PCPH Collaborative Newsletter Partner Highlights

This is a compilation of stories, websites, and initiatives from the PCPH Collaborative Newsletter that highlighted our partners and the work they have done in regards to primary care public health integration. To go to a partner blurb, click on the title in the Table of Contents and it will send you to where it is located in the document.

Table of Contents Agency for Healthcare and Research Quality The Institute for Healthcare Improvement American Academy of Family Physicians- Inter‐professional Education Collaborative Fostering Collaboration Mayo Clinic American Academy of Family Physicians-Family Minnesota Department of Human Services Medicine Campaign Million Hearts American Association of Colleges of Nursing National Academy for State Health Policy American College of Physicians National Association of Community Health American College of Preventive Medicine Centers American Heart Association The National Association of County and City American Medical Association Health Officials The Arizona Center for Integrative Medicine National Association of Medicaid Directors (AzCIM) and The Academic Consortium for National Improvement Partnership Networks Integrative Medicine and Health National Network of Public Health Institutes Association of American Medical Colleges National Quality Forum The Association of Maternal & Child Health Programs New York Department of Health Association for Prevention Teaching and The North American Quitline Consortium Research Practical Playbook Association of Public Health Nurses Prevention Institute The Children and Recovering Mothers Public Health Foundation Council of State and Territorial Epidemiologists Rhode Island Department of Health Department of Health and Human Services & SAMHSA‐HRSA Center for Integrated Health National Quality Forum Solutions Department of Population Medicine School Based Health Alliance George Washington University & School of State of Colorado Public Health and Health Services University of Kentucky College of Public Health Georgetown University Medical Center University of South Florida Health Leads Veterans Health Administration The Health Policy Institute of Ohio The Hilltop Institute Health Resources and Services Administration Institute for Clinical Systems Improvement

Newsletter Partner Highlights

AHRQ Explores Clinical‐Community Relationships to Improve Delivery of Preventive Services (March 2013) The Agency for Healthcare Research and Quality's (AHRQ) integration efforts include a Clinical Community Relationships Measures Atlas developed to improve the delivery of clinical preventive services, an "Evaluation Roadmap" based on a literature review and evaluation of research gaps, and the Candidate Measures Report with a suggested core set of candidate measures. In addition, AHRQ's Health Care Innovations Exchange includes innovation profiles and tools for improving quality and reducing disparities in healthcare. For more information, visit Linking Primary Care and Resources in the Community to Improve Health.

American Academy of Family Physicians Fosters Collaboration (March 2013) The American Academy of Family Physicians (AAFP) represents more than 110,600 physicians and medical students nationwide and is the only medical society devoted solely to primary care. The AAFP is committed to fostering collaboration between public health officials and primary care health professionals including promoting the ASTHO‐Supported Primary Care and Public Health Collaborative. One example: AAFP Director Dr. Rebecca Jaffe's June 26th AAFP Leader Voices blog post calling on family physicians to share their personal integration stories. "We need to share the success stories from our communities so we can learn from them and possibly even replicate them elsewhere," says Dr. Jaffe in the post.

American Association of Colleges of Nursing Incorporates Population Health Into Nursing Education (September 2013) The American Association of Colleges of Nursing (AACN) is the national voice for baccalaureate and graduate nursing programs in the United States. Recent AACN efforts have focused on incorporating population health into collegiate nursing education. In November 2013, AACN completed two national webinars for both faculty and students focused on the integration of public health concepts into undergraduate nursing curricula. In September 2013, AACN completed a curriculum supplement with guidance on the integration of public health and undergraduate nursing. Additionally, AACN will sponsor graduate concurrent sessions at the national nursing doctoral and master's curriculum conferences in January and February.

American College of Physicians Efforts to Integrate Primary Care and Public Health (April 2012) American College of Physicians (ACP) is a national organization of internists. With 133,000 members, ACP is the largest medical specialty organization and second‐largest physician group in the United States. ACP has been actively involved in integrating primary care and public health. National level integration efforts include the recent position paper Strengthening the Public Health Infrastructure, the High Value Care initiative, and the promotion of the patient‐centered medical home model. Local level integration activities include presentations at state chapter CME meetings, success story write ups, education of medical students and residents, and future webinars to educate governors and interested

members. ACP also uses newsletters to disseminate best practice information and link state members with ASTHO’s integration resources.

