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BOOK
REVIEWA5 Am J Prev Med 2017;53(3):A5–A6 & 2017
American Journal ofThe Practical Playbook: Public Health and Primary Care Together Edited by J. Lloyd Michener, Denise Koo, Brian C. Castrucci, and James B. Sprague Oxford University Press, 2015. 400 pages. $27.95, ISBN-13: 978-0190222147
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Order Paper NowIn 1997, an important monograph was published bythe New York Academy of Medicine entitled Medi-cine & Public Health—the Power of Collaboration.1 In this report, a national committee of experts reviewed and commented on collaboration between health care and population health in terms of history, effective models, and the compelling need to advance such collaboration. Fifteen years later, a National Academy of Medicine report called for enhanced partnerships between primary care and public health.2 In addition, a number of provisions within the Patient Protection and Affordable Care Act (2010)3 were designed to foster linkages between clinical care and public health. It is in this context that a new book, The Practical
Playbook: Public Health and Primary Care Together (Playbook), was written. The aim of the Playbook, according to the authors, is to “support public health and clinical practice in working together…to improve the health and well-being of our communities.” The Playbook complements a website (www.practicalplaybook.org) that has similar content. However, the book covers topics in more depth and provides a user-friendly overview of the conceptual models that are easier to visualize in book form than through the website. The three partners responsible for creating and sup-
porting the Playbook in book and website form are the deBeaumont Foundation; the Centers for Disease Control and Prevention; and the Department of Community & Family Medicine, Duke University School of Medicine. There is an editor for the Playbook from each of these institutions. Fifty-three contributors are listed. Based on graduate degrees and affiliations, the great majority of the authors are from public health or population health backgrounds as opposed to clinical positions. The Playbook’s 28 chapters are divided among five
sections: Fundamentals of Partnerships Between Public
Health and Primary Care; Working Together; Health and Health Care; Working With Data; and Success Stories. Interestingly, 11 of the chapters are called “essays.” The essays are not really commentaries or editorials. Instead, they seem to be more in-depth explorations of a selected number of topics (e.g., the role of electronic health records in linking primary care with public health [Chapter 23]). Overall, the Playbook is a very practical handbook for
public health and population health specialists to develop a partnership with primary care to address a target of mutual interest. There are many vignettes and case studies that demonstrate that collaboration between the two spheres of activity can achieve substantive improvements in health. In addition, there are figures, models, tips, and sample work- sheets that emphasize putting concepts and theory into practice. Practitioners will appreciate that the Playbook does not understate the potential challenges and difficulties that may arise in trying to develop a collaborative project. In fact, Section II, Working Together, addresses how to anticipate difficulties and use a range of tools to foster success. Perhaps some potential readers may wonder why they
should use the Playbook in book form when there is an existing website with at least some of the core content. The first point is that there is, in fact, more information in the book than the companion website—information that is practical as opposed to theoretic minutiae. The second point is that the Playbook will not be read front to back by most readers. Instead, practitioners will use the Playbook as a handbook and read relevant chapters to conceptua- lize and launch a specific project. There are a few areas that the Playbook could have
addressed in more depth. For example, high-utilizer populations (e.g., the top 5% of higher-risk populations that typically utilize 50% or more of the healthcare budget) are an important group that benefits from a collaborative approach between primary care and public health. Similarly, primary care providers are just one component of the healthcare system. Additional content on the linkages primary care must have with specialists and behavioral health would have been useful. Finally, readers of the Playbook would also have gained if there were greater coverage of the complexities of managed care (e.g., how health plans contract with multiple entities such as medical groups, independent practice associa- tions, community clinics, and often a combination of such entities to construct a provider network). Although
Preventive Medicine. Published by Elsevier Inc. All rights reserved.
Kohatsu / Am J Prev M
there is a chapter on accountable care organizations, the reader from a public health background needs to know how health care is structured. In spite of these relatively minor quibbles, the Playbook
fills an important need by providing practical, real-world methods to create a richer collaboration between public health and primary care. The many examples of successes show that meaningful improvements in health are, in fact, quite possible. The Playbook provides a lighted path for professionals and other stakeholders from both worlds, to work together, to better advance population health.
Reviewed by Neal D. Kohatsu, MD, MPH, Medical Director, California Department of Health Care Services, MS 0000, P.O. Box 997413, Sacramento CA 95899. Email: neal.kohatsu@dhcs.ca.gov.
https://doi.org/10.1016/j.amepre.2017.03.013
September 2017
REFERENCES 1. Lasker RD and the Committee on Medicine and Public Health.Medicine
& Public Health—The Power of Collaboration. New York, NY: New York Academy of Medicine; 1997.
