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Advisory Group on Prevention, Health Promotion, and Integrative and Public Health - Meeting Summary March 9-10, 2015

Day 1 - March 9, 2015

Attendees

Advisory Group Members: JudyAnn Bigby, Valerie Brown, Patrik Johansson, Jerry Johnson, Janet Kahn

Charlotte Kerr, Jeff Levi (Chair), Jacob Lozada, Elizabeth Mayer-Davis, Dean Ornish, Barbara Otto, John Seffrin, Susan Swider, Sharon Van Horn, and Kimberlydawn Wisdom

On phone: Jonathan Fielding, Herminia Palacio, and Linda Rosenstock

Regrets: Richard Binder, Ned Helms, and Ellen Semonoff

HHS: Surgeon General VAMD Vivek Murthy, Corinne Graffunder (DFO), Melissa Brodowski, Ayanna Johnson, Sudeshna Mukherjee, Karen Silver, Rick Troiano, Brigette Ulin, and Elizabeth Walker

9:30 a.m. – Administrative Session (closed to public)

 

12:30 p.m. Roll Call and Introductions

Dr. Corinne Graffunder called the roll and confirmed a quorum was present.

Dr. Jeff Levi reviewed the agenda and invited Dr. Kimberlydawn Wisdom to provide an update.

Dr. Kimberlydawn Wisdom shared with the Advisory Group progress on a study regarding establishing State Surgeons General. In 2014, fourteen key informant interviews were conducted in order to inform the development of a white paper on advancing health care reform through establishing State Surgeons General. The white paper discussed advantages and challenges of creating Surgeons General positions for the states and territories. Florida, Michigan, and Alaska are the only states that currently have Surgeons General. Plans are underway to pilot this initiative in other states.

12:45 p.m. Presentation of the Surgeon General’s Priorities

Surgeon General VADM Vivek Murthy described his priorities for the upcoming year, which included learning from and engaging with local communities at the grassroots level. The Surgeon General recounted his 23+ city tour across the U.S. and noted that the following health concerns were consistently identified: obesity, chronic disease, mental health, substance abuse, and declining rates of immunizations among children. The Surgeon General laid out a set of themes and approaches that will guide his work, and should guide the work of the Advisory Group and the National Prevention Council (Council). Overarching themes included: accountability (all sectors have a stake in health); make health positive and engaging; and prevention and equity. Approaches include: changing structure so the healthy choice is the easy choice; shifting culture so the healthy choice is the desirable choice; cross-sector collaboration; and modernizing communication by using effective messaging through multiple channels. He also stated that the National Prevention Strategy should continue to be used. Moving forward, the Surgeon General plans to focus on reducing obesity and tobacco use. However, he noted that these themes and approaches can be applied to addressing other health concerns mentioned on his U.S. city tour.

1:10 p.m. National Prevention Council Update

Brigette Ulin, Office of the National Prevention Strategy

The Council is comprised of representatives from 20 federal departments and agencies that are working to advance the National Prevention Strategy through the following commitments: increase access to healthy and affordable foods, expand tobacco-free environments, and identify new opportunities to consider prevention and health. Ms. Ulin provided an update on the Council’s progress on (1) integrating healthy food service guidelines into federal food service operations, and (2) implementing tobacco-free campus policies within federal workplaces. Ms. Ulin also highlighted stories from the 2014 Annual Status Report which showcased efforts by Advisory Group members.

Question and Answer Session Highlights

Advisory Group members raised the following questions and comments:

  • The Advisory Group should convene stakeholders in their communities and nationally to discuss ways to help make living healthy easier for the nation.
  • The role of culture in promoting or discouraging healthy behaviors should be furthered addressed in interventions supported by the Advisory Group.
  • Members noted that incentivizing vendors to provide healthier options could be an effective way to increase access to healthy, affordable foods.
  • Members would like to see healthy food service guidelines and tobacco-free policies being adopted by entities that receive federal dollars such as hospitals and contractors.
  • The Advisory Group would like to see additional focus on external opportunities to promote prevention, particularly in breaking down silos to increase collaboration.

