Connecting Public Health and Medicine through Prevention: The SPARC Program Sickness Prevention Achieved through Regional Collaboration Doug Shenson, MD.

Connecting Public Health Connecting Public Health and Medicine through and Medicine through

Prevention: Prevention: The SPARC ProgramThe SPARC Program

Sickness Prevention Achieved Sickness Prevention Achieved through Regional Collaborationthrough Regional Collaboration

Doug Shenson, MD Doug Shenson, MD MPHMPH

Austin, TXAustin, TX

June 15, 2010June 15, 2010

THE RIGHT THE RIGHT TOOLS FOR TOOLS FOR

COMMUNITY-COMMUNITY-WIDE WIDE

PREVENTIONPREVENTION

Echocardiography

Flu Vaccination

Dementia Screening

Pneumococcal Vaccine

Mammogram

Colorectal cancer Screening

Pap Test

Thyroid Disease screening

Hepatitis B Vaccine

STD Screening

PPD test

EKG

Blood Pressure Screening

HIV screening

Downs Syndrome Screening

Carotid artery stenosis Screening

Cholesterol Screening

Glaucoma Screening

Skin Cancer Screening

Prostate cancer Screening

Diabetes Screening

Lung cancer Screening

Osteoporosis Screening

Pregnancy Screening

Abdominal Aortic aneurysm Screening

PKU Screening

Clinical Preventive Clinical Preventive ServicesServices

Flu ShotsFlu Shots Pneumococcal Pneumococcal

immunizationimmunization MammographyMammography Pap TestPap Test Colorectal Colorectal

cancer cancer screeningscreening

Hypertension Hypertension screeningscreening

Cholesterol Cholesterol screeningscreening

Tetanus Tetanus immunizationimmunization

Adolescent Adolescent immunizationsimmunizations

Child Child immunizationsimmunizations

HOW WELL ARE HOW WELL ARE WE DOING?WE DOING?

Estimated Percentage Of U.S. Adults Estimated Percentage Of U.S. Adults Aged >65 Up-to-date On Routine Aged >65 Up-to-date On Routine

Clinical Preventive Services. Clinical Preventive Services. 1997, 2002, 1997, 2002, 2004 Behavioral Risk Factor Surveillance System. Am J Prev 2004 Behavioral Risk Factor Surveillance System. Am J Prev

Med 2007;32(1)Med 2007;32(1)

Estimated Percentage Of U.S. Adults Estimated Percentage Of U.S. Adults Aged 50-64 Up-to-date On Routine Aged 50-64 Up-to-date On Routine

Clinical Preventive Services. Clinical Preventive Services. 1997, 2002, 1997, 2002, 2004, 2006 Behavioral Risk Factor Surveillance 2004, 2006 Behavioral Risk Factor Surveillance

System.System.

Adults and Infants “Up-to-Adults and Infants “Up-to-Date” Date”

with Clinical Preventive with Clinical Preventive Services Services

(2006 BRFSS)(2006 BRFSS)

THE CURRENT THE CURRENT STRATEGYSTRATEGY

10

Patient

Pulmonologist

Cardiologist

Low Community-wide Preventive Service Delivery Rate

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Diffuse Responsibility: Diffuse Responsibility:

Primary Care Clinician

Obstetrician / Gynecologist

Gastroenterologist

Geriatrician

Patient Primary Care Clinician

Current Preventive Service Delivery Rates

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Patient

Acute Care Acute Care VisitsVisits

Adults Age Adults Age >>65 “Up-to-date” with CPS65 “Up-to-date” with CPSInsurance Status, Provider status, and Insurance Status, Provider status, and

Recent CheckupRecent Checkup(2006 BRFSS)(2006 BRFSS)

THE CHALLENGE THE CHALLENGE WE FACEWE FACE

14

Obstacles to Preventive Obstacles to Preventive Service Delivery We Know Service Delivery We Know

About: CliniciansAbout: Clinicians Poor office reminder Poor office reminder

and flagging systemsand flagging systems Disease prevention a Disease prevention a

lower prioritylower priority Doctors not aware of Doctors not aware of

changing guidelines changing guidelines Low insurance Low insurance

reimbursement ratesreimbursement rates

15

Obstacles to Preventive Obstacles to Preventive Service DeliveryService Delivery

We Know About: Patients We Know About: Patients

Patients not aware Patients not aware of health benefitsof health benefits

Patient focused Patient focused exclusively on exclusively on treatmenttreatment

Patient not aware Patient not aware that insurance that insurance covers preventive covers preventive carecare