2. National Academy of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: National Academies Press; 2012.
3. Patient Protection and Affordable Care Act 42 U.S.C. § 18001 (2010).
ed 2017;53(3):A5–A6 A6
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PUBLIC HEALTH 3.0 | 1
Public Health 3.0
A Call to Action to Create a 21st Century Public Health Infrastructure
U.S. Department of Health and Human Services
2
Table of Contents
Letter from the Acting Assistant Secretary for Health . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Progress on Health Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Significant Health Gaps Remain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Key Influence of Social Determinants of Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Public Health 3.0: A Renewed Approach to Public Health . . . . . . . . . . . . . . . . . . . . . . . 10
The National Dialogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Spotlight and Feedback: Public Health 3.0 Regional Meetings. . . . . . . . . . . . . . . . . . . 14
Key Findings: Strong Leadership and Workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Key Findings: Strategic Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Key Findings: Flexible and Sustainable Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Key Findings: Timely and Locally Relevant Data, Metrics, and Analytics . . . . . . . . . . . 23
Key Findings: Foundational Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Recommendations to Achieve Public Health 3.0. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
PUBLIC HEALTH 3.0 | 3
Letter from the Acting Assistant Secretary for Health We have made great strides in the last several years to expand health care coverage and access to medical care and preventive services, but these successes have not yet brought everyone in America to an equitable level of improved health. Today, a person’s zip code is a stronger determinant of health than their genetic code. In a nation as wealthy as the United States, it is unconscionable that so many people die prematurely from preventable diseases; even worse are the health disparities that continue to grow in many communities.
High-quality health care is essential for treatment of individual health conditions, but it is not the only tool at our disposal. In order to solve the fundamental challenges of population health, we must address the full range of factors that influence a person’s overall health and well-being. From education to safe environments, housing to transportation, economic development to access to healthy foods—the social determinants of health are the conditions in which people are born, live, work, and age.
Public Health 3.0 recognizes that we need to focus on the social determinants of health in order to create lasting improvements for the health of everyone in America. Public health is what we do together as a society to ensure the conditions in which everyone can be healthy. We often think of the health care industry when we think of health, but building healthy communities requires strategic collaboration across all sectors. When we build a complete infrastructure of healthy communities, we can begin to close the gaps in health due to race or ethnicity, gender identity or sexual orientation, zip code or income.
For Public Health 3.0 to succeed, local and state public health leaders must step up to serve as Chief Health Strategists for their communities, mobilizing community action to strengthen infrastructure and form strategic partnerships across sectors and jurisdictions. These partnerships are necessary to develop and share sustainable resources and to leverage data for action that can address the most urgent community health needs.
Public Health 3.0 exemplifies the transformative success stories that many pioneering communities across the country have already accomplished. The challenge now is to institutionalize these efforts and replicate these triumphs across all communities for all people.
Our collaborative action must ensure, for the first time in history, that every person in America has a truly equal opportunity to enjoy a long and healthy life. This report outlines the initial steps we can take to get there. I hope you will join me in Public Health 3.0.
Sincerely,
Karen B. DeSalvo, MD, MPH, MSc Assistant Secretary for Health (acting) U.S. Department of Health and Human Services
4
Executive Summary
P ublic health is what we do together as a society to ensure the conditions in which everyone can be healthy. Though there are many important sectors and institutions with a key role to play, the governmental public health infrastructure is an essential part of a strong public health system. But local public health agencies have been under extreme stress due to significant funding reductions during the Great Recession, changing population health challenges, and in certain circumstances changes brought on by the Affordable Care Act (ACA). In addition, they are increasingly working with others in the broader health system to address the social determinants of health in response to the mounting data on disparities by race/ethnicity, gender identity or sexual orientation, interpersonal violence and trauma, income, and geography.
To meet these new challenges head on, local public health has been reinventing itself in partnership with others in their communities, and is undergoing a transformation into a new model of public health we call Public Health 3.0 (PH3.0). In this model, pioneering local public health agencies are building upon their historic success at health improvement and are adding attention to the social determinants of health—the conditions in the social, physical, and economic environment in which people are born, live, work, and age 1 —in order to achieve health equity. They do this through deliberate collaboration across both health and non-health sectors, especially with non-traditional partners, and, where appropriate, through assuming the role of Chief Health Strategist in their communities.
Secretary for Health (OASH) launched an initiative to lay out the vision for this new model of public health, to characterize its key components, and to identify what actions would be necessary to better support the emergence of this transformed approach to public health, with particular attention to the efforts needed to strengthen the local governmental public health infrastructure as a critical and unique leader in advancing community health and well-being.
