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Advisory Group on Prevention, Health Promotion, and Integrative and Public Health Conference Call

December 11, 2013

Attendees

Advisory Group Members:
Jeffrey Levi (Chair), JudyAnn Bigby, Richard Binder, Valerie Brown, Jonathan Fielding, Ned
Helms, Patrik Johansson, Janet Kahn, Charlotte Kerr, Jacob Lozada, Elizabeth Mayer-Davis,
Dean Ornish, Barbara Otto, Herminia Palacio, John Seffrin, Ellen Semonoff, Sue Swider, Sharon
Van Horn, Kimberlydawn Wisdom

Regrets:
Jerry Johnson, Vivek Murthy, Linda Rosenstock

HHS Staff:

Brian Bowden, Corinne Graffunder, Boris Lushniak, Brigette Ulin
Dr. Jeffrey Levi, chair of the Advisory Group on Prevention, Health Promotion, and Integrative
and Public Health (hereinafter called the Advisory Group) welcomed participants and introduced
Dr. Corinne Graffunder, Designated Federal Official, to conduct the roll call. Dr. Levi stated that
the primary goal for the call was to discuss the draft report to the incoming Surgeon General.
Materials from the call will be posted online.

Update from the National Prevention Council

Dr. Levi turned the call over to Dr. Boris Lushniak, Acting Surgeon General, for an update from
the National Prevention Council. Dr. Lushniak thanked the Advisory Group members for
attending the call and added that now is a good time to look back at achievements. He noted the
following during his update:

  • The President has nominated Dr. Vivek Murthy for the position of Surgeon General. Dr.
    Murthy is also a member of the Advisory Group. The nomination is in the early stages
    and the timeline for confirmation is uncertain.
  • Some highlights of work by the National Prevention Council member agencies include
    the U.S. Department of Agriculture (USDA) making strides to expand farmers’ markets,
    the Department of Defense’s work around tobacco cessation, and the Departments of
    Justice and Education’s efforts around youth violence prevention.
  • January 2013 is the 50th anniversary of the Surgeon General’s Report on Smoking and
    Health, and commemoration of the anniversary will be an important focus throughout
    2014.
  • Plans are underway to highlight the work and activities of the National Prevention
    Strategy in new ways, including a quarterly update that will showcase activities
    happening across government and will be shared with various stakeholders; this is a great
    way to get prevention message out.
  • There are ongoing efforts to work with partners to implement the National Prevention
    Strategy across the country. This includes work with the Association of State and
    Territorial Health Officials and the release of a toolkit to support state-level
    implementation. Another example is work with America Public Transportation Agency
    — linking public transportation with healthcare as a major theme for 2014.
  • The next National Prevention Council meeting will be held on December 12, 2013, and
    more updates will be forthcoming.

Dr. Lushniak thanked all of the members for their service and turned the call back over to Dr.
Levi.

Review of Draft Recommendations to the Next Surgeon General

Dr. Levi began the review of the draft report to the next Surgeon General that the group wanted
to frame items as advice to the next Surgeon General. A drafting committee within the Advisory
Group developed a draft outline of the recommendations and shared it with the full group for
feedback. Members of the drafting committee included Dr. Dean Ornish, Dr. Elizabeth Mayer-
Davis, Mr. Ned Helms, Ms. Barbara Otto, Dr. Kimberlydawn Wisdom, and Dr. Levi.
The drafting committee received an initial list of priorities from Advisory Group members and
organized and synthesized them into actionable items. Dr. Levi asked if members of the drafting
committee had anything else to add and noted that the timeline for completion of the
recommendations can likely slip to beyond the end of the year. The group began to review each
section of the draft outline.

