Chronic Disease Prevention and Management: Place-Based Strategies

State: OK Type: Promising Practice Year: 2015

:

The innovative practice focuses on improving the health outcomes for residents in our most disparate health ZIP codes; this includes communities with high concentration of African Americans and Hispanics.  Each component of the practice focuses on a different intervention area that collectively addresses systems, environment and behavior.  The approach aggregates successful programmatic best practices including the Coordinated School Health Model (Health at School), Chronic Disease Prevention and Management (My Heart) and Lifestyle Interventions (Total Wellness) in the target communities in order to engage multiple generations at multiple sites common to the communities. 

:
Oklahoma City-County Health Department
:
Chronic Disease Prevention and Management: Place-Based Strategies
The Oklahoma City-County Health Department (OCCHD) serves a population of more than 750,000 residents.  Oklahoma City and County are diverse communities, with more than one-fourth of the population representing a minority group (28%).  The largest ethnic minority is Hispanic (16%), equal to the current African American population.  Nearly one-third of the community population is 18 years old or younger (32.4%).  In 2013, the United Health Foundation ranked Oklahoma 44th in overall health, an improvement from 46th in 2012.  Oklahoma ranked 45th in the nation for obesity, 44th for physical inactivity, 42nd for poor physical health days,46th in fruit consumption, 42nd for youth obesity (2012 measure), and 41st in vegetable consumption.   Physical Activity In Oklahoma County only 45% of residents get the recommended 150 minutes of moderate activity per week.  Statewide physical activity is lowest among Hispanic adults (37%) and highest among African Americans (47%). Nutrition Oklahoma ranks 46th for fruit consumption and 41st for vegetable consumption according to the 2013 United Health Foundation, American Health Rankings.  According to a Gallup Poll conducted in 2013, 28% of Oklahoma County adults consume the recommended amount of fruits and/or vegetables.  Only 14% of youth report they meet this recommendation.  In Oklahoma County, only 32% of the population is classified as normal weight. Chronic Disease/Access to Health Care The United Health Foundation, American Health Ranking (2013) has ranked Oklahoma 48th in the nation for cardiovascular disease.  Both African Americans and Hispanics are less likely than other races and ethnicities to have their blood cholesterol assessed for risk (65% and 50%, respectively).  In Oklahoma County, 34% of adults have been informed they have high blood pressure (SMART BRFSS, 2011).  African Americans are disproportionately represented in this risk factor (42%), while Hispanics are underrepresented (21%).  The overarching goal is to reduce disparities in health outcomes (10% reduction in overall mortality in our jurisdiction between 2010 and 2020).  Recent data analysis demonstrates between 2010 and 2012, OKC-County realized a 1.2% reduction in overall mortality rates, demonstrating that our strategies are effective at moving the community towards this goal.  Program specific goals and objectives for each strategy intervention include: Total WellnessGoal: Improve the health of citizens in Oklahoma County by increasing awareness of healthy eating and physical activity.Objectives: (1) reduce obesity among at least 20% of participants (metric: 5% reduction in body weight), (2) increase physical activity among at least 20% of participants (metric: 20% report 150 minutes of weekly physical activity), (3) increase awareness of nutritional intake by utilizing weekly food diaries (metric: 100% of participants). My HeartGoal: Provide chronic disease prevention and management tools to at least 200 clients annually for three years, beginning July 1, 2014.Objectives: (1) reduce obesity among all participants within 12 months (metric: 5% reduction in body weight), (2) improve clinical baseline measures within 12 months (metric: 5% improvement in blood pressure, blood glucose and lipid panels), (3) improve clients’ adherence to clinical appointments and prescribed medication(s) within 12 months (metric: 100% of clients attend scheduled appointments, 100% of clients report taking medication(s) as prescribed). Health at SchoolGoal: Implement 8 of the 10 components of the Coordinated School Health Model (CSHM) in all participating schools by the end of the 2014-2015 academic school year. Objectives: (1) create a flexible programming menu that allows schools to select evidence-based strategies of interest  (metric: at least 3 program options available for each component of the CSHM), (2) develop partnerships to support CSHM programming options for the schools (metric: identify at least 2 partnerships for each component of the CSHM), (3) implement sustainability strategies for all participating schools to assure long-term availability of CSHM programming (metric: 100% of schools participating will have at least 2 faculty and/or staff trained in the continued provision of selected evidence-based strategies by end of academic year). Innovative activities occurred concurrently to assure multi-generational, multi-setting engagement.  Since the launch of the 8-week Total Wellness classes in concert with the My Heart program and Health at School activities, we have realized early evidence of future success.  Early results have shown that objectives related to the Total Wellness classes and My Heart program have been met; additionally, the Health at School programming menu has been completed.  Specific factors of success include: integrated and strategic delivery of program interventions derived from the evidence base and engaging partners and program implementation staff in program design.  The public health impact of this practice will be a reduction in disparities in health outcomes and improvement of county-wide health status.
