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Welcome! 2015 MCH Workforce Academy

Leading in a transformative environment to improve population health

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• Good morning & welcome!

• Time as a gift

• Learner-teachers

• Additional resources and slides on amchp.org-Transformation Station

• Today’s events

• Luggage & airport transportation

Housekeeping

Implications of Population Health Initiatives for the MCH

Workforce

Brian Castrucci

Health Equity with Population Health Initiatives

Diane Rowley, MD, MPH

Department of Maternal and Child Health

UNC Gillings School of Global Public Health

Population health perspective:

Considers a broad set of determinants in improving the distribution of health and well-

being outcomes.

MCHB:

“Our vision of a Nation where all children and families are healthy and thriving,

where every child and family have a fair shot at reaching their fullest potential.”

Lu MC, Lauver CB, Dykton C, Kogan MD, Lawler MH, Raskin-Ramos L, Watters K, Wilson LA. Transformation of the title V maternal and

child health services block grant. Matern Child Health J. 2015 May;19(5):927-31.

.

Culture

Capacity

Resources

Resilience

Inputs are the same, but

Outcomes are

unequal

With Equity, inputs may need to be different to achieve equal outcomes

This is EQUITY

How to

Develop an

Equity Plan

Hogan VH, Rowley DL

Outlines the five new domains of action you need to make it

an Equity Plan

R4P

Otherwise, it’s just

“a plan”

• PROVIDE • Culturally and economically feasible health education and medical care are required,

along with the required resources and environmental supports, so that it is the easiest

option for people to choose and sustain health promoting actions

REPAIR RESTRUCTURE

REMOVE REMEDIATE

Repair the damage of the past. Historical risk is embedded in current physiologic, biologic, psychological, behavioral and social structures. Historical trauma sets a population group back in the present.

Societal structures (where we live, work, play…..) can function inequitably and continue to expose new populations and produce risk. Structural changes (changes in social, economic, educational equity, rules, regulations, etc…) are needed to stop new production of risk and permanently remove the stressors and toxic exposures.

Forces that are adverse to health, health maintenance and health seeking are embedded in most societal institutions. Such forces-- like Power imbalances, Racism, SES inequities-- must be directly acknowledged and removed.

While we wait for structural changes to be completed, the social context continues to be a source of adverse exposures. At-risk populations need to be buffered from these exposures to reduce their vulnerability until such time that the negative stressor is completely removed.

R4P Copyright 2010, Hogan and Rowley

What past exposures

produced damage that

impact on current ability

(of population) to access

health care, maintain

health, or practice healthy

behaviors?

REPAIR

REPAIR THE DAMAGE OF THE PAST

• Historical risk is embodied in current physiologic, psychologic, behavioral and social structures

• Actively recognize and discuss historical disadvantages of populations we serve

• Actively undo historical

disadvantages of populations we serve

• What processes/social forces continue to produce risk,

disadvantage and other adverse effects in vulnerable populations?

• How can I revamp the process or structure so that future generations

are no longer exposed?

Restructure

BET questions

Institutional policies and processes need to be restructured so that they stop producing more risks. Assess the structures in organizations that maintain systematic exclusion of disparity populations while simultaneously providing advantage or privilege to others. Interventions that include the restructure component will focus on changing institutions and organizations rather than attempting to change people.

How can we buffer people from the adverse effects

while we wait for structural change?

• While we wait for structural changes the social context continues to product risks.

• It is important to minimize effects until restructuring occurs.

Remediate

R4P Copyright 2010, Hogan and Rowley

Where do racism and

other ‘isms’ operate

here?

The remove component may overlap with repair, restructure, and remediate, but this component requires explicit attention to racism, sexism, and classism that could be overlooked in previous steps.

Remove

R4P Copyright 2010, Hogan and Rowley

Culturally and socioeconomically feasible

interventions (or policies) and ensure that families have the tools and resources to carry

out recommended care PLANS

• Services should be planned and delivered in a way that the resources and environmental supports are easily attainable for disparity populations.

• Not only do we need to define the right EBP, but we also need to focus attention on the way that practice is implemented vis a vis the population factors with respect to race, class, gender, history.

Provide

R4P Copyright 2010, Hogan and Rowley

• •

• When you include these- it becomes an equity plan!

Woo Hoo!

Whenever a need, a problem, or a gap is identified:

Always Do Something!

Practicing Equity requires this!!!