Background/Introduction

  • Summarize the Advisory Group’s role — requirement to provide recommendations, etc.
  • Frame the background section in context of IOM report U.S. Health in International Perspectives: Shorter Lives, Poorer Health.
    • The U.S. one the wealthiest nations in the world but far from the healthiest.
  • Full implementation of the NPS would address many deficiencies — i.e., improve clinical and community interventions, encourage and facilitate better lifestyle choices, and
    address structural and social determinants issues.
  • A primary determinant of health and well-being for individuals is lifestyle choice, with a
    need to make healthy choices the easy choices each day.
  • Meaningful progress has been made by the National Prevention Council. While progress
    is significant, the Advisory Group offers recommendations in a number of areas for
    Surgeon General’s consideration.

Dr. Levi asked for comments on the background section.

Dr. Jonathan Fielding stated that the background looks good and mentioned as a reminder that
when talking about root causes of illness, there is a behavioral connection, but there are other
issues that impact health including poverty, education, health literacy, etc.

Dr. Levi noted that this was written before the President’s speech on economic equality and
mentioned that some themes from the speech can be incorporated into this section of the report.

Dr. Fielding also noted the need to talk about policies and systems changes and the importance
of economics and decisions that are made in terms of resource allocation. It is also important to
indicate that the root causes are because of the policies that are adopted at the national, state, and
local level. Mr. Helms noted that the intersection of school and wellness that the Advisory Group
focused on at the last meeting is an example of the many social determinants.

Policy Recommendation #1

  • The SG should develop one or more focused initiatives to facilitate and enhance
    interagency collaboration to improve community health that would engage a cross-section
    of NPC agencies and demonstrate the co-benefits of collaboration.
    • Examples of approaches will be offered for consideration by the SG– e.g.,
      braiding of existing funding streams or joint FOA; changes in CTG that allow
      broader collaboration
    • Examples of intervention areas could include– e.g., behavioral health, lifestyle
      change

Dr. Levi noted that this recommendation comes out of several discussions around a de-siloing of
the National Prevention Strategy. Individual agencies are implementing different aspects of the
National Prevention Strategy, and this recommendation asks for a collaborative effort similar to
initiatives like Sustainable Communities, where agencies have come together to braid funds. Dr.
Levi asked for comments on this recommendation.

Dr. Fielding suggested starting with an example that has a clear opportunity for cross-cutting
work or something that has been started that is embryonic and could be catalyzed by the Surgeon
General’s involvement. Dr. Binder asked if the report should focus on something achievable and
noted that breaking down silos is very difficult given all of the players involved.

Ms. Valerie Brown likes the attempt to address the need to break down silos. She added that with
a reduction in government dollars, there is an important focus on implementing programs that are
evidence-based. She would recommend including wording to that effect.

Dr. Levi summed up the comments and stated that of all the recommendations this one is the
stretch goal that may be difficult to pull off, but it is the Advisory Group’s job to push. Promise
Zones is an example of an existing program that is breaking silos and braiding funding. Another
approach would be using examples from the behavioral health presentations at the last Advisory
Group meeting.

Dr. Fielding mentioned that he likes the idea of targeting sub-populations, with the early
childhood period being the most critical and then the other vulnerable population is also the
fastest growing, the elderly population. Dr. Mayer-Davis stated that it would be good to have
more emphasis on health equity built in, especially related to the background section and also
could be emphasized here because there are substantial problems in the area of health equity.

Policy Recommendation #2

  • The SG should ensure that the implementation of the Affordable Care Act (ACA)
    promotes a prevention-driven agenda.
    • Several ACA provisions will be offered as examples and used as discussion
      points. These include:
      • Monitoring uptake of insurance and access to preventive services by highrisk
        populations
      • Implementation of Section 2706 (provider non- discrimination)
      • Monitoring CMMI projects related to population health
      • Sharing best practices in CTGs that are consistent with the NPS
      • Assess opportunities in new insurance marketplaces to encourage
        evidence-based clinical and community prevention practices - MA got its
        marketplaces up and running and thinking about these issues

Dr. Levi stated that this recommendation provides examples of issues the Surgeon General might
address around the ACA implementation and ensuring that it promotes a prevention-driven
agenda. The examples are issues that have been discussed before by the Advisory Group. This
recommendation encourages the Surgeon General that the rest of the department is thinking
about the ACA and is reminded about the prevention part of the policy.