American College of Preventive Medicine (July 2013) The American College of Preventive Medicine (ACPM), founded in 1954, is the premiere organization for physicians dedicated to disease prevention and health promotion. ACPM is a strong supporter of integration, as preventive medicine physician’s work at the nexus of primary care and public health. ACPM physicians are employed in diverse research, academia, government, clinical and other settings worldwide, yet all of its members emphasize using evidence‐based health promotion, disease prevention, and systems‐based approaches to improve health and healthcare. ACPM seeks to promote the specialty of preventive medicine and the advancement of scientific knowledge in preventive medicine through professional, multi‐disciplinary education, collaboration, and communication. As a part of its work in the ASTHO‐supported Primary Care Public Health Collaborative, the ACPM co‐chairs the Value Proposition Committee.

American Heart Association Links Public Health and Primary Care Through Stroke Prevention Efforts (2010) The American Heart Association (AHA) is the nation's oldest, largest voluntary organization devoted to fighting cardiovascular diseases and stroke. In 2010, AHA partnered with the Illinois Critical Access Hospital Network to improve the quality and timeliness of stroke care in participating critical access hospitals (CAHs). Through the use of the AHA Get with the Guidelines measurement tool, and the implementation of community and professional education resources and programs, participating CAHs demonstrated steady improvement on all measures for treating qualified acute stroke patients with tissue plasminogen activator within 60 minutes of hospital arrival. AHA continues its efforts to bring together primary care and public health with yesterday's release of new guidelines that expand evidence‐based treatment recommendations, offer new risk calculations for African Americans, and recommend behavioral modifications to reduce the risk of heart disease and stroke to improve population health.

American Medical Association (AMA) Partners to Improve Health Outcomes (December 2014) AMA is dedicated to creating tools and resources for physicians that result in better health outcomes for patients, and to strengthening links between the clinic and community through novel strategies and collaborations. One example is the Improving Health Outcomes Initiative, where the AMA is committing its resources, expertise, and reach to prevent heart disease and type 2 diabetes and to improve outcomes for those suffering from these diseases. The AMA has teamed up with the YMCA of the USA to help prevent the onset of diabetes among Medicare participants who have prediabetes. To prevent heart disease, the AMA is working with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality and the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities by supporting practices in their efforts to improve hypertension control. The AMA aims to create a nationwide professional movement that includes connecting physician practices to community resources to help prevent diabetes and control hypertension.

APTR Advances Physician and Health Professional Education in Prevention and Population Health (February 2014) The Association for Prevention Teaching and Research (APTR) is the national professional membership organization for individuals and institutions advancing the education of physicians and other health professionals in prevention and population health. APTR's commitment to prevention in clinical and community settings bridges primary care and public health and drives the development and dissemination of its educational and professional activities, including Prevention and Population Health Teaching Modules, the Paul Ambrose Scholars Program and other fellowship programs, the annual Teaching Prevention conference, and the American Journal of Preventive Medicine.

The Arizona Center for Integrative Medicine (AzCIM) and the Academic Consortium for Integrative Medicine and Health’s National Center for Integrative Primary Healthcare (April 2015) The Arizona Center for Integrative Medicine (AzCIM) and the Academic Consortium for Integrative Medicine and Health (The Consortium) in cooperation with the Health Resources and Services Administrating (HRSA) create the National Center for Integrative Primary Healthcare (NCIPH). The NCIPH is charged with advancing the incorporation of competency and evidence based integrative health (IH) curricula and best practices into primary care education and practice. The most important gap filled by this 3‐year project will be the development of a set of competencies and educational materials relevant to and appropriate for use across the entire inter‐professional spectrum of primary care practitioners. View slides and minutes from the NCIPH presentation for the Workforce Committee on April 22, 2015.

Association of American Medical Colleges' (AAMC) Public Health Integration Efforts (October 2014) The AAMC is a not‐for‐profit association representing all 141 accredited U.S. and 17 accredited Canadian medical schools and nearly 400 major teaching hospitals and health systems. Through these institutions and organizations, the AAMC represents 128,000 faculty members, 83,000 medical students, and 110,000 resident physicians. Through the AAMC‐CDC cooperative agreement aimed at improving the integration of public health concepts into health professions education, the AAMC supports and engages constituents through the Public Health in Medical Education Online Community of Practice, MedEdPORTAL Public Health Collection, and the AAMC‐CDC Public Health Policy Fellowship open to early‐career physicians. Through a cooperative agreement with the NIH, the AAMC collaborates with the Coalition of Urban Serving Universities/ Association of Public and Land‐grant Universities to support a National Learning Collaborative, Urban Universities for HEALTH, to expand and enhance a diverse and prepared health workforce to reduce health disparities in urban communities.

