Primary Care and Public Health Exploring Integration to Improve Population Health (2012) / Chapter Skim
Currently Skimming:
4 Policy and Funding Levers
4 Policy and Funding Levers
Pages 105-142
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From page 105... ...
is arguably the most significant health policy event since the creation of Medicare and Medicaid in 1965, other advocacy and legislative efforts have recently been undertaken that create opportunities for primary care and public health to work together. These efforts attest to the momentum that exists for improving the health system, as well as the commitment to incorporating population health goals into health policy.
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From page 106... ...
For example, the Sustainable Communities Regional Planning Grant Program is a collaborative effort of the Department of Housing and Urban Development, the Department of Transportation, and the Environmental Protection Agency to support planning for community improvement and address, among other issues, public and environmental health concerns. Another effort under way is the Health in All Policies movement.
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From page 107... ...
Using these data to inform population-level policies is one way in which primary care practices and public health departments can work together around a shared goal. Although many of ARRA's provisions ended after 2 years, it is important to recognize that even before the ACA became law, there was a movement to invest in and improve the nation's health system.
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From page 108... ...
In other words, health insurance deals only with payment of medical costs, whereas population health investments provide an opportunity for containing and maintaining health care costs within an affordable trajectory. The committee believes that within the numerous provisions of the ACA lie the seeds of opportunity to catalyze the integration of primary care and public health and embed population health improvement as an objective in achieving wellness and health for Americans.
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From page 109... ...
Clinical preventive services are embedded in the basic structure of the Community Transformation Grants program, making health care providers a core partner in the types of broad-based coalitions whose involvement is essential to the program. All applicants are expected to focus on tobacco-free living; active living and healthy eating; and increased use of high-impact, quality clinical preventive services.
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From page 110... ...
The Community Transformation Grants program and the National Network share a set of important purposes: to launch multiple interventions whose goal is making fundamental improvements in population health; to lessen the burden on the health care system while achieving its central involvement in the effort; to develop a new approach to the collection and use of public health information in order to bring an immediacy and action orientation to long-standing surveillance practices; and to accelerate the rate at which public health innovations are replicated nationally, regardless of whether the replication sites receive support from the Community Transformation Grants program. In this sense, the Community Transformation Grants program can be viewed as the public health counterpart to the CMS Innovation Center (CMMI)
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From page 111... ...
Of greatest interest to the committee is the obligation to undertake a community health needs assessment. The community health needs assessment is a triennial process10 that must commence no later than the taxable year 2 years after the ACA's enactment.
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From page 112... ...
Examples of these activities include the extension of primary care services into nontraditional settings; the formation of collaboratives among community primary care providers and local health departments, with the aim of strengthening primary care; community health promotion activities involving diet, exercise, and injury risk reduction; and other population-level interventions.
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From page 113... ...
The guidance also might describe best practices in making preventive services more accessible to Medicaid beneficiaries through the use of expanded managed care provider networks; out-of-network coverage13 in nontraditional locations such as schools, public housing, workplace sites, and other places; qualification criteria for participating providers; recruitment of providers; measurement of quality performance; and assessment of impact on population health. The ACA establishes a grant program under which the secretary of HHS will award grants to states that seek to incentivize the use of preven 11 42 U.S.C.
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From page 114... ...
Because of the serious shortage of Medicaid providers in many communities, HRSA and CDC have a crucial role to play in the implementation of state demonstrations, particularly in outreach to community providers, training and technical support to state Medicaid agencies, active outreach to public health departments and health centers in demonstration states, and collaboration with CMS in the development of outcome standards and scalability criteria. Community Health Centers One major challenge to the rapid expansion of health insurance coverage is the need for expanded capacity for primary care delivery (Adashi et al., 2010)
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From page 115... ...
Of necessity, outreach campaigns to promote clinical preventive services in underserved communities, as well as initiatives aimed at improving the quality of primary care for populations with serious and chronic health conditions, must focus on how to improve the performance of health centers. Most important perhaps, every effort should be made to forge what often has been an uneasy relationship between health centers and public health departments.
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From page 116... ...
The failure of health centers and public health departments to act collaboratively would cost HRSA and CDC one of the greatest local levers for community change because their interests in population health are so aligned. Health Care Transformation The ACA contains provisions whose aim is to stimulate new approaches to the organization and operation of health systems in order to improve effectiveness, efficiency, and quality.
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From page 117... ...
As stated in the National Prevention Strategy, "the Council helps each agency incorporate health considerations into decision making, enhances collaboration on implementing prevention and health promotion initiatives, facilitates sharing of best practices, and, as appropriate, coordinates guidance and funding streams" (National Prevention, Health Promotion and Public Health Council, 2011, p.
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From page 118... ...
In HRSA's case, health centers represent one of the most important sources of care for these populations, while CDC's expertise in chronic disease measurement is important as well. Local health departments may have a central role to play in creating the types of practice support environments and tools that are essential to transforming the quality of care available to dual enrollees.
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From page 119... ...
Such collaboration models might emphasize the role of public health in needs assessment, performance measurement and improvement, health promotion, and patient engagement, all of which are central elements of ACOs. Patient-Centered Medical Homes and the Community Health Team Patient-centered medical homes are defined in Section 3502 of the ACA as a mode of care that includes "(a)
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From page 120... ...
PCEP agents will establish relationships with practices, much as pharmaceutical representatives did during the last 50 years, but with a detailing function geared to incorporating evidence-based techniques, preventive medicine, health promotion, chronic disease management, and mental and behavioral health services into primary care practices. The goal is to facilitate adoption of the principles of the patient-centered medical home and population health management.
