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

September 26–27, 2013

Attendees

Advisory Group Members:
Jeffrey Levi (Chair), JudyAnn Bigby, Jonathan Fielding (participated by phone on Day 1), Ned Helms, Patrik Johansson, Jerry Johnson (present Day 1), Janet Kahn, Charlotte Kerr, Jacob Lozada, Elizabeth Mayer-Davis, Vivek Murthy, Dean Ornish, Barbara Otto, Herminia Palacio, Linda Rosenstock, John Seffrin, Sue Swider, Sharon Van Horn, Kimberlydawn Wisdom

Regrets: Richard Binder, Valerie Brown, Ellen Semonoff

HHS Staff:
Boris Lushniak, Dawn Alley, Corinne Graffunder, Brigette Ulin

Panelists:
David Hawkins, Social Development Research Group

Tony Biglan, Oregon Research Institute

Richard Spoth, Partnerships in Prevention Science Institute

Bob Pynoos&John Fairbank, National Center for Child Traumatic Stress

Dawn Wilson, Society for Behavioral Medicine

Fran Harding, SAMHSA

James Scanlon, Office of Science and Data Policy, HHS

Rashida Dorsey, Office of the Assistant Secretary for Planning and Evaluation, HHS 

Cara James, Office of Minority Health, CMS 

David Mineta, ONDCP

Fran Harding, SAMHA

Harold Perl, NIDA

8:30–8:45 Welcome, Roll Call, and Introductions

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. He then reviewed the agenda and referred participants to the notebooks containing information and materials for the meeting. Dr. Graffunder notedthose materials would be posted online after the meeting.

8:45–9:30 Update from the Office of the Surgeon General

Dr. Levi introduced Dr. Boris Lushniak, Acting Surgeon General, and thanked him for his demonstrated commitment to Advisory Group.

Dr. Lushniak reiteratedthe important roleof the Advisory Group within the National Prevention Strategy and the fieldof prevention.He summarized recent activities of the Surgeon General’s office and National Prevention Council agencies. Highlights include:

  • The White House Champions of Change program, which in September honored eight public health professionals who have promoted prevention.
  • The addition of three new departments to the Council: Office of Personnel Management, General Services Administration, and the Department of the Interior (National Park Service).
  • Continued progress in the Department of Defense’s Healthy Base Initiative, which can have an effect not only on military personnel, but also on families and communities. Dr. Lushniak challenged participants to consider the possibility of a healthy office initiative.
  • Continuing efforts to achieve tobacco-free environments. HHS campuses are all tobacco- free, and Dr. Lushniak wants other departments to follow HHS. In January 2014, the USPHS Commissioned Corps will become the first uniformed service to prohibit smoking while in uniform.
  • Work on a Surgeon General’s report to commemorate the 50th anniversary of the first Surgeon General’s Report on Smoking. This is a joint effort with CDC, the Office on Smoking and Health, and almost every entity at HHS that plays a role in smoking.
  • Issuing of a Federal Register notice to inform a Surgeon General’s Call to Action on Walking, slated for May 2014.

Dr. Lushniak also shared that interviews with several Advisory Group members provided valuable input. Common themesthat emerged include: desire for broader dissemination of the Strategy, actionable strategies, and a focus on new and broader partnerships. The interviews also garnered information about some work that uses the National Prevention Strategy (e.g., Mass in Motion, Henry Ford Wellness Center’s Live Well program, the Healthy University of New Hampshire initiative) and ideas for next steps as the Strategy is disseminated and implemented.
Finally, Dr. Lushniak noted that his office continues to report quarterly to the Deputy Secretary for Health on the National Prevention Council, Advisory Group, and National Prevention Strategy. These reports discuss not only successes but also barriers.

Dr. Levi noted that the Champions of Change event was a high-profile public statement about the importance of the Prevention and Public Health Fund—as the work the champions were honored for was funded by the PPHF—as well as recognition that prevention is critical to achieving goals of the Affordable Care Act (ACA).

Dr. Dean Ornish asked if prevention has bipartisan support. Dr. Lushniak indicated that for those interested in prevention, it is bipartisan. The goal is to convince people on both sides of aisle of the importance of prevention; evidence is necessary to show that prevention works.

Dr. Kimberlydawn Wisdom asked about the population health category in CMS’ Innovation Awards and whether there might be opportunities to enhance support for the National Prevention Strategy. Dawn Alley noted that the Advisory Group received an invitation to be reviewers;population health was largest category of proposals received.

Dr. Lushniakreaffirmedthe importance of contact with agencies and organizations outside the National Prevention Council and encouraged Advisory Group members to initiate contact.
Sister Charlotte Kerr suggested it is important to show the connection between no smoking and better breathing and to address violence as part of an integrative health approach.She also asked if someone involved with the HealthyBase Initiative could be on the National Prevention Council. Dr. Lushniak indicated that they are represented and could be added to the agenda for a future Advisory Group meeting.