Dr. Levi asked for comments on this recommendation.

Dr. Fielding stated that one critical issue is the integration of public health with the healthcare
delivery system. The other is sharing best practices with the CTGs that exemplify the tenets of
the National Prevention Strategy.

Policy Recommendation #3

  • The Surgeon General should encourage, coordinate, or conduct health impact assessments
    of key federal policies as a way of promoting the National Prevention Council’s
    commitment to “identify opportunities to consider prevention and health” within their
    departments.
    • Health impact assessments of federal policies and programs would enable and
      inform policymaking and implementation, with the aim of improving population
      health, equity, and sustainability. (Reference value of the farm bill HIA.)

Dr. Levi stated that the goal here is to encourage greater use of health impact assessments. With
this recommendation, the health impact assessments should be done systematically within the
deliberations of the federal government as it is making cross-cutting policy decisions.

Ms. Brown stated that health impact assessments are very important when looking at land use
issues and schools, and they are essential if you want walkability and access to services, etc.

Policy Recommendation #4

  • The Surgeon General and National Prevention Council should identify ways to link
    opportunities related to hospital community benefit requirements, bank community
    reinvestment requirements, and social impact investing that can promote the goals of the
    National Prevention Strategy. These efforts should be a catalyst for new nongovernmental
    stakeholders to work together with government and other partners to
    influence health and create healthier communities.
    • Public health should adapt a “culture of community development finance” as an
      essential component of scaling successful models of community, school, and
      workplace health promotion.

Dr. Levi stated that this recommendation is focused on community benefit and how the Surgeon
General and National Prevention Council can catalyze collaboration around activities outside of
government. There are requirements incentivized by the government, but implemented by the
private sector, and there are new ways to think about investing using a health lens. This reflects a
convening role for the Surgeon General and the National Prevention Council.

Mr. Helms mentioned that the burgeoning area of Accountable Care Communities and work in
Toledo, OH, could be an example to support this recommendation as the kinds of collaboration
we mean.

Dr. Sue Swider asked if, in addition to community finance, the Advisory Group wants to include
the development of metrics that cross silos and also highlight best practices in this area. Dr.
Fielding added that so many efforts do not get evaluated, and the Surgeon General can push that
these cross-sector cross agency initiatives need to be evaluated in terms of impact.

Dr. Levi stated that language can be incorporated to mention that initiatives should be evidencebased
and also need to be systematically evaluated.

Dr. Swider asked if, as a next step, the Advisory Group would reconvene to decide how these
recommendations would guide our work. Dr. Levi answered that there should be a conversation
with the new Surgeon General about how the Advisory Group can be most helpful in achieving
these recommendations.

Process Recommendation #1

  • The Surgeon General should take steps to strengthen the relationship between Advisory
    Group members, the Surgeon General, and the members of the National Prevention
    Council.
    • To maximize impact, a greater level of engagement is needed between Advisory
      Group members, the Surgeon General, and the National Prevention Council.

Dr. Levi stated that this reflects what the group has discussed before and asked if there were
comments about this recommendation.

Ms. Brown agreed that this recommendation is imperative, but she asked how much of an
emissary Advisory Group members can be in their communities to spread the word and be an
adjunct to the council and National Prevention Strategy.

Dr. Levi stated that this was discussed at the last in-person meeting. There is now more staffing
at the National Prevention Strategy office and Surgeon General’s office to support more of those
activities. Ms. Otto agreed and mentioned that there has been no staffing for external
communication and no liaison through which to build a relationship with council members. Now
that there is staffing, this can help channel our activity more appropriately and advance the work
of the National Prevention Council through our networks.