• I’m tough enough

• Acknowledge

the risk of

failure… and be

at peace with

the

consequences

Effectively Advancing Population Health Priorities:

What, How and Who

Agenda

Context setting

The What

The How

The Who

Getting started Getting Better

23

Facilitators Sharron Corle, Amy Mullenix, Sarah Beth McClellan, Steve Orton, Oscar Fleming

Objectives

• Demonstrate the use of active implementation concepts to inform the design, preparation, delivery and sustainability of population health strategies

• Apply population health planning tool to move participants from theory to appropriate action

Methodology

• Form Small Groups

– All state representatives together

– Pairs and Individuals will be joined with others

• Activity Blocks

– Content Review, Applied Example, Group dialogue & action planning

• Reflect, Discuss, Capture

PopHealth Connections

Evidence base

Implementation Effectiveness

System Performance

Population Health Outcomes

• NPMs represent population health outcomes

• The Title V program creates the collective action platform & plans

ESMs NPMs NOMs

SPMs

Evidence-based

strategies / practices

Improved performance

leads to improved outcomes

Title V Measurement Framework

STATE PRIORITIES

Block Grant Guidance

NPMs and SPMs drive improved

MCH population outcomes (i.e. NOMs).

ESMs: • Measure evidenced-based/informed

practices that will impact population-based NPMs.

• State-specific and actionable,

• Track Title V program’s strategies and activities

• Provide accountability for improving quality and performance

Evidence-based Practices - Selected Sources • AMCHP Innovation Station: Best,

promising, and emerging practices from MCH programs

• NACCHO Model Practices Database: programs, resources and tools from local health departments

• The Community Guide: effective program and policy interventions

• National Center for Education in MCH: Evidence Briefs by domain and national performance measure

• Child Trends’ What Works/LINKS database: over 650 programs with at least 1 randomized, intent-to-treat evaluation to assess child or youth

• Strengthen The Evidence Base For MCH Programs: Resources from Johns Hopkins University, HRSA, Welch Medical Library at JHU, and AMCHP

• What Works in Health: information to help select and implement evidence-informed policies, programs, and system changes

System: Policy and Infrastructure

Organizational Leadership

Site Leadership

Providers

Constituents

External Su

pp

orts

Systems Complexity Funding

Policy

Culture

History Economy

Definition

• Implementation:

A specified set of activities designed to put into practice an activity or program of known dimensions1

1 National Implementation Research Network (NIRN). Implementation defined. NIRN Web site. http://nirn.fpg.unc.edu/learn-implementation/implementation-defined. Accessed November 13, 2014.

Why it Matters

Women, children and families

do not benefit from interventions they do not receive.

• Developing and identifying evidence-based/informed programs and practices has improved significantly…

• The science and practice of Implementing these programs with fidelity, in real-world settings, has lagged behind…

…but the science is emerging rapidly

ACTIVE Implementation

Moving from Letting it happen (Diffusion ) & Helping it happen (dissemination) to…

Making it happen

All too often…

Effective Interventions

Effective Implementation

Enabling Contexts

Significant Outcomes

Implementation Equation

Active Implementation Frameworks

Frameworks

The “What”

• Neither “Rigorous evidence” for evidence-based/informed interventions nor promising results from emerging practice is enough…

• Well-defined interventions must be teachable, learnable, doable, assessable, and repeatable in practice

Effective Interventions

The “What”

3. Operational Definitions

1. Clear Description

4. Performance Assessment

2. Essential Functions

1. Clear Description of the program Philosophy, values, principles

Inclusion – exclusion criteria

2. Identified Core Components (aka, active ingredients, essential functions)

3. Operational Definitions of core intervention components (what practitioners do, say)

4. Practical Performance/Fidelity Assessment

Effective Interventions

Title V & Interventions

• NPM: “Medical home”

• Selected Strategy: Care Coordination for CYSHCN

• Potential Interventions:

Care Coordination

Services Family

Engagement

Medicaid Partnerships

Applied Example:

Usable Interventions

Effective Interventions

Pulse Check

For each state or territory, select ONE intervention linked to a population health strategy

• Reflect on the Usable intervention criteria

• Discuss – How well defined is the population health

intervention you selected?

– What is needed to further define the intervention?

• Capture your action ideas

Interlude

The “How”

• Implementation Stages: Describe and guide how the work unfolds over time.

• Implementation Drivers: Identify the capacity and infrastructure linked to effective intervention delivery across the stages.