The Oklahoma City-County Health Department (OCCHD) serves a population of more than 750,000 residents, but on weekdays, the population grows to an estimated 1.2 to 1.3 million as people from outlying counties come into Oklahoma County to work.  The residential population is approximately one-fifth of the total state population, but the commuter population brings that number closer to one-third of the state population.  Oklahoma City and County are diverse communities, with more than one-fourth of the population representing a minority group (28%).  The largest ethnic minority is Hispanic (16%), equal to the current African American population.  Our youth population has been expanding rapidly in recent years with nearly one-third of the community population 18 years old or younger (32.4%).  The growing youth population presents unique challenges to community infrastructure and planning.  Data illustrates there is reason to be concerned for the future of our young families with nearly one-fourth of children living in poverty (22%), one in three female headed households living in poverty (34%) and one in five children residing in single parent households (18%).  The Wellness Now (WN) coalition has been an instrumental partnership to improve health outcomes, and since its inception, Oklahoma County has realized some important improvements in health outcomes, illustrated in the most recent release of the Wellness Score. The Wellness Score is updated every third year and released to the community at-large as a tool for directing and allocating resources utilizing place-based strategies according to greatest need internally at OCCHD as well as for our community partners and coalition members.  The first release in 2010 directed OCCHD resources to ZIP code 73111 and surrounding geography, a primarily African American community.  The 2014 release of the Wellness Score revealed an overall reduction in all causes of mortality by 1.2% (883.8 per 100,000 to 873.5 per 100,000, comparing 2008-09 AAR to 2010-12 AAR), and also revealed that ZIP code 73111 was no longer the poorest health outcome ZIP code.  Additional county wide reductions were observed in mortality rates for other common chronic conditions including Stroke (3.9%), Cardiovascular Disease (2.9%), Lung Cancer (3.5%), Breast Cancer (4.7%), and Prostate Cancer (6.8%).  The OCCHD cites the development and successful sustainment of the Wellness Now Coalition, its resources and dedicated partners, and the implementation of place-based strategies for the measurable improvements in select outcomes.  Since early 1990, Oklahoma has seen a trend of increasingly poor health outcomes, demonstrating a clear divergence from the rest of the country which at that time began to see improvements in lifespan and overall health and well-being.  In 2010, the trend of declining health outcomes slowed until we observed some measured improvement statewide in 2011, presumably from new grant dollars and funds coming into the state as well as targeted planning and strategy among health officials.  In 2012 and 2013 the first continued improvement in health rankings was demonstrated for Oklahoma since the trend for increased poor health outcomes began in the 90s.  In 2013, the United Health Foundation ranked Oklahoma 44th in overall health, an improvement from 46th in 2012.  When considering factors that directly impact rates of chronic disease morbidity and mortality, Oklahoma ranked 45th in the nation for obesity, 44th for physical inactivity, 42nd for poor physical health days, 46th in fruit consumption, 42nd for youth obesity (2012 measure), and 41st in vegetable consumption.  According to the United Health Foundation, there are a number of core measures that impact a community’s health outcomes. Physical Activity Oklahoma County continues to lag behind national averages for physical activity with less than half (45%) of residents getting the recommended 150 minutes of moderate activity per week.  Nationally, over half of U.S. adults (52%) are achieving this objective (BRFSS, 2011).  While county specific data is not available for this measure, statewide physical activity is lowest among Hispanic adults (37%) and highest among African Americans (47%).  As with tobacco use, income is a significant predictor of physical activity, with only 40% of those earning less than $15,000 per year engaging in physical activity, while those earning greater than $50,000 are meeting the national average (52%), (BRFSS, 2011).  Similar trends are also observed for educational attainment with College Graduates in Oklahoma actually exceeding the national average (55%) while only 36% of those without a high school diploma achieve this objective.  Nutrition As a state, Oklahoma ranks 46th for fruit consumption and 41st for vegetable consumption according to the 2013 United Health Foundation, American Health Rankings (2013).  According to a Gallup Poll conducted in 2013, just over one-fourth (28%) of Oklahoma County adult consume the recommended amount of fruits and/or vegetables (5 or more servings, 4 days per week).  Youth are in a worse state with only 14% reporting they meet this recommendation.  Approximately 19% of African American youth and 20% of Hispanic youth meet the recommendation.  Oklahoma is the 6th most obese state in the nation according to Trust for America’s Health (2012).  