The Association of Maternal & Child Health Programs (AMCHP) Innovation Station (July 2014) The Association of Maternal & Child Health Programs (AMCHP) Innovation Station Maternal and child health programs achieve greater impact when public health and primary care are well integrated and partner effectively. To facilitate the sharing and replication of effective approaches, AMCHP collects, reviews, and disseminates innovative practice examples across a continuum ranging from emerging to promising to best practice. AMCHP's Innovation Station is a searchable database that allows maternal and child health programs to benefit from the lessons learned by their peers in such areas as health reform implementation, service coordination and integration, preconception and inter‐conception care, adolescent health, services for children and youth with special health care needs, and family involvement, among others. Click here to learn more about AMCHP's Best Practices Program and submit your own example to be included in the Innovation Station.

Association of Public Health Nurses Supports Integration (June 2013) The Association of Public Health Nurses (APHN) includes public health nurses working across the 50 states and U.S. territories to promote the health and safety of the population and create healthy communities. Public health nursing practice focuses on population health, with the goal of promoting health and preventing disease and disability. APHN has been a part of the ASTHO‐supported Primary Care and Public Health Collaborative since its beginning with the creation of the Primary Care and Public Health Strategic Map. It is also strongly engaged in other national initiatives, including Million Hearts, and was a part of a recent study on Enumeration and Characterization of the Public Health Nurse Workforce.

The Children and Recovering Mothers (CHARM) Collaborative: Improving Health Outcomes for Women with a History of Opioid Dependence and their Infants (September 2014) The CHARM Collaborative in Vermont brings together a multidisciplinary group of agencies to provide comprehensive care management for pregnant and post‐partum women with opiate addiction and their infants up to 18 months, depending on need, in an effort to improve short‐ and long‐term health outcomes. The CHARM Collaborative serves approximately 200 women and their infants annually, and coordinates a range of clinical and social services (e.g., child welfare; Medication Assisted Treatment; home visiting; treatment for co‐occurring mental health disorders; medical services for incarcerated pregnant women), as well as support in securing reliable transportation, housing, and daycare. CHARM mothers are supported by a team comprised of a physician, registered nurse, medical assistant, and social worker who meet monthly to discuss cases. Click here to learn more.

Colorado Plans to Establish Partnership Between Public Health, Behavioral Health and Primary Care (December 2014) Colorado is one of 11 awardees of the State Innovation Model Initiative Model Test Awards Round Two. Colorado's plan, entitled "The Colorado Framework," creates a system of clinic‐based and public health supports to spur innovation. The state will improve the health of Coloradans by: (1) providing access to integrated primary care and behavioral health services in coordinated community systems; (2) applying value‐based payment structures; (3) expanding information technology efforts, including telehealth; and (4) finalizing a statewide plan to improve population health. Funding will assist Colorado in integrating physical and behavioral health care in more than 400 primary care practices and community mental health centers comprised of approximately 1,600 primary care providers. In addition, the state will work to establish a partnership between their public health, behavioral health and primary care sectors.

Council of State and Territorial Epidemiologists (CSTE) Public Health and Primary Care Efforts (2012) CSTE is a not‐for‐profit association representing epidemiologists in governmental public health. Public health and primary care integration efforts permeate much of the work led by epidemiologists. Engaging the clinical community has facilitated a coordinated response to Ebola through hospital preparedness and screening, shared guidance on infection control and personal protective equipment and contract tracing. CSTE provides trainings and discussion forums for Centers for Disease Control and Prevention's Epi Info and community health assessments. Fellowship training opportunities are offered as skill‐ building opportunities to improve population health through inter‐professional education. Integrating public health surveillance with primary care through electronic laboratory reporting, syndromic surveillance, and the use of registries allows for real‐time, data‐driven patient care and community health.

The Department of Population Medicine Provides Future Medical Professionals with Population Health Skills (January 2014) The Department of Population Medicine (DPM) resides within the Harvard Pilgrim Health Care Institute and is an appointing department of Harvard Medical School (HMS). DPM directs the HSM Clinical Epidemiology and Population Health course and is home to the Primary Care and Population Medicine Residency Program. The goal of DPM's Center for Population Health Education is to develop innovative curricula to provide future medical professionals with the skills needed to understand the population context of health and illness, actively participate as part of public health systems, and apply population‐ level strategies. These efforts include the Pop Med Portal, an online platform for sharing content and ideas that further teaching population health concepts and skills to future healthcare professionals.

Family Medicine Campaign to Promote Primary Care (2014) The American Academy of Family Physicians, along with seven other family medicine organizations, have joined together to launch Family Medicine for America's Health. The goals of this effort are to transform perceptions and behavior around health and health care and foster awareness and action to support the essential role of primary care. A key element of these activities is a three‐year communications campaign – Health is Primary – that will combine advertising, media outreach, workplace partnerships and stakeholder engagement to demonstrate the role of primary care in keeping people healthy, improving population health and reducing health care spending.

