challenges and opportunities of this piece of the puzzle. This past spring, the Brookings-Rockefeller Project on State and Metropolitan Innovation released Community Colleges and Regional Recovery: Strategies for State Action to promote the idea that the time is ripe for states “to maximize their return on every public investment dollar for long-term, sustainable economic growth.” While the report is not framed in population health terms, its message clearly aligns with a population health framework that recognizes social and economic factors as key drivers of health.

Pop Health Twitter Roundup (9/14/11)

The latest and greatest from @PopHealth:

• New from Health Affairs:  "A Decade Of Health Care Cost Growth Has Wiped Out Real Income Gains For An Average US Family"

• Cities versus rural for healthy living

• Massachusetts Lawmaker Introduces Bill To Minimize Disparities In Health Care Prices

• Medicare Chief Donald Berwick turns 65, signs up

• Supporting Health in All Policies: National Research Council gives guidance on use of Health Impact Assessment

• Cross-state partnership creates a win-win for maternal & child health

• Heard about RWJF's new initiative to transform health care?

• New bike share program offering $15/yr memberships for low income residents & free helmet

• U.S. Census reveals current poverty rate highest since 1993

CMS Turns an Ear to Population Health

By David A. Kindig, MD, PhD

Last month I was privileged to be part of a group invited to the federal Center for Medicare and Medicaid Innovation (“Innovation Center”) to discuss population health models and opportunities. Why would the federal agency with the overwhelming job of controlling health care costs and implementing health reform be concerned about this?

The reason is that the Centers for Medicare and Medicaid Services (CMS) is viewing its approach to health improvement through the lens of the Triple Aim, with its Innovation Center being a new engine for revitalizing and sustaining Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) and ultimately, for improving the health care system for all Americans.

Pop Health Twitter Roundup (9/7/11)

The latest and greatest from @PopHealth:

• Families feeling sharp edge of state budget cuts

• NACCHO has released its 2010 National Profile of Local Health Departments

• Colleges increasingly inhospitable to smoking

• Announcing plans for a course on telling the stories of public and population health

• Hoping for Change: Health and Social Disparities Facing Men and Boys of Color

• Coming soon from the National Research Council -- new report on the role of Health Impact Assessment

• New report from TFAH & RWJF -- Remembering 9/11 and Anthrax: Public Health's Vital Role in Nat'l Defense

• F.D.A. to review safety of popular bone drugs

• Food for thought: revive home economics classes to fight obesity?

• Great post on struggles grocery stores find in food deserts

Locally Customized Population Health Policy Packages?

By David A. Kindig, MD, PhD

In my last post I suggested that those who allocate resources must provide ample guidance to ensure that local level health improvement strategies actually align with the best available evidence. I mentioned the University of Wisconsin What Works data base as well as the approach that the previous administration allocated its State Health Improvement Plan (SHIP) resources in the state of Minnesota. But I indicated that What Works is not tailored to individual communities and that the Minnesota example is limited to health behavior interventions, not all population health determinants.

We know from the County Health Rankings and our own experiences that communities vary widely in both their health outcomes and the factors or determinants of those outcomes. There are many examples of both high and low ranking counties which vary on their determinant profile…some have high health care quality and access but poor behaviors, others have high social factors like education and income but poor air and water quality. Given limited resources, it is critical that investments be made carefully to have the most impact.

Would it be helpful to identify a set of Population Health Policy Packages that suggest the best options for local communities to make, given their outcomes and health determinants profile? 

Gone Fishing

Please stay tuned for a new post next week!

Can Policy Models be Helpful to Local Decision Makers?

By David A. Kindig, MD, PhD

Two recent posts have featured population health policy models (see Modeling Long Run Population Health Costs and Outcomes and A Population Health Opportunity Map). Such models will be increasingly important as we strive to effectively allocate resources appropriately across sectors to improve overall health outcomes and improve health equity. But to those in the local trenches, particularly in a time of resource reductions, models may seem abstract and irrelevant. What do we know NOW that can help communities make the best decisions possible in these challenging times? Can top down models or tools be helpful to communities looking for bottom up solutions?

A Population Health Opportunity Map

By David A. Kindig, MD, PhD

A commentary in the May 25 JAMA by Jonathan Fielding and Steve Teutsch caught my eye a couple of months ago. Both authors play influential roles in national population health policy, from their practice based experiences in the Los Angeles County Department of Public Health.

They begin by arguing that as we reform the health CARE system, complementary improvements are needed in community prevention programs and policies as well. The challenge for both national and local policy makers is to be able to “identify and implement those interventions that provide the greatest benefits and value,” including the relative effectiveness of both clinical and community prevention efforts. They suggest that a first step has to be a sound framework for “identifying and organizing” the universe of interventions which have been shown to have evidence of effectiveness.