In Oklahoma County, only one-third (32%) of the population is classified as normal weight.  The remaining population is categorized as overweight (35%) or obese (32%).  Obesity disproportionately impacts African Americans (46%) while Hispanics are slightly below the county at 31%.  As illustrated with tobacco use and physical activity, those with higher educational attainment tended to be less obese.  In a divergence from trends observed in other risk factors, those earning more (greater than $50,000) were actually more likely to be obese (38%) than those earning less than $15,000 (33%).  Chronic Disease/Access to Health Care It is unsurprising, given the statistics for tobacco use, physical activity and nutrition behaviors, that preventable chronic disease is a tremendous burden on our healthcare system in Oklahoma.  Cardiovascular disease, for example is one of the leading causes of death in Oklahoma, and the United Health Foundation, American Health Ranking (2013) confirms that with our ranking of 48th in the nation for cardiovascular disease.  Heart attacks are more common among low income residents as well as those without a high school education. Both African Americans and Hispanics are less likely than other races and ethnicities to have their blood cholesterol assessed for risk (65% and 50%, respectively).  High cholesterol appears to impact low income earners (49%) and those without a high school diploma (45%) at higher rates than higher income earners (37%) with a college degree (36%).  Blood pressure awareness serves as another cost effective opportunity to prevent onset of chronic disease, and in Oklahoma County, 34% of resident adults have been informed they have high blood pressure (SMART BRFSS, 2011). African Americans are disproportionately represented in this risk factor (42%), while Hispanics are underrepresented (21%); nearly one-half (44%) of low-income earners report high blood pressure.  It is possible that Hispanic populations are underrepresented as a result of obstructed access to primary care providers.  As a state, Oklahoma ranks 39th in the nation for uninsured residents (17.1%), in Oklahoma County this rate is closer to one in every four residents (23%) are uninsured.  Of the uninsured population, African Americans and Hispanics represent the highest uninsured racial and ethnic groups, combining for two-thirds of the total uninsured population in Oklahoma County, 28% and 48%, respectively (BRFSS 2012), a disproportionate share of the one-third of total population they represent for the community.  Social and economic indicators continue to follow the trend of other risk factors, with stark disparities noted for low income earners—42% uninsured as opposed to only 7% uninsured among those earning more than $50,000.  Educational Attainment follows with 46% of those without a high school diploma uninsured as compared to college graduates where only 8% are uninsured.  Target Population and Reach The innovative practice focuses on improving the health outcomes for residents in our most disparate health ZIP codes; this includes communities with high concentration of African Americans and Hispanics (16% and 16%, respectively, of the total city-county population).  The target ZIP codes represent more than 50% of the county-wide minority populations within the LHD jurisdiction.  The technical package the OCCHD has implemented utilizes a multi-generational, multi-setting approach to improving health outcomes and includes school, community and clinical-based strategies.  School-based strategies are estimated to reach 30 schools in a 3 year period.  Currently, approximately 4,600 students and 400 teachers and staff are benefitting from school-based strategies.  Community-based strategies have reached nearly 2,500 residents Spring 2012, and clinical strategies have reached nearly 180 residents since July 2014. Background of InnovationHistorically, the OCCHD has subscribed to the identification and implementation of existing evidence-based best practices to improve health outcomes for its jurisdiction.  These practices were consistently implemented according to guidelines, but largely without coordination across target populations.  Efforts have been operating in silos even within the LHD with resources scattered throughout the county, without recognition of the need to allocate resources geographically or within specific population.  The initiation of the Wellness Score, described previously, was the first opportunity for OCCHD to begin planning for implementation based on geographic needs, health disparity, and with an emphasis on upstream indicators of health outcomes.  While the data and information presented previously paints a fairly bleak picture for Oklahoma City and County residents, the OCCHD and WN Coalition have committed significant resources to leverage partnerships and develop a plan of action to direct community planning and implementation efforts aimed at developing systems and environmental improvements through the use of a technical package  approach to health systems improvement. Use of a technical package that focuses resources on a single goal is critical to the success of the proposed strategies.  Each component of the innovative practice focuses on a different intervention area that collectively addresses systems, environment and behavior.  