Dr. Levi provided an update on some previous Advisory Group recommendations:

  • Last spring, the group called on the Administration to undertake a national campaign to mobilize sectors to achieve better health status. A prospectus from the Institute of Medicine (IOM) and The Public Good Projectsaddresses this concern and how to better inform the American people about both the issues and possiblesolutions. Dr. Levi recommended Advisory Group members review the prospectus and determine how the group can interact with this public-private project.
  • The Center for Medicare and Medicaid Services (CMS)policy regarding reimbursement of evidence-based community prevention services by non-licensed providers takes effect January 1, 2014. Several Advisory Group members have been working with HHS, SAMHSA, and others to ensure that states will use this opportunity.

9:30–10:45 Health and Education Work Group Update

Dr. Levi described the Health and Education Work Group’s efforts—a public-private, multisector process that included 31 representatives from health and education sectors at the national, state, and local levels and Advisory Group members Richard Binder, Jonathan Fielding, Patrik Johannson, Janet Kahn, Herminia Palacio, and Ellen Semonoff. The work group engaged members of the National Prevention Council, including representatives from HHS, Department of Education, Office of National Drug Control Policy (ONDCP), U.S. Department of Agriculture (USDA), and the Environmental Protection Agency (EPA).

Rochelle Davis, President and CEO of the Healthy Schools Campaign, co-chaired the work group with Dr. Levi, and summarized the group’s recent activities and recommendations. The work group considered transformations happening in health care and education and worked to understand goals and objectives, similarities and differences, and key levers that could work together to achieve improvements in both sectors. One key theme was ensuring that the education sector is part of the health care delivery system redesign. Workforce development was another issue in both education and health care.

The group discussed the organization and charge of a more permanent, formal health and education collaboration. They determined the public-private partnershipwould be a convening body, facilitate communication between the public and stakeholders, have a shared government, and be flexible and sustainable. They discussed having a national steering committee and convening additional working groups to delve deeper into specific issues.

The work group identified priorities they encourage the Advisory Group will bring to the National Prevention Council:

  1. Health system transformation—
    1. CMS should clarify the “free care rule” including that schools can receive Medicaid reimbursement for health services. Improve access to health care sector dollars for screening and prevention related to mental health in the school.
    2. Integrate schools into state innovation models, accountable care organizations, Medicarehealth homes, essential health benefits, etc.
    3. Improve data and metrics. Immediate opportunities exist for sharing data and defining metrics that are more expansive than eithersector currently has.
  2. Encourage a deeper examination of opportunities to promote prevention within early education organizations.
  3. Ensure the education sector is able to use Health Impact Assessments. Ask for some interagency workon common school siting standards.
  4. Work with the Department of Education to improve and update standards and recommendations for healthy school environments.

Dr. Levi noted that these recommendations are very specific and short-term. He suggested the Advisory Group begin a discussion, but continue it further on Day 2.

Question and Answer Session Highlights

Dr. Herminia Palacionoted that equity was an overarching theme in the work group’s deliberations, and she encouragedthe Advisory Groupto address this moving forward.

Dr. JudyAnn Bigby noted that a general framework is needed for how schools and the health community work together to promote children’s health so kids are ready to learn and perform

well. Schools with subgroups of unhealthy kids face different challenges than the general school environment. She noted the opportunity to explore collaboration with health, education, social services, police, mental health services, and others. Ms. Davis agreed that it will take more than the health and education systems to address the disparity issue. Although the work group’s recommendations do not look at that specifically, those groups were represented in discussions.

Sister Kerr suggested the education sector is where we can start to teach self-care as preventive care. She also encouraged the group to acknowledge noise in the issue of health and education, as noise affects cognitive activity.

Barbara Otto noted that the Advisory Group was invited to participate in the Center for Medicare & Medicaid Innovationreview process. Additionally, she encouraged group members to promote school reimbursement with partners at CMS, acknowledging that it could transform the types of disease management services that schools provide; it would also take looking at the capacity of schools.

Ned Helmsstated the importance of looking at social determinants. He noted the recent recommendationsto cut funding from the Supplemental Nutrition Assistance Program (SNAP); which is concerning given the scientific linkages between health and education. He recommended the Advisory Group reflect on that and note it in some way. Dr. Dean Ornish seconded that recommendation. Dr. Levi suggested the group look at the Pew Charitable Trust’shealth impact assessment of the Supplemental Nutrition Assistance Program (SNAP) and asked Dr. Ornish and Mr. Helms to draft concise language for the full Advisory Group to consider on Day 2.

