Finger Lakes Health Systems Agency

Addressing Disparities and the Social Determinants of Health through

Consumer and Community Engagement

Wade Norwood, Chief Program Officer

PHIP Contractor Orientation

January 23, 2015

Presentation Aims

• A model for addressing identified health priorities and making population health data actionable

– The High Blood Pressure Collaborative

• The Social Determinants of Health (SDOH)

• A model for convening around health disparities– Beyond episodic convening to standing African American and

Latino Health Coalitions

January 23, 2015 www.flhsa.org 2

High Blood Pressure Collaborative (HBPC)• High Blood Pressure Registry• Best Practice

– Disseminate guidelines, recommendations and literature, design practice reports, address clinical inertia

• Practice Improvement Consultants– Academic detailing model, clinicians based in local

health systems, motivate transformational change

• Community-Based Interventions

January 23, 2015 www.flhsa.org 3

Registry Date

Monroe Co Population 18 & Older

Estimate of HBP

Population (30%)

Patients in HBP

Registry with BP

Info

Control Rate < 140/90

Control Rate < 150/90

Dec-10 578,200 173,460 59,400 62.7% 71.3%Dec-11 582,000 174,600 88,900 64.4% 72.2%Dec-12 585,900 175,770 104,300 66.7% 74.9%Dec-13 589,788 176,937 112,549 70.8% 77.8%Jun-14 591,745 177,524 114,568 70.1% 77.5%

Control Rate is age-sex adjusted % of established patients with BP read in last 13 months with BP <140/90

High Blood Pressure Registry Monroe County Residents 18 & Older

January 23, 2015 www.flhsa.org 4

5

HBPC Community-Based Interventions• Community Engagement

– Churches– Barber shops/beauty

salons– CBOs, community events– Kiosks

• Communication– Website– Collateral materials

January 23, 2015 www.flhsa.org

Effect of Race/Ethnicity and Socioeconomic Status on Blood Pressure Control

Dec_2011 Dec_2012 Dec_2013 Jun_201450

55

60

65

70

75

80

57.559.5

61.837885657414660.395307570977957.3

64.465.903405811044865.981873111782566.3

69.5

74.166213521841673.3084278527789

HBP Control Rate - By Race/Ethnicity

Black - Non Hispanic Hispanic

White - Non Hispanic

Dec_2011 Dec_2012 Dec_2013 Jun_201450.0

55.0

60.0

65.0

70.0

75.0

80.0

60

64.265.865204214172364.5713435205398

65.7

67.3

71.446933529195871.752807199171866.569.2

74.755455229495973.9582742249712

HBP Control Rate - By Social Economic Sta-tus

Low Moderate High

January 23, 2015 www.flhsa.org 6

Healthy People 2020 SDOH Framework

“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”

- World Health Organization

January 23, 2015 www.flhsa.org 7

FLHSA’s African American and Latino Health Coalitions

• The 2014 editions of "What's Goin' On" and "Nuestra Salud" provide a clear view of the health of the region's African American and Latino communities and of the nature of health disparities.

• These reports demonstrate that "place matters" in health outcomes and that those who residing in Rochester's poorest neighborhoods experience higher rates of premature death.

January 23, 2015 www.flhsa.org 8

www.flhsa.org 9January 23, 2015

Not meet recommendations for aerobic activity No leisure-time physical activities in past month0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

44%

25%

31%

12%

Percent of Respondents With Select Physical Activity Habitsby Geography, Monroe County, 2012

AAHC Focus Area Balance of Monroe County

Pe

rce

nt

of

Re

sp

on

de

nts

wit

h S

ele

ct

Ph

ys

ica

l Ac

tiv

ity

Ha

bit

s

Recommended aer-obic activity - 150 minutes per week

Differences are statistically significant (per MCDOH)Focus Area = ZIP codes 14605, 14606, 14608, 14609, 14611, 14613, 14619, 14621Data Source: MCDOH AHS, 2012 Finger Lakes Health Systems Agency

10January 23, 2015 www.flhsa.org

HBPC Consumer Engagement Methodology• Registry-generated Consumer Profile

– Hypertensive Crescent Residents 35-54

• Facilitated Representative Consumer Engagement – 4 Focus Groups (February – May 2014)– 12 Key Informant Interviews (May – July 2014)

Finding #1: It’s not awareness! Even among the very poor, the barrier to control is far less about awareness and far more about the situational and socio-economic challenges of behavioral change.

Finding #2: It’s hard to be poor! Two Realities, Both Unhealthy: Either too much to do as a single parent!

Overwhelmed, exhausted, stressed, anxious, unhealthy

Or TOO MUCH OF NOTHING! = Boredom + disability + no work Depression and unhealthy negativity.

January 23, 2015 www.flhsa.org 11

www.flhsa.org

Finger Lakes Health Systems Agency

Finger Lakes Health Systems Agency is the health planning center for Rochester and the Finger Lakes. Through extensive data collection and analysis, the agency identifies community needs, then brings together residents, hospitals, insurers, physicians and other healthcare partners to find solutions. Located in Rochester, FLHSA serves the nine counties of Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne and Yates.

1150 University Avenue • Rochester, New York • 14607-1647585.224.3101 • www.flhsa.org

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