Patient

Patient

Patient

Patient

Patient

Community Resident

Primary Care Clinician

Patient

Primary Care Clinician

Community-wide Preventive Service Delivery

Community Resident

Community Resident

Community Resident

Community Resident

Community Resident

Community Resident

Community Resident

Community Community PerspectivePerspective

SPARC: Program SPARC: Program RationaleRationale

and System Critiqueand System Critique Currently no responsible local Currently no responsible local

agency for population-wide provision agency for population-wide provision of clinical preventive servicesof clinical preventive services

Currently no local accountability Currently no local accountability Currently no coordination of deliveryCurrently no coordination of delivery Clinical preventive services falls Clinical preventive services falls

between the cracks of medicine and between the cracks of medicine and public healthpublic health

DEVELOPING A DEVELOPING A FRESH STRATEGYFRESH STRATEGY

Patient Clinician Office System

Community Resident

New Community Access Point

Increase Supply of

CPS

Increase Demand for

CPS

Higher Community-wide Delivery

Population-Wide Perspective

Accountable Agency (SPARC)

Data

Build local Build local collaborations of collaborations of

prevention service prevention service “stakeholders”“stakeholders”

Visiting nursing Visiting nursing agencies agencies

Elder servicesElder services Public health Public health

agenciesagencies Churches and Churches and

synagoguessynagogues

HospitalsHospitals Public schoolsPublic schools Medical Medical

practicespractices Community Community

centerscenters

Elements of SuccessElements of Success

Establish a SPARC Establish a SPARC Steering CommitteeSteering Committee

Selection of one or Selection of one or more more geographically-geographically-bounded bounded communitiescommunities

Selection of Selection of community (non-community (non-clinical) sitesclinical) sites

Selection of clinical Selection of clinical preventive services preventive services to be deliveredto be delivered

Plan community-Plan community-base activities base activities

Plan evaluation Plan evaluation strategystrategy

Develop information Develop information links back to the links back to the medical homemedical home

Outcomes AssessmentOutcomes Assessment

Reach Reach (inclusions and (inclusions and exclusions)exclusions)

Efficacy Efficacy (meeting (meeting outcomes goals)outcomes goals)

Adoption Adoption assessmentassessment

ImplementatioImplementation assessmentn assessment

Maintenance Maintenance assessmentassessment

BUILDING THE BUILDING THE RIGHT TACTICAL RIGHT TACTICAL

APPROACH:APPROACH:EXAMPLES OF EXAMPLES OF

PROJECTSPROJECTS

Percent Change in Percent Change in Pneumococcal Immunization Pneumococcal Immunization Rates, Connecticut CountiesRates, Connecticut Counties

1997 HCFA Reimbursement Claims1997 HCFA Reimbursement Claims

Bundling Preventive Bundling Preventive Services: Services:

Vaccinations and Cancer Vaccinations and Cancer ScreeningScreening

Can mammography Can mammography rates be improved by rates be improved by

facilitating breast facilitating breast cancer screening at cancer screening at community-based flu community-based flu

clinics?clinics?

SPARCVNA DPH MD RAD

PLANNING

Mamm.Scheduling

RadiologyDept.

Community Flu Clinics

MedicalHome

Residents

Data

Mammography rates, Mammography rates, Litchfield County, CT, women Litchfield County, CT, women

age >65. age >65. Am J Prev Med 2001;20(2).Am J Prev Med 2001;20(2).

Offering Annual Fecal Occult Blood Tests at Annual Flu Shot Clinics Increases Colorectal Cancer Screening RatesMichael B. Potter, MD1, La Phengrasamy, MPH1, Esther S. Hudes, PhD, MPH2, Stephen J. McPhee, MD3 and Judith M.E. Walsh, MD, MPH2,3 1 Department of Family and Community Medicine, University of California San Francisco, San Francisco, California2 Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California3 Department of Medicine, University of California, San Francisco, San Francisco, California CORRESPONDING AUTHOR: Michael B. Potter, MD Department of Family and Community Medicine Box 0900, UCSF, San Francisco, CA 94143 [email protected]

Why Vote & Vax?Why Vote & Vax?

More than 126 million Americans More than 126 million Americans vote in national elections.vote in national elections.

Approximately 70% the voters Approximately 70% the voters are over age 50.are over age 50.

Fewer than 40% of adults ages Fewer than 40% of adults ages 50-64 receive an annual flu shot.50-64 receive an annual flu shot.