Dr. Wisdom raised the challenges many families face in navigating services like school-based clinics, SNAP, and SNAP-Ed, andshe suggested community health workers could help connect families with these services.Ms. Davis noted that the issue of workforce development on boththe health and education sides was a big focus for the workgroup.

Regarding community health workers, Dr. Levi added it is important to help state Medicaid directors understand the new rules for reimbursement.

Dr. Elizabeth Mayer-Davis noted that educators are pressed to address core curriculum;she asked what feedback the workgroup got from people in the schools.

Ms. Davis responded that teachers and school administrators understand healthy students are better learners, but they lack skills to apply that knowledgein the classroom, and accountability metrics donot support that inclusion. It is important to helpeducators learn new strategies and to include health and wellness indicators in school report cards. She added that what happens in the

school setting is more important than pre-professional training, and it would be more effective to incorporate health into some common rubrics for teacher and administrator performance and development.

Dr. Sharon Van Horn noted that information sharing between physicians and schools is laborious. Ms. Davis indicatedthat the work group hadlearned where communities had done this successfully, workingaround privacy and technology issues. The group can examine those examples to identify best practices and infrastructure support needed.
To close, Ms. Davis posed three questions: How do we help educators implement what they know about healthin their classrooms? How do we make sure that addressing health is valued through their accountability systems? How do we communicate to the public how a school is doing integrating health into all aspects of the school experience? Dr. Levi added that he hopes by the next Advisory Group meeting the collaborative will be in place and members of the Advisory Group will continue to participate.

11:00 a.m.–12:00 p.m. Data Work Group Update

Dr. Linda Rosenstocksummarized the efforts of the Data Work Group, whose goal was to better understand current data collection, analysis, and linkages and to explore opportunities for improvement resulting from changes with the ACAand health care transition. She stated the following the presentations, decision points for the Advisory Group would include: Do we need an ongoing working group for this issue? Who is interested in participating?

Dr. Levi introduced three panelists from HHS to summarize what the federal government is doingrelated to data and where opportunities and challengesexist.

James Scanlon, Acting Deputy Assistant Secretary, Office of Science and Data Policy, provided an overview of HHS efforts to improve surveys and other data systems to monitor the implementation and impact of ACA. Hesummarized the role of the HHS Data Council and theHealth System Measurement Project, and referred the Advisory Group to two reports: Enhancements to HHS Surveys to Monitor Health System Change and the Guide to HHS Surveys and Data Systems—both on the HHS Assistant Secretary for Planning and Evaluation (ASPE) website.

HHS continues to address the challenges of getting data at state and local levels and attaining adequate sample sizes at the state or community level; for smaller vulnerable populations, surveys cannot get the data needed.

Dr. Rashida Dorsey, Office of the Assistant Secretary for Planning and Evaluation, summarized the new data collection standards, whichexpand race/ethnicity questions and other demographic items to capture better data on vulnerable populations.The standards—

  • Add granularity for race, expanding from 5 OMB categories to 11
  • Standardize to biologic sex and include gender identity
  • Measure English proficiency (firstself-reported language proficiency data)
  • Assess disability status with a new 6-item measure, which OMB is recommending for all federal agencies that collect disability status

HHS has exploredsocioeconomic status as a data collection standard. The National Committee on Vital and Health Statistics reviewed measures already collected to classify socioeconomic status—income, education, family status and composition, and occupation—and determined that standardization would be very complicated. They recommended starting with standardizing data on education. HHS is also considering standardizing age data.

They have also looked into clinical measures to assessuse of preventive services covered in ACA with no cost sharing. With appropriate sample sizes, it should be possible to see how populations are using these services and determine trends before and after ACA.

Emerging areas for data collection and analysis include low-income populations, particularly low-income men, and history of incarcerationand re-entry populations.

Dr. Cara James, Director, Office of Minority Health, CMS, shared that her agencyisworking to implement the expanded data collection on race/ethnicity. They are looking at ways to improve data qualityand standardization for bothMedicare andMedicaid. And the streamlined application for the health care marketplace includes the expanded race/ethnicity standard, the English proficiency standard, and a modified disability question that addresses the eligibility issue; the questions on gender identity werenot ready for streamlined application.

In Offices of Minority of Health across the agencies, champions have been established to help drive implementation of the expanded data standardsand, later, evaluation and reporting.

CMS has a couple of pilot areas to assess messages that educate people about the preventive services available with coverage through the ACA.Through about 100 stakeholder interviews, CMS has found that there is a need to educate newly insured people about prevention and benefits available, as they donot think of coverage as something to stay well.

Question and Answer Session Highlights

Dr. Rosenstock thanked the panel and acknowledged the wealth of data being collected. She said the question is, can we analyze it all and how will that be done? Do we have linkages among data pieces to answer important questions?