Georgetown University Medical Center (August 2013) Georgetown University Medical Center (GUMC) educates trainees at all levels in population health. In response to a charge from the dean of the medical school to train the next generation in population health and prevention, medical students will complete a longitudinal curriculum in population health. Interested students may apply for a summer internship at ASTHO to get exposure to public health policy and complete a mutually beneficial project. GUMC partners with the Johns Hopkins Bloomberg School of Public Health for students seeking a MD/MPH. Georgetown primary care residents have the opportunity to participate in a Health Policy and Public Health elective. In addition, Georgetown collaborates with the Robert Graham Center to offer a one‐year Primary Care Health Policy fellowship.

George Washington University Integrates Education and Training in Public Health and Medicine (January 2014) The George Washington (GW) School of Medicine and Health Sciences and School of Public Health and Health Services have been working jointly to provide education and training in public health to medical students and residents as well as education and training in clinical medicine to master of public health students. Examples include the Community Health Elective, the joint MD/MPH Program, an Underserved Medicine and Public Health Program, the MPH track in Community Oriented Primary Care. The GW School of Medicine is currently revising its curriculum to include integrated education and local experiences in public health and health policy for all medical students. GW's 2013‐2014 Health Workforce Speaker Series includes recent and upcoming lectures on workforce challenges and healthcare transformation.

Health Leads Connects Providers with Community Resources (June 2015) Health Leads envisions a healthcare system that addresses all patients' basic resource needs as a standard part of patient care. Founded in 1996, Health Leads has demonstrated that it is possible to integrate patient resource screening and navigation into care delivery. As a service provider, Health

Leads partners with health systems to integrate patient social needs into care by operating Health Leads Desks in clinical settings. Providers "prescribe" basic resources (like food and heat) and well‐trained student Advocates stationed in the clinics work side‐by‐side with patients to "fill" those prescriptions by accessing community resources and public benefits. View the slides and minutes from Health Leads presentation on the All Partners Call.

HHS and National Quality Forum Population Health Framework Project (August 2014) Under contract with the Department of Health and Human Services, the National Quality Forum (a not‐ for‐profit, nonpartisan, membership‐based organization that works to catalyze improvements in healthcare) is utilizing a multi‐stakeholder, collaborative process to develop a common framework for characterizing, measuring, and improving population health. The first year of the project resulted in a report called the Action Guide 1.0 that offers practical guidance for communities working on collaborative population health initiatives. Currently the report is being tested out by 10 communities across the nation, and their feedback will inform a revised version (Action Guide 2.0) to be released summer 2015. However, all stakeholders are strongly encouraged to provide input on this work, in particular through an open comment period on draft revisions to the report that will open in early to mid‐June. To learn more about the National Quality Strategy, please see the Stakeholder Toolkit.

The Health Policy Institute of Ohio (HPIO) Makes Progress to Measure Health Value (November 2014) HPIO, a health policy and public health institute in Ohio, provides independent, unbiased, nonpartisan information needed to create sound health policy. Currently, HPIO is developing a dashboard of health outcome and cost measures to track Ohio's progress in improving health value. This includes tracking population health outcomes, health costs, health care system performance, public health system performance, access to health care and evaluating Ohio's social, economic and physical environment. The HPIO Health Measurement Advisory Group consists of representatives from public health, public and private payers, state agencies, employers, providers and consumer groups. This work will lead to the creation of an Ohio Health Value Dashboard (to be released later this year). Read more about HPIO's Measurement Initiative.

The Hilltop Institute Hospital Community Benefit Program (April 2014) The Hilltop Institute at the University of Maryland, Baltimore County is a nonpartisan health research organization dedicated to improving the health and wellbeing of vulnerable populations. Hilltop's Hospital Community Benefit Program, funded by the Robert Wood Johnson and Kresge Foundations, is a central resource created specifically for state and local policymakers who seek to ensure that tax‐ exempt hospital community benefit activities are responsive to pressing community health needs. Products include: Hospital Community Benefits after the ACA, an issue brief series, the Community Benefit Briefing (newsletters), and the Community Benefit State Law Profiles, an interactive online resource that describes the community benefit landscape in each of the fifty states.

HRSA Collaborative Integrates Maternal and Child Health and Healthcare (January 2012) ASTHO, in partnership with HRSA's Maternal and Child Health Bureau, the Association of Maternal and Child Health Programs (AMCHP), and other partners, are working together to support the continuation of the HRSA Collaborative Improvement and Innovation Network (CoIIN) for Regions IV, V, and VI. The state and strategy teams (which include state hospital associations, physician champions, state perinatal quality collaborative representatives, state Medicaid, state health plans, and hospital representatives) work towards state infant mortality plans and collaborative work around early elective deliveries,

perinatal regionalization, preconception and inter‐conception health, SIDS/SUID, and social determinants of health. Next steps include a national rollout of the COIIN in partnership with the National Initiative for Children's Healthcare Quality (NICHQ). The CoIIN represents an excellent example of how effective public and private partners can work together around health and healthcare integration.