Why Polling Places?Why Polling Places?

They attract residents from all They attract residents from all communities.communities.

They are mandated to be maximally They are mandated to be maximally accessible.accessible.

They are widely distributed They are widely distributed throughout all communities.throughout all communities.

There are 186,000 of themThere are 186,000 of them

Vote & Vax GuidelinesVote & Vax GuidelinesPermission from Permission from

Local Election Local Election AuthorityAuthority

Not Just for Not Just for VotersVoters

Charge for Charge for Vaccine as UsualVaccine as Usual

For All For All CommunitiesCommunities

Vote & VaxVote & VaxNational CollaboratorsNational Collaborators

AARPAARP American Public American Public

Health Association Health Association (APHA)(APHA)

Association of Association of Immunization Immunization Managers (AIM)Managers (AIM)

Association of State Association of State and Territorial Health and Territorial Health Officials (ASTHO)Officials (ASTHO)

Immunization Immunization Coalitions Technical Coalitions Technical Assistance Network Assistance Network (IZTA)(IZTA)

National Association of National Association of Area Agencies on Aging Area Agencies on Aging (n4a)(n4a)

National Association of National Association of Chronic Disease Chronic Disease Directors (NACDD)Directors (NACDD)

National Association of National Association of County and City Health County and City Health Officials (NACCHO)Officials (NACCHO)

National Association of National Association of State Units on Aging State Units on Aging (NASUA)(NASUA)

Visiting Nurse Visiting Nurse Associations of America Associations of America (VNAA)(VNAA)

How Did We Do in 2008?How Did We Do in 2008?

Vote & Vax Vote & Vax clinics delivered clinics delivered 21,434 flu vaccinations at 21,434 flu vaccinations at 331 locations in 42 states 331 locations in 42 states plus the District of Columbia.plus the District of Columbia.

Vote & VaxVote & Vax: A : A Nationwide SuccessNationwide Success

We hit the most important targets…

67% were in CDC priority groups.

We reached new We reached new populations…populations…

48 % were irregular or unlikely 48 % were irregular or unlikely flu shot recipients – that is, they flu shot recipients – that is, they did not receive a shot last year did not receive a shot last year or would not have otherwise or would not have otherwise received one this year.received one this year.

52% were regular flu shot 52% were regular flu shot recipients.recipients.

Including underserved populations…

Percent irregular and unlikely flu shot recipients:

60% among African-Americans

65% among Hispanics

71% among uninsured

SUMMING UPSUMMING UP

The SPARC ProgramThe SPARC Program Community-based program focused on Community-based program focused on

expanding prevention across entire expanding prevention across entire populationpopulation

Emphasis on primary and secondary Emphasis on primary and secondary prevention of major chronic diseases prevention of major chronic diseases (USPSTF A or B)(USPSTF A or B)

Builds community-wide accountability Builds community-wide accountability for better access to preventive servicesfor better access to preventive services

Vehicle for public health & healthcare Vehicle for public health & healthcare integrationintegration

Tools and AssistanceTools and Assistance

Project Project manuals and manuals and research research findings findings

SPARC SPARC presentationspresentations

Conference Conference CallsCalls

Technical Technical AssistanceAssistance

Site VisitsSite Visits SPARC Action SPARC Action

GuideGuide

Lessons LearnedLessons Learned

AmbitionAmbitionSystemsSystemsSustainabilSustainabilityity

AlliesAlliesCreativityCreativity

Leading SPARC FundersLeading SPARC FundersNationalNational

AARPAARP CDC Healthy Aging ProgramCDC Healthy Aging Program CDC National Immunization CDC National Immunization

ProgramProgram HRSAHRSA Local Initiatives Funding Local Initiatives Funding

Partners Program of RWJFPartners Program of RWJF Pfizer FoundationPfizer Foundation Robert Wood Johnson Robert Wood Johnson

Foundation (RWJF)Foundation (RWJF)

Regional and LocalRegional and Local

Atlanta Regional Atlanta Regional CommissionCommission

Berkshire Taconic Berkshire Taconic Community FoundationCommunity Foundation

Jessie B. Cox TrustJessie B. Cox Trust Patrick and Catherine Patrick and Catherine

Donaghue FoundationDonaghue Foundation QIOs of CT, MA, NYQIOs of CT, MA, NY Seth Sprague Seth Sprague

FoundationFoundation Weinberg FoundationWeinberg Foundation