Mr. Scanlon and Dr. James responded that, although current surveys collect many important data, there isstill work needed to makemeaningful connections.

Mr. Helms referenced the All PayerClaims Data Council as providinginformation on costs and preventive services. He encouraged conversation with the 14 states participating.Dr. Bigby suggested it is important tolook at claims in aggregate because there are people who go between categories of insurance, and to look at Medicare in context of other claims. She also asked about efforts for an all-payer claims system at the federal level.Mr. Scanlon noted an HHS pilot study, now in beta testing, is exploring options to establish a multi-payer claims database. It has been difficult because of issues of ownership and reluctance to share data with competitors.

Dr. Wisdom asked for additional information about self-reporting for race/ethnicity data, consideration of Middle Eastern descent in ethnicity categorization, and accessibility of data to communities. Dr. Dorsey responded that allrace/ethnicity data for the new standards are self- reported. Based on OMB standards, Middle Eastern is categorized as white; systems can add more granularity within the categories if they choose. Data are accessible through public use files on most agency websites, and they come with tools/tutorials for users.

Dr. Jacob Lozadaasked that data collection and analysis better include the6 million American citizens in the Virgin Islands, Puerto Rico, Samoa, other U.S. territories. Mr. Scanlon noted that the territories participate in the BRFSS; he added that this needs to be publicized more.

Dr. Patrik Johansson asked if the new standards are part of all surveys used by the federal government and the states.Dr. Dorsey responded that the standards apply to all major surveys
with self-reported data. The ASPE website has list of surveys that use the new data standards.

Dr. Johansson asked if there are plans to capture this expanded data in the community health needs assessment that charitable hospitals are mandated by the IRS to conduct, given that many of them serve these populations.Mr. Scanlon responded that they would need to look into this.

Sister Kerr highlighted the importance of evaluation, and asked about using data to evaluate health outcomes. Mr. Scanlon indicated HHS will beupdating their evaluation planning this fall; this discussion gives them some ideas to think about.

Dr. Rosenstock thanked the panelists and suggestedthe Advisory Group discuss on Day 2what ongoing role, if any, the group will play in this area going forward.Dr. Levi dismissed the group for lunch.

1:00–3:15 p.m. Behavioral Health Panel and Discussion

Dr. Levi introduced a discussion on behavioral health, a topic of continued interest within the Advisory Group and welcomed the panel members.

Dr. Dawn Wilson, Society for Behavioral Medicine, presented a comprehensive approach to primary prevention, along with evidence for developing intervention frameworks that simultaneously address physical, social, and mental health domains that affect youth early in the lifespan.Sheshared three recommendations with the Advisory Group. Dr. Wilson’s full presentation can be found on the Prevention Advisory Group Meetings webpage.

Dr. Tony Biglan, Oregon Research Institute, referenced several family interventions, each of which has been shown to have benefits across multiple problems and to have lasting effects. He also notedthe importanceof evidence-based policies and poverty reduction in improving health and well-being. Dr. Biglan’s full presentation can be found on the Prevention Advisory Group Meetings webpage.

Drs. Bob Pynoos and John Fairbank, National Center for Child Traumatic Stress (NCCTS), discussed the role of trauma exposure—both as victim and witness—as a sub- ingredient in risk determinants, and shared the efforts of NCCTS and its partners to address this issue across individual, school, and community levels. Their full presentation can be found on the Prevention Advisory Group Meetings webpage.

Dr. David Hawkins, Social Development Research Group, noted the challenge in empowering communities and developing their capacityto put effectiveprograms and policies into place within their own prevention system.He shared Communities that Care, a systemfor prevention that has helped communities achieve lasting improvements in youth risk behaviors. For Dr. Hawkins’ full presentation, see the Prevention Advisory Group Meetings webpage.

Dr. Dick Spoth, Partnerships in Prevention Science Institute, discussed the PROSPER system, which engages local leaders and builds on a community’s existing infrastructures to address priority youth risk behaviors. The programs implemented have demonstrated cost efficiencies and helped to overcome challenges related to sustainability.Dr. Spoth’s full presentation is available on the Prevention Advisory Group Meetings webpage.

Question and Answer Session Highlights

After a brief break, Dr. Levi opened a time for discussion with the panelists.

Dr. Sue Swider asked if there is an optimal size for the community for the efforts the presenters described. Both Dr. Hawkins and Dr. Spoth worked in towns ofabout 50,000 people or less,where decisions are made and services provided at the local level.Drs. Pynoos and Fairbank noted that their efforts are in a range of communities in terms of size, location, and cultural make-up.

Dr. Mayer-Davis noted that many of the interventions presented are multi-level, which can pose problems with reimbursement. She suggestedthe Advisory Group address this issue. Dr. Levi responded there are some examples of creative funding for integrated programs. There is tremendous opportunity as the health care system starts changing to test different approaches to reimbursement.