3:00 p.m. Afternoon Session – Reflection and Comments

Dr. Jeff Levi opened discussion to hear comments on the earlier presentations.

Question and Answer Session Highlights

Advisory Group members raised the following questions and comments:

  • Question was posed to the Advisory Group about how to leverage their expertise and connections to support the Council’s priorities of tobacco use and obesity reduction.
  • Discussion was held on defining the Advisory Group’s role in drawing on respective arenas, expertise, and experiences to advance cross-sector collaboration and engagement at the community level.
  • Advisory Group members express the need to develop interventions and activities that go beyond the “one size fits all” mentality. Intervention should be broad, but accomplishable.
  • The Advisory Group was encouraged to define concrete, measurable goals that can be achieved and celebrated within the next two years.

3:25 p.m. Report from Council, AG Working Groups, and Discussion of Future Directions

Jonathan Fielding, Prioritization Working Group Chair

Dr. Fielding presented on the activities of the Prioritization Work Group. The Prioritization Working Group examined the role of the social determinants of health, the life cycle approach, and how metrics can be used to document and leverage successes in public health. This group started by exploring what the priorities should be for cross-sector interventions address the social determinants of health. Mr. Fielding also described recommendations for and characteristics of agencies who might adopt cross-sector interventions.

Judy Ann Bigby, Collective Impact Working Group Chair

Dr. Bigby outlined the activities of the Collective Impact Working Group, which discussed how the Surgeon General could use the collective impact approach as a framework to ultimately move across silos, agendas, and agencies. The working group identified five key elements needed for a collective impact framework, including identifying what works across sectors and how various initiatives and projects can collectively combine to achieve one unified goal. The working group also identified potential barriers to the sustainability and achievability of collective impact goals. Dr. Bigby presented on the models for success that can leverage collective impact approaches, emphasizing the funding and related preparatory work needed to build a community of collaboration.

Discussion Highlights

Advisory Group members raised the following questions and comments:

  • The National Prevention Strategy is a collective impact framework with a common agenda from which the Advisory Group and others can work.
  • Members are willing to provide federal agencies with suggestions on how to work with external partners to promote the National Prevention Strategy.
  • The Advisory Group can use the collective impact framework to facilitate opportunities to leverage multiple funding streams.
  • The Advisory Group noted the potential to influence collective impact work through educational organizations and how the growing interest in inter-professional education also models the collective impact framework.
  • The success of a hospital collaborative using the National Prevention Strategy as a framework to map collective health impact for mental health interventions was noted.

3:00 p.m. Presentation on and Discussion of Chronic Absence and My Brother’s Keeper

Rochelle Davis, Healthy Schools Campaign

Ms. Davis presented on the progress of the National Collaborative on Education and Health (Collaborative), which convened at the Advisory Group’s recommendation. In 2014, the Collaborative identified the following areas of focus: (1) developing health and wellness metrics related to student success, e.g. grade reports, and (2) identifying new models for wellness and health care delivery. The Collaborative identified chronic absenteeism as the foremost issue to address. Chronic absenteeism is often seen as the responsibility of the educator, but chronic absenteeism requires a broader, multi-faceted solution. Tackling this issue would present an opportunity for early intervention strategies and bring health and public health sectors into education.

Hedy Chang, Attendance Works

Ms. Chang presented on Attendance Works’ multi-level approach (national, state, and local) to addressing chronic absenteeism through raising awareness and providing resources to communities. Chronic absenteeism is defined as missing 10% or more of school. This metric includes both excused and unexcused absences (truancy) as well as suspensions. Defining 10% as the threshold allows for early identification and better comparisons. Among the leading causes of chronic absenteeism are: chronic disease, lack of access to health or dental care, poor transportation, trauma, and no safe path to school. Students who are chronically absent from school are academically at-risk as they miss exposure to language, in-classroom instruction, are not on track for success, and create attendance patterns that reflect later in college enrollment and attendance. Attendance Works is trying to promote the use of the chronic absenteeism measure in school reporting mechanisms in order to identify students, schools, and communities at greater risk.