Effective Implementation

Exploration Installation Initial

Implementation Full

Implementation

2-4 Years

Implementation Stages

Effective Implementation

Performance Assessment (Fidelity)

Coaching

Training

Selection

Systems Intervention

Facilitative Administration

Decision Support Data System

Adaptive Technical

Leadership Drivers

Consistent Uses of Innovations

Reliable Benefits

Integrated & Compensatory

Effective Implementation

Competency: Build provider confidence and competence to deliver intervention with fidelity

Organizational: Align organizational and system resources to support high fidelity delivery

Leadership: Provide sustained vision, motivation & support for the change process; Responds appropriately to adaptive and technical challenges

Integrated & Compensatory: The divers reinforce each other and gaps in one driver can be compensated by another

Effective Implementation

Implementation Drivers

Exploration Installation Initial

Implementation Full

Implementation

• Assess needs • Examine

intervention components

• Consider Implementation Drivers

• Assess fit

• Acquire Resources • Prepare

Organization

• Prepare Implementation Drivers

• Prepare staff

• Activate Data Systems

• Manage change

• Strengthen Implementation Drivers

• Initiate Improvement Cycles

• Achieve and improve Fidelity and Outcomes

• Monitor & manage Implementation Drivers

Drivers and Stages Together

Effective Implementation

2-4 Years

Applied Exploration

Accessed on 8/21/2105 at http://implementation.fpg.unc.edu/sites/implementation.fpg.unc.edu/files/resources/NIRN-TheHexagonTool_0.pdf

Applied Example:

Implementation Drivers &

Stages

Effective Implementation

Pulse Check

In your groups Reflect, Discuss and Capture

• Which Implementation Stage are you in with the selected intervention? Briefly justify your response.

• How are the Implementation Drivers being addressed? Which need more attention?

Interlude

The “Who”

Implementation Teams: Integrate the use

of implementation stages, drivers and

improvement cycles to support the

implementation, sustainability, and scale-

up of usable interventions

Teams “MAKE IT HAPPEN”

Effective Implementation

Site Implementation

Team

Regional Implementation

Team

State Implementation

Team

Implementation Teams have…

- Competencies • Know the Intervention

• Know and apply Implementation Science

(e.g. Active Implementation

Frameworks)

• Know and facilitate Organization and

Systems Change

– Minimum of three people • four or more preferred

Effective Implementation

Exploration: - Evaluate and recommend

potential interventions to address your priorities

Installation:

- Develop communication protocols for program stakeholders (e.g. parents and leaders)

Effective Implementation

What Implementation Teams do: Implementation Teams are involved in all stages.

Initial Implementation: - Regularly review performance

data related to strategies

Full Implementation: - Formalize technical assistance

plans for ongoing program support and resources;

Applied Example:

Implementation Teams

Effective Implementation

Pulse Check

In your groups…

• Who can be engaged in an Implementation Team to support the effective delivery of the intervention?

• What’s your role?

Interlude

• Sustained Attention – Keeping the goals in focus, energizing the effort

• Stable Resources – Ensuring human, financial and material supports aligned with goals

• Support for Learning - Getting Started, Getting Better; Fail forward

Enabling Contexts

Leadership

Quality Improvement

“Getting Started, Getting Better”

• Rapid Cycle Improvement

• Usability Testing

• Practice Policy Feedback Loops

Enabling Contexts

Form Supports Function

Policy

Practice

Do Exte

rnal

Imp

lem

en

tati

on

Su

pp

ort

Policy

Practice

Structure

Procedure Stu

dy

Act

Pra

ctic

e In

form

s P

olic

y

Po

licy Enab

les P

ractice

Plan

Practice Policy Feedback Loops

Enabling Contexts

All organizations are designed, intentionally or unwittingly, to achieve precisely the results they get.

R. Spencer Darling, Leadership Institute, Inc.

The reality is that any social system is the way it is because the people in that system want it that way.

Heifetz, Grashow, & Linsky (2009, p.17)

Systems trump programs. Patrick McCarthy, Annie E. Casey Foundation

System Wisdom

Enabling Contexts

Discussion

Oscar Fleming Oscar.fleming@unc.edu

http://nirn.fpg.unc.edu/

www.globalimplementation.org

http://implementation.fpg.unc.edu/

Additional Resources

Website: http://mchwdc.unc.edu/

Website: http://www.amchp.org

Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. (2005). Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231).

Implementation Research:

A Synthesis of the Literature

• Health Resources and Services Administration (Maternal and Child Health Workforce Development Center)

• Annie E. Casey Foundation (EBPs and Cultural Competence)

• William T. Grant Foundation (Implementation Literature Review)

• Substance Abuse and Mental Health Services Administration (Implementation Strategies Grants; National Implementation Awards)

• Centers for Disease Control & Prevention (Implementation Research)

• National Institute of Mental Health (Research And Training Grants)

• Juvenile Justice and Delinquency Prevention (Program Development And Evaluation Grants)

• Office of Special Education Programs (Scaling up and Capacity Development Center)

• Administration for Children and Families (Child Welfare Leadership; Capacity Development Center)

• The Duke Endowment (Child Welfare Reform)

Recognition

©Copyright Oscar Fleming, Dean Fixsen and Karen Blase

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Lunch Panel with: Mallory Cry

Owen Erquiaga Eileen Forlenza

Moderated by: Anita Farel