Dr. Bigbyobserved that the panel started discussing health behaviors butshiftedto behavioral health. She asked whether there is a difference in programmatic interventions when you consider one end of the spectrum vs. the other. She also askedabout barriers and facilitators to implementing evidence-based practices and whether panelists had exploredthe potential use of social impact bonds to fund these initiatives.

Dr. Biglan said he worries the term “health behaviors” will lead to an emphasis on getting kids to be more active and eat better. Dr. Wilson agreed there is aneed for terminology that reflects the continuum of behaviors to be addressed rather than language that compartmentalizes the issues.

In response to the question about social impact bonds, Dr. Hawkins stated that there are nowoutcomesthatshowthat these initiativescan be an investment. For example, the WA legislature was going to build another prison, but decided instead to invest in preventive and rehabilitative interventions.

Dr. Levi asked how toreplicate the thought process in the WA legislature. Dr. Hawkins stated that the legislature hasreceived cost-benefit information for yearsfrom a trusted economist and has seen the value of these programs. He suggested the Advisory Group invite Steve Aos, Director, WA State Institute for Public Policy, to speak about the experience in Washington.

Mr. Helms noted that when you look at the per-member-per-month cost, behavioral health issues raise health care costs tremendously. It is time to investigate best practices that have been starving for resources for years, because mechanisms may now exist to pay for these things through Medicare and Medicaid and even commercial insurers.

Dr. Ornishdiscussed isolation and depression as underlying factors for many health problems. He also stressed the importance of showing cost savings, which provides thepolitical argument for “softer” lifestyle-change programs, which continue to prove highly effective and powerful.He would like the Advisory Group to include in its recommendations the broader context, beyond specific behavioral interventions.Dr. Van Hornadded anxiety as another underlying factor for behavioral health issues.

Sister Kerr expressed concern that the emphasis on evidence-based interventions might lead communities toautomatically discardnewer, promising approaches that do not yet havethe science base. Dr. Hawkins responded that in Communities that Care, communities are encouraged to select a combination of programs that are provenand those that are innovative and promising.

Dr. Johannson askedfor the panelists’thoughts about theexpanded data standards. Dr. Biglan noted community-based systems to monitor risk factors and problem behaviors would make iteasier to see which problems were getting worse and which better, and we could select better practices. Dr. Hawkins stated that federal surveillance systems do not provide local communities with the information they need;he would like to see health surveillance at a local level.

National Prevention Council Member Response to Behavioral Health Panel Discussion
Dr. Levi introduced a panel of federal representatives to respond to the behavioral health presentations and discussion.

David Mineta, Deputy Director for Demand Reduction, ONDCP, noted that addressing behavioral health issuesrequires universal approaches along with tailored, targeted approaches.For example, screening, brief intervention, and treatment (SBIRT) can identify substance abuse; when such abuse is addressed in schools, there arehealth and academic benefits.ONDCP is talking with SAMSHA, HHS, and the Department of Education about substance abuse prevention efforts in schools. Mr. Mineta noted that with more than 38,000 people a year dying from prescription drugs,this is the time for federal agencies to work together on this issue.

Fran Harding, Center for Substance Abuse Prevention, SAMHSA, discussed the importance of cross-cutting interventions to address mental health and substance abuse and noted the impact of behavioral health on physical health. She noted that prevention will require collaboration to fund and implement evidence-based and promising programs using the strategic prevention framework model. For Ms. Harding’s full presentation, see the Prevention Advisory Group Meetings webpage.

Dr. Harold Perl, Chief, Prevention Research Branch, National Institute on Drug Abuse,noted that many of the interventions described by the previous panelistsare showing positive effects decades later, even if those outcomes were not originally targeted. This is a key selling point. He noted it is critical to put evidence in place so it becomes standard practice. This is part of changing the culture, so that teaching competence, building families, and improving parenting skills are as much a part of the social system as the health care system. One example is Family Check-Up, which Dr. Biglan presented (NIDA funded that study with other NIH institutes); ONDCP featured it as a resource for National Substance Abuse Prevention Month in October.

Question and Answer Session Highlights

Dr. Levi asked about braiding federal funding in a meaningful way so it is easier to tap resources for integrated care or interventions.Mr. Mineta highlighted a couple of efforts in this area. Performance Partnership Pilots reaches out toyouth ages 18–25that are not connected with employment or educational institutions;they use a model from EPA to braid funding streams. This initiative was slated for multimillion dollars, but that funding was pulled, and there is a need to look for existing discretionary dollars and ways to relieve administrative requirements.