Institute for Clinical Systems Improvement Provides Resources for Clinicians to Connect with Community Partners (October 2014) The Institute for Clinical Systems Improvement (ICSI) is an independent, nonprofit health care improvement organization that is a collaboration of medical groups, hospitals, nonprofit health plans, employers, and consumers to bring innovation and urgency to improve health, the patient experience and quality, and affordability of care (the Triple Aim). ICSI is comprised of 50+ medical groups representing 8,000 physicians and is supported by member dues, sponsorship by nonprofit health plans and contracts/grants. ICSI's Going Beyond Clinical Walls Series funded by the Robert Wood Johnson Foundation supports the development of communication materials directed to a healthcare audience to promote greater integration of health care with public health and other community health resources. Going Beyond Clinical Walls is a series of communications and resources — including white papers, videos, a table of examples and related tools — inviting clinicians, clinical staff and administrators to connect with community partners and resources for effective problem‐solving in health care. The series is designed to support conversations that identify problems and opportunities, develop a shared vision for connections with community partners, and build practical next steps.

The Institute for Healthcare Improvement (IHI) Collaborative Program (February 2015) The Institute for Healthcare Improvement (IHI) is partnering with the MacColl Center for Health Care Innovation to launch a new collaborative program – Optimize Primary Care Teams to Meet Patients' Medical and Behavioral Needs. This 12‐month initiative, which launches in February, 2015, is designed to create the next generation of high performing primary care teams to address patients' medical and behavioral health issues and improve primary care's ability to care for the full range of patient needs. The collaborative is based on IHI's work on integrating behavioral health and primary care as well as evidence and insights assembled by the MacColl Center through Primary Care Teams: Learning from Effective Ambulatory Practices (PCT‐LEAP), a national program which studied exemplary primary care practices across the U.S. Participants will then deploy these optimized care teams to provide high quality medical and behavioral health care to their patients.

Inter‐professional Education Collaborative Prepares Future Practitioners for Team‐Based Disease Prevention and Quality Care (October 2013) In 2009, the Inter‐professional Education Collaborative (IPEC) was formed by six national health professional school associations: the Association of Schools and Programs of Public Health (ASPPH), American Association of Colleges of Nursing, American Association of Medical Colleges, American Association of Colleges of Osteopathic Medicine, American Association of Colleges of Pharmacy, and American Dental Education Association. IPEC's partners work collaboratively to promote constituent efforts that prepare future practitioners for collaborative, team‐based disease prevention and quality care through the creation of core competencies, faculty development institutes and conferences, and a MedEd portal. To learn more about IPEC, view the slides presented by Dr. Harrison Spencer, ASPPH President and CEO, to the ASTHO‐Supported Primary Care and Public Health Collaborative Workforce Committee.

Mayo Clinic and Partners Join Efforts to Address Health and Care for Olmsted County Residents (October 2013) Mayo Clinic is an equal partner in the Olmsted County Community Healthcare Access Collaborative (CHAC), a volunteer partnership of public health, social service, mental health, medical, school‐based, and other community‐based service providers working to identify and address issues of health and care for individuals in Olmsted County, Minnesota. CHAC creates sustainable system‐level and environmental changes to improve health and health equity. CHAC has positively impacted community health, by addressing cooperative care of asthma for school children, enhanced coordination of resources for community‐based health services, and health systems navigation for clients and providers.

Million Hearts Learning Collaborative State Teams to Present to Primary Care and Public Health Collaborative (October 2013) In October 2013, ASTHO selected 10 states to participate in a Million Hearts Learning Collaborative that utilizes a quality improvement process to partner across sectors to implement best practices and evidence‐based policies to identify, control, and improve blood pressure. On June 2, leaders from four of the ten Million Hearts state teams (New Hampshire, New York, Oklahoma, and Vermont) will present on steps taken to improve collaborations between public health and clinical care to identify, control and improve blood pressure.

Minnesota's Integrated Healthcare Delivery Program (June 2014) Hennepin Health is an innovative, integrated healthcare delivery program serving adults in Hennepin County, Minnesota. The program takes a holistic view of healthcare, focusing on each member's medical, behavioral health, and social needs. Services include housing, social services navigators, employment specialists, targeted case management, and specialized clinics with expanded hours to meet the needs of complex patients. From 2012 to 2013, the rate of emergency department use per 1,000 Hennepin Health members declined by 9.1 percent, while the rate of primary care visits increased by 2.5 percent. Hennepin Health is proving that reforms in the healthcare delivery system can improve clinical outcomes, improve quality and patient satisfaction, and decrease unnecessary expenditures. For more information, visit Hennepin Health's website, Facebook page, and most recent newsletter.