My Brother’s Keeper, Joaquin Tamayo, Department of Education

Mr. Tamayo briefed the Advisory Group on the Presidential Initiative called My Brother’s Keeper. My Brother’s Keeper was launched in February 2014 to improve outcomes for boys and men of color by focusing on specific milestones across the education continuum from Pre-K to higher education. My Brother’s Keeper is built on the theory of collective action. The initiative leverages unique strengths in order to improve education for this vulnerable population. The Department of Education, the Department of Justice, the Department of Housing and Urban Development, and the Department of Health and Human Services have been instructed to develop an approach to chronic absenteeism as part of the My Brother’s Keeper initiative.

Discussion Highlights

Advisory Group members posed the following questions and comments:

  • The Advisory Group desired to know the current rate of chronic absenteeism in the U.S. Unfortunately, there are no national data to show the current rate and causes of chronic absenteeism.
    • In Maryland, data showed that kids in schools that experienced higher levels of violence were more likely to miss school.
    • In Oakland, California, violence, food desserts, asthma, and environmental issues were linked to communities with chronic absenteeism close to 20-30%.
    • New York City has identified 18 risk factors for chronic absenteeism in their communities.
    • The first national snapshot related to chronic absenteeism will be available in Spring 2016.
  • My Brother’s Keeper encourages discussion and implementation of policies that help create a systematic method of reaching at-risk children.
  • Healthy school environments are key to supporting attendance. Students can still be “present” at school, but not engaged in the classroom or in the nurse’s office. Dr. Wisdom called this “presenteeism.”
  • Concerns over funding and tracking progress were expressed.
  • My Brother’s Keeper is an opportunity to address many external barriers outside of the school that impact students and the school system.
  • My Brother’s Keeper hopes to influence policies and grants for all at-risk students, meaning there is no attempt to exclude girls from the discussion.

5:30 p.m. Public Comment

No public comment at this meeting.

5:45 p.m. Adjourn

 

Day 2 - March 10, 2015

Attendees for Day 2

Advisory Group Members: JudyAnn Bigby, Valerie Brown, Patrik Johansson, Janet Kahn, Jeff Levi (Chair), Jacob Lozada, Elizabeth Mayer-Davis, Dean Ornish, Barbara Otto, John Seffrin, Ellen Semonoff, Susan Swider, Sharon Van Horn, and Kimberlydawn Wisdom

On phone: Jerry Johnson and Herminia Palacio

Regrets: Richard Binder, Jonathan Fielding, Ned Helms, Charlotte Kerr, Linda Rosenstock, and Ellen Semonoff

HHS: Surgeon General VAMD Vivek Murthy, Corinne Graffunder (DFO), John Auerbach, Melissa Brodowski, Ayanna Johnson, Sudeshna Mukherjee, Rick Troiano, Brigette Ulin, and Elizabeth Walker

9:00 a.m. Update on Population Health Initiatives

Dawn Alley, Center for Medicare & Medicaid Innovation (CMMI)

Dr. Alley presented on the Center for Medicare and Medicaid Innovation’s (CMMI) new Accountable Health Communities concept. CMMI tests innovative models of payment delivery systems within Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) programs. Models are tested for 5 years. If successful, these models are scaled up. This concept in development would look at how health-related social needs, such as housing, food security, education, and employment can impact health outcomes and save on health costs. The Accountable Health Communities project will use a community-driven approach and sustainable payment model to evaluate the effectiveness of these three mutually exclusive intervention models:

  • Low touch referral system: In this model, all beneficiaries are screened for a specific set of social and welfare needs upon entry to a clinic. This intervention will test the effectiveness of a systematic referral system vs. usual care.
  • Social service navigation: In this model, a beneficiary will receive a package of services that help resolve all types of social and welfare needs. These services are typically provided by a community health worker.
  • Social service navigation + community intervention: Using a collective impact framework, CMMI would support a primary organization that would bring together health and social service providers to assure access to needed social services. This project will support realignment of community services at the community level.