The approach aggregates successful programmatic best practices including the Coordinated School Health Model (Health at School), Chronic Disease Prevention and Management (My Heart) and Lifestyle Interventions (Total Wellness) in the target communities in order to engage multiple generations at multiple sites common to the communities.  Programmatic activities are complemented by policy action undertaken by the Wellness Now Coalition which include school and worksite nutrition and physical activity policies, advocacy for built environment and infrastructure planning such as complete streets, and expansion of tobacco-free policies, including a targeted effort at tobacco-free multi-unit housing. This approach integrates clinical and community health providers, and concentrates resources in the areas of greatest need.  Our historical data illustrates that by allocating resources with this approach, county-wide gains in health outcomes can be achieved.  As a major population center for the state of Oklahoma, this inevitably translates into improved health status for the state as a whole.  The innovation represents a creative use of existing tools and practices found in the Guide to Community Preventive Services, MMWR Recommendations and Reports, and the United States Preventive Services Taskforce and includes the following elements, placed in targeted, disparate health outcome ZIP codes within the LHD jurisdiction:1. Comprehensive data collection, analysis and dissemination utilizing the Mobilizing for Action through Planning and Partnership Tool, conducted every third year by the LHD;2. Implementation of the Coordinated School Health Model (Health at School) in partnership with the largest school district in the LHD jurisdiction through a program menu, train-the-trainer approach;3. Integration of Clinical, Mental and Public Health preventive services utilizing Community Health Workers (My Heart) for targeted recruitment into chronic disease prevention programs that integrate clinical preventive protocols for select morbidities (diabetes, hypertension, obesity) with mental, social and environmental preventive activities through case management; 4. Lifestyle and behavior modification (Total Wellness) through an 8 week curricula adapted from the Stanford Chronic Disease Prevention Program and the CDC’s Diabetes Prevention Program; and5. Targeted nutrition, physical activity and tobacco policy implementation county-wide.
Nutrition, Physical Activity, and Obesity
The overarching goal of the innovation is to reduce disparities in health outcomes, and to improve county-wide health status through the implementation of evidence-based programming and policies utilizing place-based strategies.  The OCCHD seeks to improve overall mortality in our jurisdiction by 10% between 2010 and 2020.  Recent data analysis demonstrates between 2010 and 2012, OKC-County realized a 1.2% reduction in overall mortality rates, demonstrating that our strategies are effective at moving the community towards this goal.  Larger reductions in mortality for specific disease outcomes ranged from 2% to 7% reductions in that same timeframe.  Program specific goals for each strategy intervention include: Total WellnessGoal: Improve the health of citizens in Oklahoma County by increasing awareness of healthy eating and physical activity.Objectives: (1) reduce obesity among at least 20% of participants (metric: 5% reduction in body weight), (2) increase physical activity among at least 20% of participants (metric: 20% report 150 minutes of weekly physical activity), (3) increase awareness of nutritional intake by utilizing weekly food diaries (metric: 100% of participants). My HeartGoal: Provide chronic disease prevention and management tools to at least 200 clients annually for three years, beginning July 1, 2014.Objectives: (1) reduce obesity among all participants within 12 months (metric: 5% reduction in body weight), (2) improve clinical baseline measures within 12 months (metric: 5% improvement in blood pressure, blood glucose and lipid panels), (3) improve clients’ adherence to clinical appointments and prescribed medication(s) within 12 months (metric: 100% of clients attend scheduled appointments, 100% of clients report taking medication(s) as prescribed). Health at SchoolGoal: Implement 8 of the 10 components of the Coordinated School Health Model (CSHM) in all participating schools by the end of the 2014-2015 academic school year. Objectives: (1) create a flexible programming menu that allows schools to select evidence-based strategies of interest  (metric: at least 3 program options available for each component of the CSHM), (2) develop partnerships to support CSHM programming options for the schools (metric: identify at least 2 partnerships for each component of the CSHM), (3) implement sustainability strategies for all participating schools to assure long-term availability of CSHM programming (metric: 100% of schools participating will have at least 2 faculty and/or staff trained in the continued provision of selected evidence-based strategies by end of academic year). Implementation Activities Innovation implementation activities occurred concurrently to assure multi-generational, multi-setting engagement.  