National Academy for State Health Policy Promotes Sharing Resources for Population Health (March 2014) The National Academy for State Health Policy (NASHP) is conducting the Integrating Public Health into State Health Reform Implementation initiative to encourage state public health leaders to share resources and ideas with state officials and stakeholders focused on reforming healthcare systems. This exchange occurs through State Refor(u)m, an interactive website supported by the Robert Wood Johnson Foundation with resources for population health discussions. Products include analyses of population health components of State Innovation Model plans and primary care extension programs, as well as a webinar on ACOs and population health. Register for State Refor(u)m here.

The National Association of County and City Health Officials Leads Integration Efforts (2013) The National Association of County and City Health Officials (NACCHO) represents approximately 2,800 local health departments across the country. NACCHO provides technical assistance and training to health departments and healthcare providers to conduct collaborative, comprehensive community health assessments and implement strategic community improvement plans. NACCHO also helps local

health officials develop competencies needed for public health‐healthcare integration through the Survive and Thrive program and a partnership with the Public Health Institute's National Leadership Academy for the Public's Health. As a member of the ASTHO‐Supported Primary Care and Public Health Collaborative, NACCHO supports efforts to help the public health workforce use informatics to bridge public health and healthcare efforts.

National Association of Community Health Centers (2010) The National Association of Community Health Centers (NACHC) works with a network of state health center and primary care organizations to serve community health centers and provide them with a unified voice and a common source for research, information, training and advocacy. NACHC provides many tools and resources to health centers to promote better integration. The patient centered medical home (PCMH), community partnerships, and Accountable Care Organizations (ACOs) are just a few examples of strategies that can assist health centers to deliver and maintain excellent primary care for underserved populations. Additionally, NACHC's research department collects data, performs analysis, and applies information to empower communities in their efforts to improve public health. It also educates the public, health officials, and decision‐makers at the local, state, and national level about the critical role of health centers in promoting access to high quality, affordable healthcare that reduces disparities and advances community well‐being

National Association of Medicaid Directors' Develops Resources to Support State Integration of Primary Care (August 2014) The National Association of Medical Directors (NAMD) represents and serves Medicaid directors in all 50 states, the District of Columbia, and the U.S. territories. NAMD supports the integration of primary care and population health for Medicaid beneficiaries through initiatives that bring states (Medicaid and public health) together to engage in shared learning, as well as through the development of resources that support Medicaid directors. In April 2014, NAMD released an issue brief on the role of data and analytics in reform, which discusses the importance of data in pursuing delivery models that support integration of primary care and population health. Later this year, NAMD will launch efforts that seek to integrate primary care with behavioral health and other community‐based services under a contract with the State Health and Value Strategies Project.

National Coordinating Center for PHSSR manages Multi‐State Study of Integration and Health Outcomes (December 2013) The National Coordinating Center for Public Health Services and Systems Research (PHSSR) supports applied research on the organization, financing, and delivery of public health programs and policies, including innovative approaches for bridging the public health and health care systems. A three‐year study managed by the National Coordinating Center for PHSSR and funded by the Robert Wood Johnson Foundation is examining variation in the degree of primary care and public health integration across local jurisdictions in Minnesota, Colorado, Washington, and Wisconsin. First‐year findings of 40 key informant interviews were recently highlighted in a Research‐In‐Progress webinar. The one‐hour webinar introduces an emerging framework to characterize the collaboration between primary care and public health sectors and identifies frequently cited facilitators and barriers to collaboration.

National Improvement Partnership Networks Facilitate Primary Care and Public Health Collaboration (July 2009) The National Improvement Partnership Network (NIPN) is a network of over 20 states that have developed Improvement Partnerships (IP) to advance quality and transform healthcare for children and their families. An Improvement Partnership is a durable state or regional collaboration of public and private partners that uses the science of quality improvement and a systems approach to change healthcare infrastructure and practice. NIPN is the national coordinating center for states' IPs and draws from the leadership of Vermont’s IP. Together with the member IPs, NIPN accelerates pediatric delivery system transformation through the implementation and dissemination of quality improvement knowledge and innovation. IPs draw from the collective expertise of partners from all sectors, including representatives from state public health, mental health, education and Medicaid agencies; professional organizations (e.g. local chapters of the American Academy of Pediatrics and American Academy of Family Physicians); academic medical center pediatric departments; policymakers; private insurers; schools; pediatricians; family practitioners; obstetricians and others. Visit NIPN’s website to learn more.