Discussion Highlights

Advisory Group members posed the following questions and comments:

  • Dawn Alley noted that provider and patient experiences will be incorporated into the evaluation. The CMMI intervention will incorporate tools and resources that add value and improve service delivery.
  • Models will be flexible and diverse in geography. CMMI is looking for state Medicaid agencies to be strong partners in the intervention and application.
  • The proposed intervention aims to identify populations early in the life cycle and employ low-cost methods.
  • How are resources to support social needs funded?
  • CMMI’s work is focused on researching and evaluating service delivery.
  • CMMI has identified a number of ways to incorporate sustainability into existing programs.
  • CMMI is charged with looking for innovations that are low-cost and allow for better service delivery (i.e., increasing quality cost neutral, and simplified payment model).
  • Dr. Wisdom wondered how programs like Health Leads (Baltimore) and e-health records fit into this intervention model. CMMI did a site visit to the Health Leads, which informed the social service navigation track. CMMI is investigating the role of and determining the value of e-health records.
  • The Accountable Health Communities model will rely on a collective impact framework in order to be more effective and to ensure that social services agencies will provide coordination. The Advisory Group could help support coordination and collaboration at the local level.

10:00 a.m. Progress on Past Recommendations of Prevention Advisory Group

Dr. Jeff Levi presented on the progress made on Advisory Group recommendations:

  • The Prevention and Public Health Fund has been preserved for Fiscal Year 2015. Funds have been allocated for their original purpose.
  • Community Transformation Grants (CTGs) have been phased out. Congress created Partnerships in Community Health (PICH) to replace CTGs. Diabetes and cardiovascular disease prevention programs have been expanded through reallocation of funds to state and local health departments.
  • The Advisory Group recommended that non-profit hospitals undertaking Community Health Needs Assessments be required to consult with local public health agencies before distribution. This recommendation was incorporated into IRS final guidance.
    • Community resiliency counts towards community benefit dollars (preparedness and other).
    • The CDC provides tools and technical assistance around community benefit, and is developing a website with a searchable database to house these tools and resources.
    • Dr. Wisdom presented on the work of the Henry Ford Health System to promote the use of community benefit dollars. The YWCA (Your Work Counts Again) campaign was showcased at the Association of Community Health Improvement meeting to raise awareness around community benefit.
    • Robert Wood Johnson Foundation is supporting a project at GWU that is monitoring how community benefit dollars are being spent.
  • The CMS preventive services rule allowing use of non-traditional providers in non-traditional health settings has not resulted in any states submitting state plan amendments.
  • Most discretionary programs have not seen cuts in funding due to implementation of the ACA. Cuts have been made to breast and cervical cancer programs; prostate cancer programs; and immunization programs. These cuts only affect direct payments, not the infrastructure of existing programs.
  • Progress has been made on CMMI engaging communities and using community providers in interventions.

11:00 a.m. Discussion of Surgeon General’s Priorities & Next Steps for the Advisory Group

The Advisory Group would like to focus on the following efforts:

  • Increase involvement of the Surgeon General in public meetings and local events held by Advisory Group members. This involvement will help increase knowledge and adoption of the National Prevention Strategy at various levels.
  • Help to drive the Surgeon General’s vision for obesity and tobacco use prevention and reduction.
  • Develop and integrate efforts to shape the public health workforce. Schools of public health should be a primary target audience.
  • Serve as a resource for the Surgeon General in reaching communities.

New Recommendations/Communications

  • Advisory Group would like to focus on three areas:
    • Use the National Prevention Strategy as a framework for continuing work at the local level
    • Promote chronic absenteeism as a common metric for programs such as My Brother’s Keeper
    • Coordinate with CMMI to support innovation grants
  • In response to the discussion on the Surgeon General’s priorities, health equity and prevention will be the bedrocks of the Advisory Group’s work. Focus will also be on making health positive and engaging.
  • Members note the overlap of the Advisory Group and the Council. Members would like to foster more interaction between the two groups. The Advisory Group will report to the Council on a regular basis and/or develop a subcommittee that may interface with Council members. The Advisory Group would also suggest that the Council submit recommendations on ways that the Advisory Group can be of most value to them.

Clarification of Charges and Work Plans

Dr. Jeff Levi will lead a subcommittee tasked with drafting recommendations for this year. The full Advisory Group will meet to approve the recommendations.

11:30 a.m. Meeting Adjourned