The confluence of program strategies across a targeted geographic region was the overarching goal for successful execution of the innovation. Each program has been evaluated and re-designed in order to meet this goal, including robust evaluation protocols in support of continued process and program improvements.  Total Wellness is the longest running program within the technical package.  Its recent evaluation findings are included in support of this application, and led to the re-design which condensed the program to an 8 week class, increasing access to classes through the cross-training of Community Health Workers as instructors and on-going development of a volunteer instructor database.  Total Wellness is adapted from the Stanford Chronic Disease Management Program and the CDC’s Diabetes Prevention Program, into an 8 week class that provides adult participants with the tools and resources to improve their health through behavior and lifestyle changes.  Classes are offered several times per year, and are provided by a combination of staff including Community Health Workers, Registered Dieticians, and Health Promotion Specialists.  Conversion of the program to a peer train-the-trainer model will enable expansion into targeted communities, utilizing recognized peers and mentors for parents within the targeted schools, and their communities at large, and is an integrated aspect of the long term sustainability plan for the program.  For example, parent liaisons are hired within 60% of OKCPS, however they do not currently receive any formal training.  Our partnership with the schools will enable Total Wellness staff the opportunity to provide parent liaisons training to implement Total Wellness within school sites to support faculty and staff wellness and parent engagement as part of the Coordinated School Health Model.  Wellness Classes are provided in the targeted ZIP codes, as well as to the larger community.  The program consistently enrolls classes to capacity, and frequently has waiting lists to attend.  The program is offered in multiple community-based settings including OCCHD sites, libraries, faith-based institutions, community centers, schools and university and college campuses throughout the community.  The classes are also provided in tandem with schools participating in the Health at School program as well as for patients participating in My Heart. The Health at School program began in 2010, but was recently re-designed to accommodate that place-based strategy approach to health improvement in Oklahoma City-County.  Development and implementation of up to 20 learning gardens per year with engagement from the local county extension offices and higher education in the development of classroom curricula that can be translated into the learning garden are examples of systems changes the program re-design will support.  Linking future Oklahoma teachers to developing and implementing the curricula will be key to creating sustainable change.  Combining integrated curricula with a “train-the-trainer” approach to all existing OCCHD Health at School programming will ensure the school district will have enough internally trained faculty and staff to support continued expansion and sustainability of the integrated curricula.  OKC Public School district has also committed to “scratch cooking” in all elementary school cafeterias beginning this academic year.  This policy change internal to the district provides an opportunity to utilize produce grown in learning gardens, and from local growers in the community to provide food demonstrations and tastings during school meals, in an effort to introduce students, faculty and staff to a variety of healthy food options.  Partnerships with the Oklahoma City Police Athletic League (PALs), will support coordination of continued nutrition education and integration at the middle school level (grades 4th – 8th), while the OCCHD Health at School program, with support from the Oklahoma State Department of Health will focus activities at elementary school level (PK – 3rd grade). The OCCHD My Heart project began development early in 2011, with pilot implementation occurring later in the same year.  My Heart is a 12 month program that utilizes targeted case management and finding through Community Health Workers to identify members of the community at highest risk for developing cardiovascular disease .  The program combines lifestyle interventions (Total Wellness, described previously) with care coordination through the CHW and access to primary care and pharmacotherapy interventions as driven by standard medical protocols.  Continued development of the program has supported a fully integrated primary care, public health, mental health care clinic within the local health department at the NE Regional Health and Wellness Campus as well as temporary facilities in South Oklahoma City.  A permanent facility, being built collaboratively with OKCPS, will open in approximately 18 months and will provide additional evaluation opportunities to compare strategies across diverse racial and ethnic communities as NE and South Oklahoma City are home to primarily African American and Hispanic populations, respectively.  The program has been well received, with more than 300 clients from at-risk communities participating in the program.  Data for this approach has been anecdotal to date, but the expansion of the program began this past spring (2014).  