Pop Health Twitter Roundup (8/9/11)

The latest and greatest from @PopHealth:

• New article in British Medical Journal uses Health Impact Assessment to analyze urban bicycle sharing program

• First-Ever National Healthy Eating and Physical Activity Standards Developed for Afterschool Programs

• How does education affect your community? Check out the United Way's new Common Good Forecaster to find out

• This fall, all 34,000 Cincinnati Public School students will have daily access to a school salad bar

• NYT "Well": Friendly Workplace Linked to Longer Life

• Ample Harvest is making fresh produce available to more than 4,000 food pantries across the US

• Check out the new Health Wonk Review blog carnival hosted by Joe Paduda at Managed Care Matters

• From Washington Post: Towns change programs, enlarge street signs to adapt to an older population

• Health Leads: Slashing the Price of Health with Common Sense from NYT columnist David Bornstein

• Weight, income, public food programs: A look at how the pounds add up

Population Health Eye on "Total Worker Health" in Lincoln, Nebraska

By Kirstin Q. Siemering, DrPH, RD

Lincoln Industries in Lincoln, Nebraska is the nation’s leading supplier of products requiring high performance metal finishing. The company was established in 1955 and employs over 400 people in an operation that runs 24 hours per day, seven days per week.

The company’s commitment to worker well-being has earned it widespread recognition. Lincoln Industries has been honored by the U.S. Dept. of Health and Human Services, the American Heart Association, Partners for Prevention, and others. The company has also been named one of the “25 Best Medium Companies to Work for in America” by the Great Place to Work Institute.

Pop Health Twitter Roundup (8/2/11)

 The latest and greatest from @PopHealth:

• Separate & Unequal: The Neighborhood Gap for Black, Hispanics, and Asians in Metropolitan America (via US2010 Project)

• Linking transportation policy & health -- new report from Partnership for Prevention

• New from the Commonwealth Fund: The U.S. Health System in Perspective: A Comparison of Twelve Industrialized Nations

• New Canadian report sees key role for social media: "Communicating the Social Determinants of Health"

• SAMHSA announces new approach to Prevention and Promotion, incl. grants specifically for tribes & tribal communities

• NYT "Fixes" columnist David Bornstein writes about "Treating the Cause, Not the Illness" in his piece on Health Leads

• Environmentalists laud automakers for prioritzing fuel economy as carmakers back strict new rules for gas mileage

• How a park helped one town weather the recession

• UC Berkeley journalism students offer USDA ideas for revamping food labels

• Almost 50% of U.S. health care spending will come from government coffers by 2020 says new report from Health Affairs

Modeling Long Run Population Health Costs and Outcomes

By David A. Kindig, MD, PhD

The broad population health model that underpins this blog and the County Health Rankings must have long-term relevance because quick fixes are few and far between. There is an imperative to invest now in factors we know to be strong drivers of long-term health, such as early childhood interventions (see Can We Afford to Wait for Better Evidence on Improving Child Health? and Business Investment in Early Childhood: Making Future Workers Happier). There is also a need for more research which can better estimate such long-term impacts; the IOM’s recent report on Public Health Measurement and Accountability calls for advancing the use of predictive and system-based simulation models to understand the health consequences of the underlying determinants of health.

One such model does exist, and was reported on in the May 2011 Health Affairs issue on Environmental Health discussed last week. The article, authored by Bobby Milstein, Jack Homer and colleagues, focuses on the HealthBound policy simulation model which has been developed by the CDC over the past decade. This work seems and is ambitious, as any such analytic and projection tool has to be, but it also simplifies the sheer complexity of the U.S. health system into a tractable form that can be understood and studied by diverse stakeholders. It is built on the methodology of systems dynamics modeling, using several hundred interacting elements and differential equations tied to ten national data bases and many key reference studies.

Pop Health Twitter Roundup (7/27/11)

 The latest and greatest from @PopHealth:

• The wealth gap between whites and minorities is at its widest in 25 years

• Academy Health announces new initiative to generate evidence & leverage findings from Beacon Communities

• McDonald's adds choice of fruit or veggies to Happy Meals and reduces french fry portion by 50% (kcals down ~20%)

• Mark Bittman proposes a solution to the Standard American Diet (also see interesting interactive timeline)

• Who are America's poor children? New report examines health disparities by race and ethnicity

• Haven't heard of Health Leads? The Atlantic has a great conversation with CEO (and MacArthur Fellow) Rebecca Onie

• Pop Health win: new Russian law categorizes beer as alcohol (not food)

• Important new study links increased public health spending to reduced mortality