JourneyWell proprietary and confidential, ©© 2008 JourneyWell
Community Health ActionsCommunity Health Actions
Nico Pronk, Ph.D.Nico Pronk, Ph.D.VP and Health Science Officer, JourneyWellVP and Health Science Officer, JourneyWellSenior Research Investigator, HealthPartners Research FoundationSenior Research Investigator, HealthPartners Research FoundationHealthPartnersHealthPartnersMinneapolis, MinnesotaMinneapolis, Minnesota
St. Croix County Community Health Improvement Plan 2009St. Croix County Community Health Improvement Plan 2009--2014, 2014, February 2010February 2010
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OutlineOutline• Setting the context
– What do we mean by “health”?– What do we mean by “prevention”?– A macro-view of the community
• The role of behavior– The impact of a few simple behaviors
• The “causes of the causes” of health risks– Determinants of health
• Creating healthy community– Active stakeholders– Business and industry as a key partner
• Approach to engaging business and industry– The Triple Aim
• Open dialogue
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Health, Prevention, and Connections
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What Do We Mean by What Do We Mean by ““HealthHealth””
“Health is a state of complete physical, mental, and social well-being and not merely the absence of disease of infirmity”
-- WHO, 1948
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What Do We Mean by What Do We Mean by ““HealthHealth””
No DiseaseDisease
Wellbeing
No WellbeingIllness Continuum
WellnessContinuum
Optimal Health
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What Do We Mean by What Do We Mean by ““PreventionPrevention””
Tertiary prevention is intended to reduce, mitigate, or limit the progress or exacerbations of diagnosed disease and is an important aspect of therapeutic and rehabilitative medicine.
Tertiary
Secondary prevention is intended to cure patients and reduce the more serious consequences of disease through early diagnosis and treatment. It is directed at the period between onset of disease and the time of diagnosis, and aims to reduce the prevalence of disease.
Secondary
Primary prevention intends to limit the incidence of disease by controlling causes and risk factors.
Primary
Primordial prevention addresses the underlying conditions that may lead individuals or populations to become exposed to causative factors for disease—it is intended to prevent the occurrence of risk factors in the population. The goal is to address social and environmental conditions that create health damaging exposures and susceptibilities among the population.
Primordial
Brief DescriptionLevel of Prevention
Source: Pronk, NP. Editor. ACSM’s Worksite Health Handbook, 2nd Edition, 2009
Hea
lth a
nd C
are
Con
tinuu
m
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How Would How Would ““PreventionPrevention”” be Applied?be Applied?
Care Continuum
No Disease Disease
Hea
lth a
nd W
ellb
eing
Con
tinuu
mHealth
No Health
Tertiary Prevention
Primordial Prevention
Primary Prevention
Secondary Prevention
Sources: Adapted from: Manderscheid, R. National Health and Health Care Reform presentation, 2009. Pronk, NP. Editor. ACSM’s Worksite Health Handbook, 2nd Edition, 2009
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MicroIndividual
Gender, SES,Race
MesoRelationships
Family, Peers,
Groups
ExoCommunitySchools,
Neighborhoods,Workplace
MacroSocietal
Social Policy, Norms
A Socio-Ecological View
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““Ask YourselfAsk Yourself””
• In your world, how often do you think people…– say “health” but mean “care”?– say “prevention” and imply “early
detection?”– fail to see their own roles in health [and
health reform]?
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The Role of Personal BehaviorThe Role of Personal Behavior
• Does it matter? Or is it all genetics?
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Determinants of HealthDeterminants of Health
Behavioral patterns
40%
Genetic predisposition
30%
Health care10%
Social circumstances
15%
Env ironmental exposures
5%
The single greatest opportunity to improve health lies in personal behavior
Source: Schroeder, S. N Engl J Med 2007;357:1221-1228.
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Actual Causes of Death in the U.S.Actual Causes of Death in the U.S.
Source: Mokdad, A.H. JAMA 2004;291;1238-1245 [Errata, JAMA 2005;293:293-294].