In 2016, the U.S. Department of Health and Human Services (HHS) Office of the Assistant
To learn more, OASH visited five communities that are aligned with the PH3.0 vision. In these regional listening sessions, local leaders shared their strategies and exchanged ideas for moving PH3.0 forward. Attendees represented a diverse group of people working in public health and other fields, including philanthropy and nonprofit organizations, businesses, social services, academia, the medical community, state and local government agencies, transportation, and environmental services.
This report summarizes key findings from these regional dialogues and presents recommendations to carry PH3.0 forward, organized in the following five themes:
1. Strong leadership and workforce
2. Strategic partnerships
3. Flexible and sustainable funding
4. Timely and locally relevant data, metrics, and analytics
5. Foundational infrastructure
Recommendations Based upon what we have heard and seen from the field, we put forth the following set of recommendations to realize the PH3.0 vision for all communities in the United States:
PUBLIC HEALTH 3.0 | 5
1. Public health leaders should embrace the role of Chief Health Strategist for their communities—working with all relevant partners so that they can drive initiatives including those that explicitly address “upstream” social determinants of health. Specialized Public Health 3.0 training should be available for those preparing to enter or already within the public health workforce.
2. Public health departments should engage with community stakeholders—from both the public and private sectors—to form vibrant, structured, cross-sector partnerships designed to develop and guide Public Health 3.0–style initiatives and to foster shared funding, services, governance, and collective action.
3. Public Health Accreditation Board (PHAB) criteria and processes for department accreditation should be enhanced and supported so as to best foster Public Health 3.0 principles, as we strive to ensure that every person in the United States is served by nationally accredited health departments.
4. Timely, reliable, granular (i.e., sub-county), and actionable data should be made accessible to communities throughout the country, and clear metrics to document success in public health practice should be developed in order to guide, focus, and assess the impact of prevention initiatives, including those targeting the social determinants of health and enhancing equity.
5. Funding for public health should be enhanced and substantially modified, and innovative funding models should be explored so as to expand financial support for Public Health 3.0–style leadership and prevention initiatives. Blending and braiding of funds from multiple sources should be encouraged and allowed, including the recapturing and reinvesting of generated revenue. Funding should be identified to support core infrastructure as well as community-level work to address the social determinants of health.
6
Introduction
Progress on Health Improvement
T he United States has made enormous progress during the past century in improving the health and longevity of its population through effective public health actions and sizable investments in evidence- based preventive services and high-quality clinical care. In 2014, life expectancy at birth was 78.8 years, 10 years longer in lifespan than the 1950s.2 Smoking rates among adults and teens are less than half what they were 50 years ago.3 The Affordable Care Act (ACA) has dramatically expanded health insurance coverage, reducing the uninsurance rate to a historic low of of 9.1% in 2015, 16.2 million fewer uninsured Americans than in 2013.4 Continuous health insurance
reform efforts have also driven improvement in health care quality and have slowed the growth rate of health care costs.
Significant Health Gaps Remain However, despite nearly $3.0 trillion in annual health care spending—almost twice as much as a percentage of gross domestic product as the rest of the world—Americans have shorter lifespans and fare worse in many health indicators, including obesity and diabetes, adolescent pregnancy, drug abuse-related mortality, vaccination rates, injuries, suicides, and homicides.5 The Centers for Disease Control (CDC) recently reported that the historical steady gain in longevity in the United States has plateaued for three years in a row.6 Further, race/
PUBLIC HEALTH 3.0 | 7
ethnicity disparities persist in life expectancy, vaccination rates, infant mortality,7 and exposure to pollutants.8 Many of these vexing challenges require solutions outside of the health care system, and require more broad-based actions at the community level.
Figure 1 Short Distances to Large Gaps in Health
Source: Chapman DA, Kelly L, Woolf SH. Life Expectancy Maps. 2015-2016. VCU Center on Society and Health. http://www.societyhealth.vcu.edu/maps
Key Influence of Social Determinants of Health The lifespan of people living in different parts of the country is a powerful reminder that the opportunity to be healthy often depends more on one’s zip code than one’s genetic code. Researchers (Figure 2) found that the gap in life expectancy between people with the highest and lowest incomes is narrower in some communities but wider in others. Their data
showed significant variations in life expectancy and health risks across different regions in the country.9 Even within a city, life expectancy can vary by neighborhood. Mapping life expectancies in several cities across the United States, researchers illustrated that in some cases, life expectancy can differ by as much as 20 years in neighborhoods just a few miles apart from one another. These data suggest that investing in safe and healthy communities matters, especially for the most disadvantaged persons.1 0 Achieving the goal of Healthy People requires addressing social determinants of health, which includes both social and physical environments where people are born, live, work, and age.
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