National Quality Forum Leads Efforts to Improve Population Health (April 2014) The National Quality Forum (NQF) is an essential forum for driving improvements in health and healthcare. NQF is leading efforts to develop measures, reports, and tools to help organizations improve healthcare quality. Efforts include a Community Action Guide that is being developed to help meet communities' increasing demand for population health programs as well as a project focused on risk adjustment for outcome and resource use performance measures. NQF is accepting public comments for both projects through April 16. To learn more and submit comments, visit the Population Health Framework and Risk Adjustment for Socioeconomic Factors web pages.

New York Supports Collaboration between Public Health and Primary Care (July 2014) New York is one of 11 awardees of the State Innovation Model Initiative Model Test Awards Round Two. New York will adopt a tiered Advanced Primary Care (APC) model for primary care. This model will include behavioral and population health, and be complemented by a strong workforce and engaged consumers, with supportive payment and common metrics. The state will: 1) institute a state‐wide program of regionally‐based primary care practice transformation to help practices across New York adopt and use the APC model; 2) expand the use of value‐based payments so that 80% of New Yorkers are receiving value‐based care by 2020; 3) support performance improvement and capacity expansion in primary care by expanding New York's primary care workforce through innovations in professional education and training; 4) integrate APC with population health through Public Health Consultants funded to work with regional Population Health Improvement Program contractors; 5) develop a common scorecard, shared quality metrics and enhanced analytics to assure that delivery system and payment models support three‐part aim objectives; and 6) provide state‐funded health information technology, including greatly enhanced capacities to exchange clinical data and an all‐payer database.

NNPHI Leads Efforts to Bridge Public Health and Healthcare (April 2014) The National Network of Public Health Institutes (NNPHI) is a national membership network supporting multi‐sector activities that result in measurable improvements of public health structures, systems, and outcomes. The 2014 NNPHI Annual Conference, Leading Change Through Innovative Solutions, will explore strategies, partnership opportunities, and innovative approaches related to population health improvement. NNPHI's portfolio involves projects with the CDC and the Robert Wood Johnson Foundation, such as the Leading through Health Systems Change planning tool, a baseline assessment of

public health and health care integration activities for 19 State Innovation Model Initiative grantees, and upcoming state forums offering practical, innovative strategies for public health and healthcare collaboration.

The North American Quitline Consortium Collaborates with EHR Vendors and Providers to Support State Tobacco Quitlines (2012) The North American Quitline Consortium (NAQC) is an international, nonprofit membership organization that seeks to promote evidence‐based quitline services across diverse communities in North America. Quitlines are telephone‐based tobacco cessation services that help tobacco users quit. NAQC has established a workgroup on eReferral to ensure that 1) all state quitlines are prepared to implement eReferrals with health care providers no later than 2016; 2) NAQC works with the health care system; and 3) EHR vendors are informed about NAQC activities. As of February 2015, the NAQC workgroup on eReferral is comprised of members from 6 states, quitline service providers and health care partners. The workgroup has produced 11 case studies on quitlines, service providers and health care partners engaged in eReferral projects and published a paper on eReferral (2012). Currently, a technical guideline on eReferral is being developed and will be available to NAQC members in spring 2015. For more information on the workgroup or eReferral for quitlines, contact NAQC ([email protected]).

Practical Playbook to Support Primary Care and Public Health Integration (September 2013) This week, the Duke University Department of Community and Family Medicine is conducting beta testing for A Practical Playbook: Public Health and Primary Care Together. ASTHO and other national partners are working with Duke, the de Beaumont Foundation, and CDC on a web‐based tool to help primary care and public health entities find productive ways to work together. The playbook highlights integration success stories from across the nation, such as Connecticut's Putting on AIRS: An Asthma Education and Environmental Assessment Program.

Prevention Institute Brings Together Public Health and Healthcare to Transform Communities (January 2014) Prevention Institute (PI) develops and elevates cutting‐edge approaches to preventing illness, violence, and injury before they occur in ways useful to public health professionals. PI believes effective prevention efforts require collaboration among many sectors and commitment to policy change that activates and transforms communities. A current focus is the advancement of its Community Centered Health Homes model, which integrates community prevention with delivery of health services. PI recently profiled healthcare leaders pursuing this approach in a series of interviews in Forbes. Join PI's Health Reform Rapid Response Network for resources to help make the case for health‐system transformation.