0 5 10 15 20
Illicit Drug use
Sexual behavior
Firearms
Motor vehicle
Toxic agents
Microbial agents
Alcohol
Poor diet and physical inactivity
Tobacco
%
2000
1990
4 Behaviors cause nearly
40% of all deaths in the U.S. (year 2000)
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Optimal Lifestyle Metric Optimal Lifestyle Metric (OLM)(OLM)
• Being physically active
• Not smoking
• Eating 5 fruits and vegetables each day
• Drinking alcohol in moderation
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Optimal Lifestyle Adherence, Health,
and Costs
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Optimal Lifestyle Metric
• OLM behaviors cluster and show a significant degree of inter-correlation
• Adherence to OLM behaviors has been associated with– Improved functional health– Increased compliance with clinical preventive services– Lower overall mortality– Lower cause-specific mortality (cardiovascular causes)– Increased longevity– Lower 11-Year incidence of stroke
• Despite its association with positive health outcomes, OLM adherence is low in the population– Between 5% and 8% in the U.S. population– Approximately 10% among employed populations
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Adherence to OLM and New DiseaseAdherence to OLM and New DiseaseDifference in 2Difference in 2--year incidence of new disease between people who year incidence of new disease between people who
adhere to OLM and those who do not adhere to OLM and those who do not
(% fewer new cases of disease)(% fewer new cases of disease)
-15 -17
-24
-43 -45
-66
High BloodPressure Cholesterol Cancer Back Pain
HeartDisease Diabetes
Source: HealthPartners Health Assessment database, 2007
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Adherence to OLM and Emotional HealthAdherence to OLM and Emotional HealthDifference in emotional health concerns among employees who adheDifference in emotional health concerns among employees who adhere to re to
OLM and those who do not OLM and those who do not (% fewer people having this health concern )(% fewer people having this health concern )
-47
-74-81 -82
-93
DepressionStress
Concerns
EmotionalHealth
Concerns
Poor or FairGeneralHealthStatus
High Risk forDepression
Source: HealthPartners Health Assessment database, 2007
Hea
lth
…and w
hat about
cost?
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Lifestyle Adherence and Health Care CostsLifestyle Adherence and Health Care Costs
• Difference in annual health care costs between the two risk profiles = 49%
– “Low-Risk” profile • BMI of 25 kg/m2
• Never-smoker• Physically active
– “High-Risk” profile• BMI of 27.5 kg/m2
• Current smoker• No physical activity
Source: HealthPartners Research Foundation Study. JAMA 1999;282(23):2235-2239
WhiteWoman White Man
Non-WhiteWoman Non-White
Man
$3
,99
4$
5,93
9
$3
,12
3$
4,64
4
$5,
26
6$
7,8
32
$4
,117
$6,
123
Low Risk High Risk
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Adherence to OLM and Adherence to OLM and Productivity LossProductivity Loss
Impact on excess health-related productivity loss – Absenteeism– Presenteeism
Based on 33,956 employees (Sample company, assuming $50,000 average salary, expressed as per person per year productivity loss in 2009 dollars)
Source: HealthPartners Health Assessment database, 2009
$4,049
$3,644
$2,621
$1,342
$890
OLM 0 OLM 1 OLM 2 OLM 3 OLM 4
($)
“the costs of Doing NothiNg is too high”
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““Ask YourselfAsk Yourself””
• In your world, how difficult do you think it is to implement programs that address these 4 behaviors? – What percentage of the community do you believe
adhere to all of these relatively simple behaviors at the same time?
– Which behavior(s) do you think is the one that gives employees the most trouble?
– Which behavior(s) do you think may be mosthelpful to support changes in other behaviors?
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The Determinants of Health
Addressing the “causes of the
causes”
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Social Social Determinants of HealthDeterminants of Health
Source: Wilkinson R, Marmot M. Social Determinants of Health. The Solid Facts. Copenhagen: WHO Regional Office for Europe, 2003.
Top Ten:• The social gradient• Stress• Early life• Social exclusion• Work• Unemployment• Social support• Addiction• Food• Transport
Notable Observations:• Access to health care is not
among the top ten• Health care alone may not
be able to counteract the impact of these factors…
• …only 10% of the health determinants is ascribed to health care access
• Ergo,…the nation’s heavy investment in the personal health care system is a limited future strategy for promoting health
Sources: Schroeder, S. N Engl J Med 2007;357:1221-1228.Kottke TE, Pronk NP. Taking on the social determinants of health. Minnesota Medicine2009;Feb:36-39.