Dr. Wisdom discussed the need to address underlying factors for substance abuse in a systematic way. She asked how to get funds for effective interventions, such as Nurse Family Partnership, to

the communities. Dr. Perl responded that this is somethingmany agencies struggle with. It is not just funding; communities need to want it. He encouraged Dr. Wisdom to talk with pediatricians and OB/GYNs about promoting these programs.

Public Comment
Fowziyya Ali, Wise Choices in Health Literacy (WCHL) Communications
Nonprofit WCHL Communications promotes health literacy education for health care organizations, their workers, patients, and families using digital media technology, including webinars and conference calls. She offered several recommendations for the Advisory Group— to present recommendations to various funding sources to collaborate with WCHL to evaluate its social impact and results; to establish the importance of making an electronic formulary available; and to promote interfaith education on death and dying as a national health priority.

Claire Barnett, Founder and ExecutiveDirector, Healthy Schools Network, and Coordinator, National Coalition for Healthier Schools
Ms. Barnett presented the 3rd triennial national data reporton progress toward healthy schools, produced with partners, which she recommended as background on what is happening in states regardingschool environmental health policy development. Ms. Barnett recommended the Advisory Groupfind ways to strengthen existing work in the field; consult experts in service and data needs regarding children’s environmental health; and consider the unique issues in children’s environmental health and exposures and what the Advisory Group can address that is not currently being addressed.

Susan Geckler, Executive Director, Directors of Health Promotion and Education, and Former Chair, National Coordinating Committee on School Health and Safety
Ms. Geckler applauded the Advisory Group’s work on exploring how health and education systems can better work together. She expressed concern, however, about the recommendation to create a new public-private collaborative to address the issue. She believes such a group already exists: the National Coordinating Committee on School Health and Safety. It has private sector members and participants from federal agencies—both those on the Advisory Group’s Health and Education Work Group and those from transportation, DOJ, agriculture, defense, and several HHS agencies. The National Coordinating Committee is also a convening body, as the workgroup recommended.

Donna Behrens,Chair, National Coordinating Committee on School Health and Safety
Ms. Behrens seconded Ms. Geckler’s recommendation to encourage the Advisory Group to build on the national coordinating committee’s work in health and education. Corinne Graffunder provided dinner details; Dr. Levi dismissed the group for the day.

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

Friday, September 27, 2013

Review from Day 1 and Further Thoughts

Dr. Levi welcomed participants back for Day 2 and proposed the day’s agenda. Dr. Graffunder called the roll.

Special Presentations

New Article in Lancet

Dr. Ornish presented an article he and colleagues published in Lancet, which was the first study showing anything—lifestyle changes in this case—can affect telomere length. Risk of premature death becomes higher as telomere length decreases. Women under chronic stress had shorter telomeres; women’s perception of stress determined the telomeres. Dr. Ornish’s research found that telomere length increased by 10% in participants in the study program, and became shorter in the control group. The more people changed their lifestyle, the more they improved a wide range of health measures. There was a clear dose-response relationship between intervention and outcome. Patientswere empowered to decide how much they want to change based on their goals. Of note, social support was found to be the most meaningful aspect of the program.

Advisory group members noted the importanceof ensuring people have nurturing relationships and exploring generational impacts of stress, particularly among women of color.

Commission to Build a Healthier America

Dr. Palacio shared that the Robert Wood Johnson Foundation has sponsoredthe second Commission to Build a Healthier America, which has two main panels and two topic areas for which to issue recommendations—1) community planning and 2) early childhood education and intervention. Recommendations are being developed, and a report is expected in early 2014. David Williams of Harvard, the lead staffer for the Commission, is willing to brief the Advisory Group when the report is released. Dr. Palacio suggestedthe group consider how it can leverage the Commission’srecommendations.

Ms. Ottosaid she is working with Drs. Wisdom and Swider and the Federal Reserve in Chicago to map all of the hospitals’ community health needs assessments, identifyneeds, and put together a coordinated strategy for improvements. She would like to connect with the Commission.

Dr. Boris Lushniakintroduced Rear Admiral Scott Giberson, Acting Deputy Surgeon General, who had stepped in to the meeting. He has been in the Surgeon General’s office for 2 years and is a key member of the team.

Motion on SNAP Decision

Dr. Ornish presented a proposed recommendation in response to the bill recently passed in the Senate to cut SNAP funds. The group deliberated and revised the languagesomewhat before settling on the final recommendation, below:

Nutrition plays a critically important role in children’s brain development and academic performance. And, nutrition is a key determinant of virtually every measure of health and well-being throughout a person’s life.

The Supplemental Nutrition Assistance Program (SNAP) is the nation’s most important anti- hunger program. In 2011, it helped almost 45 million low-income Americans afford a nutritionally adequate diet each month. Nearly 75 percent of SNAP participants are in families with children. Also, more than one-quarter of participants are in household with seniors or people with disabilities.