Expansion will reach communities at risk in South Oklahoma City and Northeast Oklahoma City, with a prospective multi-cohort evaluation currently planned.  Approximately 200 clients are anticipated to enroll by December 31, 2014 to enable comprehensive evaluation.  The strategy of targeting resources to the communities in greatest need has previously resulted in overall community health improvements, and OCCHD and partners plan to continue utilizing this strategy for expanding successful programs and efforts.  My Heart will incorporate implementation of the CHW/Total Wellness modular curricula currently being developed with Langston University, a historically black college with locations in central Oklahoma.  The CHW curricula are being developed with funds from the Community Transformation grant, and implementation of curricula is a major component of the previously identified objectives for that grant.  Creating a combination CHW/Total Wellness is intended to enable community-wide access to valuable lifestyle programs.  A pilot CHW program is currently in development with local hospital systems to support coordinated care for patients without a usual source of care.  Patients without usual care are high risk for inappropriate utilization of emergency care for unmanaged chronic conditions that are otherwise preventable.  This pilot expansion is hoped to impact multiple hospital settings in order to contribute to the evidence-base of improving integration of public health and acute care health settings.  Criteria for InclusionTo be included in programs implemented as part of the innovative practice, residents must reside in selected ZIP codes within the OCCHD jurisdiction.  These include zip codes with the largest disparities in health outcomes located in the Northeast and South Oklahoma City communities including schools and residents within ZIP codes: 73111, 73108, 73119, 73114, 73129, and 73107.  Each of these ZIP codes represents a majority minority population.  With the exception of My Heart, programs are available to all residents within the ZIP code and/or within the school setting.  My Heart is limited by age and risk factor and requires participants to be between the ages of 25 and 60 and have at least two risk factors for chronic disease including obesity, blood glucose, blood pressure or cholesterol. TimeframePrograms included within the innovative practice have operated as independent programs in the OCCHD jurisdiction for a minimum of 3 years.  Programs were each evaluated within the last 18 months to determine opportunities for improvement in process or delivery of program elements.  Following independent evaluation, programs were re-designed in the spring of 2014.  All three programs undertook re-structuring and additional resources will allocated based on the community health outcomes and demonstrated need.  Programs were integrated for strategic delivery prior to the close of the last fiscal year (June 30, 2014).  Programs will operate for three years under the current model of integrated, place-based implementation, during which time a robust quantitative and qualitative evaluation has been planned to determine the cost benefit and efficacy of the innovation.  The details of evaluation are included later in this narrative. StakeholdersThe entire strategy relies heavily on the direction and support of the broad-based, multi-sector coalition, Wellness Now.  A broad array of partners has supported efforts to allocate resources based on regional health disparities, and include: City of Oklahoma City, Planning Department: The City of OKC has actively engaged its planning department in complete streets policies and development of active transportation options.  The Planning Department aids in the development of mapping of safe routes to school and identification of infrastructure supports (lighting, crosswalks, etc.) necessary to implement the walking school bus in a systematic district-wide effort. City Councils, All Municipalities: City Council in Oklahoma City, specifically, has actively engaged the OCCHD and WN in making policy recommendations for local ordinances that impact improved health through physical activity and nutrition.  Oklahoma City Public Schools: Local schools have granted permission to build greenhouse/community gardens on up to 20 identified school sites per year, for a total of 60 community garden sites.   Parent Liaisons and front office support staff at identified schools have been identified to support implementation of the developed train-the-trainer nutrition education curricula. With support from the proposed grant, OKCPS will hire a district-wide coordinator for Walking School Bus implementation and work with partners to develop and execute shared use agreements for school facilities as appropriate and feasible. University of Central Oklahoma: A university that prepares and graduates a large proportion of new school teachers in our state supports integrating physical education and nutrition education into teaching experiences of student teachers and is engaged in the development of curricula for both that can be integrated into classrooms of PK – 4th graders in OKC Public Schools as well as in afterschool settings for parent and community engagement. Oklahoma State University Cooperative Extension – Oklahoma County: Providing staff support for the management and coordination of school-based community gardens including provision of periodic trainings for garden maintenance and sustainability strategies.  