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Business and Industry as a Partner
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Community Health and Business and Industry
• Adults spend a substantial portion of their waking hours in the workplace
• Frequent and sustained messages can reach employees and dependents
• Setting facilitates the introduction of social support networks
• Companies benefit through healthy and more productive people
• People benefit trough lower costs (medical) and more productive lives (QOL)
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The Triple Aim
Population Healthand Productivity
ROI andAffordability
ExceptionalExperience
“Sweet spot”
Simultaneously achieve exceptional experience,
population health improvement, and ROI
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Approach to the Approach to the Triple Aim in Triple Aim in
Business:Business:The JourneyWell The JourneyWell
ModelModel
Source: IHI and JourneyWell
1. DESIGN
2. EXPERIENCE
3. HEALTH &PRODUCTIVITY
4. ROI
•Comprehensive•Evidence-informed•Person-centric
•Participation•Satisfaction•Willingness to refer
•Modifiable behavior•Quality of life•Human performance
•Reduced Utilization•Productivity improvement•Cost-effectiveness/ROI
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Where Does Health Impact Where Does Health Impact ““ValueValue””??
Sources: Hemp, P. Harvard Business Review, October, 2004Leutzinger, J. In: Pronk, N. (Ed). ACSM’s Worksite Health Handbook, 2nd Ed., 2009
Medical Costs
Non-Medical Costs
Medical andPharmaceutical24%
Presenteeism63%
Absenteeism6%
Short-term Disability6%
Long-term Disability1%
Workers’Compensation<1%
(Less) Tangibles:
• Decision quality• Stamina, resilience, vitality• Happiness• Interpersonal skills • Interpersonal relationships• Attitude• Company loyalty• Morale• Recruitment• Retention
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Individual
Group / Population
Organizational
Environmental
Health assessment Competitions
Social networks
Onsite classes
Seminars
EAPSelf-care
Health fairs
Implementations, Communications, Reporting, Data Management, Legal Support
Behavior change programs
Biometrics
Organizational assessment for best practices
Incentives program
Communications plan
Policy development
Leadership
Supportive activity around legislative action in the community
Employer coalitions
A Macro View
Culture of Health Initiatives
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What Works?
• Systematic Review Findings from the Task Force on Community Preventive Services (AJPM 2010;32(2S):S223-S300)– Assessment of Health Risk with Feedback
• Insufficient evidence– Assessment of Health Risk with Feedback PLUS health education
• Recommended– Work-based incentives and competitions to reduce tobacco
• Insufficient evidence– Work-based incentives and competitions to reduce tobacco PLUS
heath education• Recommended
– Smokefree policies to reduce tobacco use• Recommended
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• Essential Elements of Effective Workplace Programs and Policies for Improving Worker Health and Wellbeing– Organizational Culture and Leadership– Program Design– Program Implementation and Resources
What Works?
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What Works?
A Field Resource
To connect worksite health research and practice.
To provide a framework that supports integration of worksite health promotion into a broader set of health promoting strategies (incl. environmental, cultural, and organizational).
To provide access to information that illustrates an explicit connection between worker health and business performance.
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Multi-Level, Multi-Component, Comprehensive, and Integrated Approaches
• Leverage integration– At multiple levels– Across multiple strategies– Using online tools and enabling
technologies
• Connect individuals to groups and populations (networks)
• Modifiable and QOL health scores as indicators of individual and population health improvement
Environmental
Organizational
GroupInter-Individual
Individual
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Environmental
Organizational
Inter-individual
Individual
Community connected
Organizationallyrelevant
Personally relevant
Financially rewarding
Socially rewarding
Simple Possible
Leve
ls o
f Inf
luen
ce
Make Being Healthy…
Exceptional Customer and User Experience
OutcomesHealth
ProductivityFinancial ROI
Comprehensive, Multi-Level, Multi-Component Programming
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JourneyWell Case StudyJourneyWell Case Study
93% program satisfactionEXPERIENCE
Source: ACSM’s Worksite Health Handbook, 2nd Edition, 2009
• Tobacco use 37%• Physical Activity (% meeting Guidelines) 58%• Fruits and Vegetables 89%• Alcohol use No change (99% all years)
• OLM from 19.1% (2004) to 27.5% (2007) 44%
HEALTH &PRODUCTIVITY
ROI
•Demonstrated 3:1 ROI in 2.5 years
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Thank You!Thank You!
“Both in importance and in time, health precedes disease. Therefore we ought to consider first how health may be preserved and then how one may best cure disease.”
--Galen, circa 85 AD