Public Health Foundation Increases Collaboration between Public Health and Healthcare (April 2015) The Public Health Foundation (PHF) has developed an innovative approach to addressing various community health challenges by focusing on collaboration and alignment between public health and health care. Population health driver diagrams identify primary and secondary drivers of a community health objective, and serve as a framework for determining and aligning actions that can be taken across disciplines for achieving it. PHF has demonstrated the value of this approach through the development of the Population Health Driver Diagram to Increase Use of Oral Health Care, and the piloting of the Public Health Antibiotic Stewardship Driver Diagram. This strategy relies on public health and health care to work collaboratively, offering far reaching potential for both sectors and the communities they serve.

PHF is seeking partners at the state level to pilot these driver diagrams to align the efforts of public health and health care to address longstanding and emerging community health challenges.

Rhode Island's Immunization Programs (2013) Leadership from the Rhode Island Department of Health, primary care and vaccine advisory committees, and other key players has contributed to successful statewide vaccination efforts, including school‐ based vaccinations, public clinics, and a perinatal hepatitis prevention home visiting program, among others. To read the full story click here.

SAMHSA‐HRSA Center for Integrated Health Solutions Leads Efforts to Integrate Primary Care and Behavioral Health Services (January 2014) The SAMHSA‐HRSA Center for Integrated Health Solutions (CIHS) is a one‐stop resource to help providers, healthcare administrators, policy makers, and other healthcare professionals build behavioral health into primary care settings and primary care into behavioral health settings. CIHS provides training, technical assistance, and resources aimed at addressing the needs of individuals with mental health and substance abuse conditions within multiple domains, including: integrated care models; workforce development; financing; clinical practice; operations and administration; and health and wellness. Recent CIHS resources include Core Competencies for Integrated Behavioral Health and Primary Care and A Standard Framework for Levels of Integrated Care.

School Based Health Alliance Brings Population Health to School‐Based Health Centers (2013) The School‐Based Health Alliance is the national voice for school‐based health centers (SBHCs). In partnership with Kaiser Permanente, the School‐Based Health Alliance is leading the Hallways to Health initiative which focuses on the impact SBHCs can have on population health and is working with affiliates in California, Georgia, Maryland, Oregon, and Washington to lead program efforts on the ground. The School‐Based Health Alliance also offers resources to support community health workers through its Community Health Worker Reference Center and will launch New Directions for School‐ Based Health Center Grants to enable the school‐based healthcare field to become integrated and active participants in the larger healthcare ecosystem.

UKY Improving Community Health Through Successful Partnerships (November 2014) The University of Kentucky's (UKY) College of Public Health is leading a study to identify, compare, and contrast exceptional models of collaboration involving community hospitals, public health departments, and other stakeholders who share commitment to improving community health, and to determine key lessons learned from their experience. UKY invites nominations of strong, existing, and operational collaborations involving public health departments, hospitals, and other parties committed to working together to improve the health of the communities they serve. To learn more about the study, visit the Executive Summary and e‐Nomination Form or contact the study coordinator Ann Kelly, principal investigator Larry Prybil, co-investigator Douglas Scutchfield, or co-investigator Glen Mays.

USF Bridges the Gap Between Public Health and Medicine (February 2014) Through academics and service, students at the University of South Florida (USF) are bridging the gap between its Colleges of Public Health and Medicine. Examples include the MD/MPH program, options for medical students to obtain a scholarly concentration in public health, and an interdisciplinary USF Health Service Corps program that enables students in the health professions to participate in community activities together. Volunteers at the student run BRIDGE Clinic (Building Relationships and

Initiatives Dedicated to Gaining Equality) also bring health and social services to the uninsured. Through campus‐based organizations like the International Health Service Collaborative, students promote sustainable health projects in underserved communities within the United States and developing nations.

Veteran's Health Administration Expands Access in Rural and Underserved Areas (June 2015) The Office of Academic Affiliations (OAA) in the Veterans Health Administration (VA) oversees the statutory education mission of VA which includes the issuance of national policy and the practical implementation of trainee education, affiliation relationships, stipend distribution and transformational educational projects. In VA, trainees form a crucial workforce pipeline from which to recruit highly trained health professionals. The OAA has been heavily involved in implementing a portion of the Veteran Access Choice and Accountability Act (VACAA). The VACAA, also known as the GME Choice act, is established to expand GME (Graduate Medical Education) by expanding GME positions to places that don't have prior GME or GME programs, areas with high concentration of veterans, and in Health Professional Shortage Areas (HPSAs). Specifically, the expansion places a high priority on increasing primary care, mental health, and other specialties. VA patients tend to be poor, homeless, and often with substance abuse, so there is a huge amount of common interest between VA and community partners. With the GME expansion there is increased opportunity for providers and community partners to link with the VA's clinical and social programs to improve health in rural and underserved communities.