The average SNAP recipient receives about $4.45 per day.

Unfortunately, a bill proposing $40 billion in cuts to SNAP and SNAP-ED over the next 10 years recently passed the U.S. House of Representatives. This bill would cause 3 million people to lose benefits while another 850,000 would see their benefits cut, according to the non-partisan Congressional Budget Office.

At a time when there is more scientific evidence than ever proving the importance of good nutrition, we find it profoundly unwise, morally reprehensible, and economically short- sighted to propose a major reduction in SNAP. We urge the Administration to continue to oppose cuts in SNAP. We do not need to balance the budget by mortgaging our children’s future.

Dr. Levi will include a cover letter that indicates the motion was passed unanimously by those present.

Upon return from a break, Dr. Levi introduced Katherine (Kat) Oakar—Acting Director, Office of Health Reform—who expressed her excitement about working with the Advisory Group and let the group know they can reach out to her.

Proposed Report to the Surgeon General

Dr. Levinoted that there are multiple targets of opportunity to create change in the context of the National Prevention Strategy and health care transformation. He proposed developing a 4- to 5- page consensus documentfor the Surgeon General by January 1 to identify what the Advisory Group thinks are priorities. This would also help define the Advisory Group’s work. Dr. Levi encouraged the group to have narrow expectations on what it can produce in just a few months.

Dr. Lushniak affirmed that this is an important move for the Advisory Group. He suggested that the report tell the Surgeon General—and the National Prevention Council and its CDC leadership—three things: what they are doing well, what is not so good, where they havenot even entered the picture.

Several members of the Advisory Group concurred and offered suggestions for what to include in the report and how to go about developing it. Suggestions included:

  • Reorganizing activities in the National Prevention Council report by National Prevention Strategy priority, rather than by department, to help identify gaps.
  • Exploring community-level activities and other specific strategies not presented in the National Prevention Council report to highlight progress and efforts with intense interest and to layafoundation for what the Advisory Group looks at that is not reflected in Council report.
  • Summarizing recurring themes heard in discussions: collaboration and challenges to collaborating, coordinating and streamlining regulations, and encouraging community engagement at grassroots level.
  • Delineating a process for how the Advisory Group will advise the Surgeon General and the Council as well as laying out a strategy and metrics for cross-agency communication and collaboration.
  • Highlighting the 2 or 3 most insightful lessons individuals have learned by being in the Advisory Group based on feedback from each member and why they feel the experiences/lessons are of value or unique and would not have happened if not part of Advisory Group.
  • Bringing up issues that others are not discussing, even if that means being countercultural or politically incorrect.
  • Bringing to the forefront topics that get at the spirit of the National Prevention Strategy that might not be what the National Prevention Council is focused on.

Dr. Rosenstock suggested going back to group’s original charge—to advise the Surgeon General and National Prevention Council. She also advised spending more time at each meeting reviewing the progress of the Council, being careful that the Advisory Group meetings do not become a form of continuing education.

Dr. Levi stated he liked the idea of an electronic survey to establish a baseline of where people are. He asked for volunteers to form a subgroup to move that forward and to get a report out by January 1. Volunteers were Mr. Helms, Ms. Otto, Dr. Mayer-Davis, Dr. Ornish, and Dr.

Wisdom. Dr. Levi will make arrangements soon for this small subcommittee to be briefed on the interviews.

Dr. Bigby asked for the statutory charge to the Advisory Group to clarify who they are advising and in what capacity. Dr. Levi responded they were presidentially appointed and advisory to the National Prevention Council, which is chaired by the Surgeon General. Dr. Palacio read the description from the Surgeon General’s office and noted that who the group advises is narrowly defined, but the advice to be offered is quite broad.

Dr. Mayer-Davis said she has struggled witha lack of communication with the Council and felt the Advisory Group has been working largely in a vacuum relative to the body the group is advising. Dr. Lushniak suggested a joint meeting of Advisory Group and National Prevention Council, which he will organize.

Dr. Levi reminded everyone that the Education and Health Work Group did have active engagement of relevant Council agencies. Ms. Otto noted that funding was available to that workgroup.

Integrative Health, Community Capacity, and Public Engagement Work Group Updates

The chairs of the work groups reported on recent activities.

Dr. Rosenstock, Data Work Group, acknowledged the data being collected and efforts to expand demographic data. She noted that analysis and linkages need more attention to harmonize the data elements and enable putting survey and payer information together. Her assessment was that an ongoing work group to address this issue would not be meaningful and would deviate from the Advisory Group’s charge. However, she suggested the Advisory Group keep informed of what is being done.Dr. Mayer-Davis agreed. She proposed the group consider metrics for success for collaboration with data collection and analysis and advise in that regard.