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From page 121... ...
The State Hubs could include state health departments, state Medicaid and Medicare program administrators, and the departments of academic institutions that train providers in primary care. In addition to these entities, State Hubs might include such entities as hospital associations, primary care practice-based research networks, and state primary care associations.
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From page 122... ...
For example, all teaching health centers might be linked to community transformation activities in communities that receive Community Transformation Grants, discussed earlier. Centers also could benefit from the national educational component of the Community Transformation Grants program in order to learn about models of integration that are working and could be replicated in other communities.
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From page 123... ...
transformation grants to • s community resources for wellness improve through A improve community health the Transformation Grant system, it may be possible to activities and outcomes. encourage state and local health department recipients to develop linkages with primary care providers as a central focus of their program planning.
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From page 124... ...
, identified problems -- for example, the extension of "additional requirements primary care services into nontraditional settings; the for certain hospitals." The formation of collaboratives among community primary new requirements apply care providers and local public health and other agencies; to all facilities licensed as and community health promotion activities involving hospitals and organizations diet, exercise, and injury risk reduction, as well as other recognized by the Treasury population-level interventions. secretary as hospitals and spell out new obligations for all hospitals seeking federal tax exempt status.
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From page 125... ...
The provision expands Incentives could be built into funding for these centers to funding for health centers. promote activities and linkages with local public health departments and encourage community engagement and partnerships for community-based prevention.
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From page 126... ...
to award collaboration with CMMI to fund Primary Care Extension competitive grants to states Program models for which there is evidence for improving for the establishment of personal and population health. Primary Care Extension Programs to improve the delivery of primary care and community health.
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From page 127... ...
officers placed in state funding for the National and local health departments. Health Service Corps.
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From page 128... ...
Preventive Services Task Force. Through the National Center for Health Statistics and its ties to public health departments, CDC has an important role in presenting health outcomes and disparities by community.
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From page 129... ...
Workforce training initiatives have the potential to teach health professionals about the valuable interactions between personal and population-based health services and encourage relationships across disciplines. Specific training initiatives could include emphasizing team-based training, population health management competencies, epidemiology, and community-based health policy training within professionspecific training; training professionals in the community in practices that model integration and team-based care; training health care specialists to collaborate more closely with patients' primary care and community care teams; and expanding specialization in community-based epidemiology, geospatial health care analysis, population health management, practice transformation and improvement, and community care integration.
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From page 130... ...
This assistance would include demonstrating how the new population health data streams can support clinical decisions at the point of care, as well as teaching health coaches or other practice health care workers how to use the new data streams to better manage and monitor chronically ill patients and coordinate preventive care services. Creating new population health information technology systems will not prepare clinics for using them effectively.
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From page 131... ...
Many of the needed new or expanded functions in public and community health may best fall within the purview of CDC, especially those focused on turning personal and public health data into information that can drive interventions and practice improvement. HRSA and CDC should collaborate in reviewing their workforce programs to determine how they could be deployed to promote the production of health care workers who are able to integrate primary care and public health for the betterment of population health.
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From page 132... ...
As states seek to reduce health care spending, public health funding is an easy target for program cuts. One way to combat these cuts is to physically unite or collocate public health departments with local health centers.
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From page 133... ...
For instance, HRSA could recommend the use of public health workers in health centers as community agents responsible for patient education, behavioral and lifestyle modification, and assistance to patient communities in overcoming social determinants that adversely affect community health. These workers could utilize training and tools developed by CDC to achieve these goals, and would be responsible for relaying community health metrics to CDC and state and local health departments for inclusion in local, state, and national data reports.
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From page 134... ...
To better understand this lever, it is helpful to understand the role of HRSA and CDC (as well as CMS) in funding health centers and health departments.
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From page 135... ...
While the data do not reveal whether federal funding was primarily from HRSA or CDC, the nature of the two agencies' activities suggests the likely source: federal direct and pass-through funding for health centers would be supplied primarily by HRSA, while federal funding received by state and local health departments could be assumed to be received primarily from CDC. Figure 4-1 shows that federal direct and pass-through funding accounted for only 23.2 percent of health center revenues in 201025 (Kaiser Family Foundation, 2010)
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From page 136... ...
16% 23% State General Funds 5% Federal Funds 7% Medicare and Medicaid 4% Fees and Fines Other Sources 45% Other State/Territorial Funds FIGURE 4-2 Percentage of total annual funding for state health departments by revenue source. Figure 4-2.eps SOURCE: ASTHO, 2011.
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From page 137... ...
These awards promote collaboration among diverse sets of stakeholders to identify local health challenges and design practical solutions, and could serve as a mechanism for encouraging integration. The Social Services Block Grant (SSBG)
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From page 138... ...
As mentioned above, CMS also administers the Medicaid Incentives for Prevention of Chronic Disease Program, which provides incentives to Medicaid beneficiaries who participate in prevention programs and demonstrate changes in health risks and outcomes, and the newly created CMMI, which is working on primary care and public health issues. Finally, the Substance Abuse and Mental Health Services Administration promotes public health for mothers and children through a variety of programs, such as the Substance Abuse Prevention and Treatment Block Grant, the Mental Health Services Block Grant, and the Children's Mental Health Services Program.
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From page 139... ...
2011. Vermont's blueprint for medical homes, community health teams, and better health at lower cost.
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From page 140... ...
2011. 2010 national profile of local health departments.
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From page 141... ...
Title XX Social Services Block Grant program. In 2000 green book background material and data on programs within the jurisdiction of the Committee on Ways and Means.
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