In the past, discussion has focused on holding regional meetings in major cities that brought in
people from communities having success with practices that should be shared across the country.
That has not been possible on a broad basis.

Dr. Levi stated that one alternative is to remind the Surgeon General of the willingness of the
Advisory Group to be helpful in communities; that may actually fit with the conclusion section
of the report. As the Surgeon General travels to Advisory Group members’ communities, there
are opportunities to have ongoing discussions about the National Prevention Strategy.

Process Recommendation #2

  • The Surgeon General should refine and enhance the National Prevention Council’s report
    or develop an alternative publication that better describes the efforts and results in detail.
    • Additional information about the changes in the agencies that are the result of the
      National Prevention Strategy should be reported and shared widely.

Dr. Levi stated that this recommendation highlights two concerns: 1) how can we learn more
about what is happening to showcase efforts; and 2) how can the report become an easier tool to
disseminate?

Dr. Mayer-Davis commented that the report should have more challenging language and not only
provide a report of actions taken and progress made, but also highlight opportunities for future
work to address deficiencies. Dr. Fielding stated that it is the stories that are remembered and
have the most impact and traction. Telling a few stories well can get people excited.

Process Recommendation #3

  • Resources provided to the Surgeon General’s office to coordinate the National Prevention
    Council’s work should be reviewed in light of new and emerging priorities.

Dr. Levi stated that this recommendation highlights the need for more resources within the
Surgeon General’s office to support the National Prevention Council’s work.

Dr. Fielding stated that this recommendation is true in light of new and emerging priorities, but
asked if resources are adequate to meet the charge in terms of what works. Sister Charlotte Kerr
made a comment about the new FDA regulation to take antibiotics out of animal food. She
mentioned that this is an example of where the Council, the Advisory Group, and the USDA
could have been making recommendations around this issue and asked if this was a role for the
Advisory Group.

Dr. Levi stated he was unsure where this would fit with the report recommendations and this
may be more of an internal issue for the Advisory Group. This is one example of the regulatory
change that has taken a long time to achieve. There are also some tobacco-related and
environmental rules that are pending. If the group wanted to weigh in on those types of issues,
the Advisory Group would need a process for commenting on them as they go through the
review process.

Dr. Ornish stated it is worth considering both from the standpoint of encouraging the Surgeon
General to do it and as an ad hoc activity for issues the Advisory Group feels strongly about. Dr.
Levi stated that we might include as a commentary that in addition to the health impact
assessments, we will want to weigh in on rules that have a health impact as they come forward.

The group concluded the review of the recommendations.

Dr. Levi noted that the drafting committee will reconvene; they will turn the outline into a
narrative and circulate the next version to the Advisory Group for electronic comment. Dr.
Graffunder stated that she will check to determine the best way for the group to give final
approval for the recommendations.

Review of Draft Recommendations from the Health and Education Working Group

Dr. Levi asked if the Advisory Group wanted to revisit the recommendations from the Education
and Health Working Group or defer for discussion at the next face-to-face meeting. He noted that
the next step discussed was determining whether and how this work group could evolve into an
independent group; those discussions are continuing.

The group decided to defer this discussion until the next meeting.

Public Comment

Elaine Auld, CEO, Society for Public Health Education (SOPHE)
SOPHE is a professional society of researchers, practitioners, teachers, and students at the
national and chapter level, dedicated to providing leadership around health education and health
promotion. Ms. Auld summarized topics and recommendations made by the SOPHE-ASCD
Expert Panel on Youth Health Disparities
. The panel made recommendations in five overarching
areas: fostering cross-agency collaboration, using data for continuous improvement, increasing
health care access; supporting healthy learning environments, and promoting health-enhancing
behaviors through K–12 education and physical education classes. Ms. Auld urged the Advisory
Group to integrate these recommendations into their work and consider partnering with the
National Coordinating Committee on School Health and Safety.