Dr. Swider, Community Capacity Work Group, stated thatthrough information gathering and interviews, they tried to identify potential models and factors that facilitate community health and development work. They have some beginnings, but where to go next will depend on what the Advisory Groupclarifies as its purpose. There are some themes worth reporting to the Surgeon General regarding challenges. For now, she recommended keeping the work group on hold until they have a clearer sense of direction and only moving forward if this fits with the Advisory Group’s direction and focus.

Dr. Bigby asked if the work group considered whetherits focus fits within the Strategy’s priority of safe and healthy communities and environments. Dr. Swider responded that the work group’s recommendations are process related—bringing together people that usually donot work together and how they fund that work jointly.

Before deciding to put the work group’s recommendations on hold, Dr. Bigby suggested that a full discussion with the Advisory Group was needed.

Dr. Wisdom asked if, going forward, work group formation should result from recommendations the Advisory Group makes. Dr. Levi noted the report in January will form the framework for the Advisory Group’s work going forward.Sister Kerr noted the group has not done much with integrative health or health promotion, two elements in their name.

Dr. Kahn, Integrative Health Work Group, said she would like to wait onpriority setting for the Advisory Group and then see what her group’s role is. Only one recommendation is needed regarding the Section 2706 workforce issue. It is challenging to pursue that goal because the greatest stumbling block is an HHS/DOL/Treasury FAQ that explains the law very differently. Sister Kerr shared Senator Harkin’s letter about this law.

Dr. Kahn asked for distinction between health promotion and disease prevention. She noted that everything they heard on Day 1 indicates there are a handful of factors that have to do with well- being across the lifespan. She suggested it is better to pursue this issue across the whole body than isolated in work group meetings.

Ms. Otto, Public Engagement Work Group, noted her group had outserved its purpose once CDC and the Surgeon General’s office were staffed up to disseminate information. Participation in this work group was limited, and much of the work was done by Ms. Otto’s and Dr. Levi’s staffs. If the Public Engagement Work Group needs to continue, she would like it to be more than a dissemination body.

Mr. Helms noted that he, Dr. Levi, and Mary Beth Bigley had discussed how to bring the National Prevention Council report to life.

Dr. Swidersuggested that the public engagement piece seems to transcend whatever direction the Advisory Group takes. Ms. Otto noted that partners tell her that they want to know more about the Strategy, and there is room to do more public engagement—but she would like to wait and hear from the group about what to move ahead with.Dr. Palacio stated she thinks of public engagement as different from public dissemination or public relations. She proposed a different charge is to advise the federal government about public engagement activities they might want to consider. Ms. Otto agreed.

Dr. Leviurged the group to be strategic in its recommendations. If they make many, the National Prevention Council gets to prioritize. If they offer fewer priority recommendations, the group can hold the Council accountable to those few. Dr. Wisdom suggested aligning their recommendations with Secretary Sebelius’ and other agencies’ priorities, so recommendations don’t occur in a vacuum.

Wrap-Up Discussion (Potential Next Steps, Scheduling of Work Groups, etc.)

Dr. Levi asked the group to decide whether to pursue the Health and Education Work Group’s initial vision to catalyze a collaboration that would extend beyond its relationship with the Advisory Group. He reminded members that the work groups report to the Advisory Group, which then transmits recommendations to the Surgeon General. The larger group needs to review the recommendations of the Health and Education Work Group before putting them forward.

He recalled the previous day’s presentations from the National Coordinating Committee on School Health and Safety (NCCSHS). He spoke with chair Donna Behrens, and she would like to have the agenda of the two groups mesh, so everyone feels involved and heard.

Mr. Helms stated that the work group’s report points to early education and intervention that they have all talked about; he agreed it would be good to birth something that goes forward on its own.

Dr. Bigby stated it is important to be clear on what a new health and education group can and should do and to be careful about duplicating efforts. She encouraged conversation with and about NCCSHS. Dr. Rosenstock agreed. Dr. Levi noted the work group knew that the committee existed, and the overlap was not a concern to work group members, but he was comfortable waiting and reporting back after further discussion with NCCSHS.

Regarding the report to the Surgeon General, Dr. Levi said he and the subgroup will set out a process and timeline (with the goal of submitting in January) and then begin gathering feedback from the Advisory Groupregarding recommendations in the four priority areas of the National Prevention Strategy.

Dr. Wisdom asked if and how the Advisory Group would respond to the public’s presentations on Day 1. Dr. Graffunder recommended developing a statement that can be read at the end of public comments to explain that the Advisory Group doesnot issue a formal response because it would require the same process as everything else they deliberate on.

Dr. Graffunder reminded the group to turn in travel vouchers to Nicole in as soon as possible, and to expect payment in mid-October. Dr. Levi adjourned the meeting.