Oklahoma City Police Athletic League (OKCPALS): OKCPALs is actively engaged in OKC Public Schools, and recently entered into a partnership with the Health at School program to pick up the technical assistance and support of integrated nutrition education for middle school age youth in targeted communities to ensure the continuation of environmental changes by implementing leadership and character building initiatives.  The OKC PALs will support identification and partnership opportunities for community-based officers and walking school bus strategies. Regional Food Bank: Provides on-site diet specific food boxes to patients receiving care at the integrated community health clinic on OCCHD sites. Physical Activity & Nutrition Workgroup: A WN workgroup actively engaged in policy development to support and advocate for the implementation of tax-free produce days in Oklahoma City and other Oklahoma County based municipalities.  OU Physicians Community Health Clinics: Provides primary care services as an integrated component of chronic disease prevention efforts in the My Heart Project. Northcare Mental Health: Provides mental health services as an integrated component of chronic disease prevention efforts in the My Heart Project and is listed as a partner on the Health at School program menu to provide counseling, social services, and life skills groups. North Rock Pharmacy: Provides low or no cost prescriptions for clients enrolled in the My Heart project. Langston University: A historically black university in Oklahoma, Langston University is currently piloting a modular Community Health Worker training program that will be adaptable to varying traditional and non-traditional healthcare delivery systems.  FundingFunds to support the described innovative practice have been allocated as a combination of the OCCHD local tax levy base and periodic grant funds.  The OCCHD Wellness Now coalition benefited from three years of funding through the Center for Disease Control’s Community Transformation Grant (CTG) for a total of $2,150,112.  These funds supported the development of environmental and infrastructure needs to expand the reach and capacity of the OCCHD and its partners.  For examples, CTG funds directly supported the development and implementation of the Community Health Worker curriculum and incentives to recruit clients into the evaluation components of the My Heart project.  Additionally, funding is received from the Oklahoma Tobacco Settlement Endowment Trust (OK TSET) for a total $979,288 from fiscal year 2013 through fiscal year 2015 in support of physical activity and nutrition workgroup activities, and $1,237,876 over the same timeframe to support tobacco prevention.  OK TSET funds are specifically earmarked for the development and implementation of policy and systems approaches to health improvement.  The Wellness Now coalition utilized OK TSET funds to expand tobacco-free policies throughout the Oklahoma City and County communities, and to increase awareness and adoption of policies related to the built environment and physical activity and nutrition in the schools.  Additionally, OCCHD, with partners, seeks to identify opportunities to draw reimbursements through the traditional public and private insurance payor systems to legitimize public health integration into primary care prevention to expand successful integration of the CHW role.
The OCCHD believes strongly that public health interventions should be implemented utilizing place-based strategies that employ a technical package. By targeting program expansion to areas with high disparity, the OCCHD is allocating resources to areas where the greatest improvement can be achieved in the shortest time frame.  Additionally, locally elected officials, constrained by term limits, push health officials to demonstrate return on investment in terms of 12 – 18 month cycles in order to effectively advocate for relevant policy and ordinance changes. Given these parameters, the evaluation efforts for this innovative practice were developed with the end in mind, and focus on considering cost-benefit, program efficacy and broad health outcomes collectively.  Evaluations for each component of the innovative practice have been developed to incorporate qualitative and quantitative analysis, and incorporate multiple checks through the course of implementation to allow for program adjustments.  The inclusion of program evaluation as a component of the program planning and development was purposeful and is considered an aspect of the innovative practice. My Heart and Total WellnessThis will be a quasi-experimental design evaluation, with 2 intervention cohorts and one control cohort. Patients eligible for My Heart, but declining participation will be utilized as the control group.  Target enrollment is estimated at 300 patients.  A minimum of 100 clients will be allocated to each cohort, for a total of 300 patients to be followed for the 12-month timeframe.  The evaluation will establish baseline metrics at recruitment and prior to enrollment in Total Wellness classes.  •Cohort 1: Enrolled in My Heart, Active CHW (Intervention)•Cohort 2: Enrolled in My Heart, No CHW (Partial Intervention)•Cohort 3: Eligible for My Heart, No CHW (Control) The evaluation design will ensure the following:1.Providers and CHWs are properly trained on protocol implementation and are able to implement the protocol in a consistent and uniform manner.2.Data collection is accurate and provided in a timely and consistent manner.3.Patients are informed regarding the 12-month follow up timeframe and agree to maintain up to date contact information with providers and/or community health workers.4.The program administrator and supervisors complete regular audits and quality assurance activities to ensure clients are not lost. The overall goal of the evaluation is to determine the efficacy of the My Heart Program, with the following aims:1. Assess the effectiveness of CHWs as providers on patient adherence to clinical protocols and medical appointments2. Estimate the financial impact of My Heart for private and/or public insurers to detect:a. Changes in financial claims when compared over historical trends in 12 month increments; andb. Reduction in patient mobility across insurers and providers measured by uninterrupted coverage and/or single primary care/medical home over a 12- month time period. 3.Understand the effect of integrated and coordinated care on maintenance and/or improvement of select CVD indicators including:a.Blood Pressureb.Comprehensive Lipid Panelc.Weight/BMI The analysis plan will include descriptive statistics (i.e. frequency), and comparison over time using the differences among the before, and after clinical metrics to measure the changes in metrics defined in Section 3.2 (Paired T-Test).  To meet Aim 1 (assessing the effectiveness of CHWs), patient compliance in areas such as keeping appointments and adhering to will be estimated using logistic regression analyses. Compliance will be modeled as a function of working with a CHW, the primary variable of interest, participation in the wellness class, controlling for health status and socio-demographic characteristics. To meet Aim 2 (assessing financial impact), the cost estimates will be examined in a number of ways. The cost of My Heart program will be calculated for per sample member for each cohort and broken down by key program components. There are three program cost components for Cohort 1: expenditures for program enrollment activities, including recruitment and completion of comprehensive intake assessment;expenditures for program components, including cost of CHWs and total wellness classes; and expenditures for health services, including primary care visits, pharmaceuticals, and emergency department visits. The total cost per Cohort 1 member will be calculated by summing these three cost elements. Cohort 2 will have the same expenditures for program enrollment activities and expenditure for health services as Cohort 1. The expenditure for program components for Cohort 2 will be less than Cohort 1 in that there is no cost for wellness classes. Cohort 3 will have expenditures for program enrollment activities and health services, but no expenditures for program components. The cost analysis will focus on the three program cost components. These costs will reflect the 12-month period following the patient’s enrollment in the program. In addition, the analysis will distinguish between gross and net costs. Net costs are the difference between the gross cost for an average member of Cohort 1 and the gross cost for an average member of Cohort 2 or 3. For example, the net costs between Cohort 1 and 3 will calculate the incremental costs over and above the costs of existing services, which represent the cost of services that would have existed in the absence of the My Heart program. To meet Aim 3, an analysis of variance (3-way MANCOVA) will be conducted to determine differences in risk factors (i.e., blood pressure, lipid panel, and BMI) across cohorts.  Clinical de-identified patient data will undergo trend analysis over-time to determine any reductions in overall risk factors. A longitudinal analysis of clients enrolled into the My Heart program will be conducted to determine variation in clinical measures across cohorts.  Health at SchoolSimilar to the aims of the My Heart program evaluation, the Health at School evaluation seeks to determine the cost-effectiveness and health improvements of the selected strategy.  The primary aim of the evaluation is to determine the efficacy of training and technical assistance as a sustainable strategy for improving health outcomes and academic performance in high health disparity schools. This will be a mixed methods evaluation that incorporates case study and multivariate analysis.  Case study process evaluation will incorporate 6-10 pilot schools in year one of evaluation and an additional 6-10 schools each year for a period of three years. Schools eligible for inclusion in the program are those schools that are identified as being located in high disparity communities with low socioeconomic status and high  negative health outcomes (obesity, diabetes, CVD, etc). Schools will be recruited prior to the beginning of the new school year and will be followed throughout the school term.  Schools were selected based on the community health needs assessment an subsequent Wellness Score (described previously), which describes health outcomes as a function of the social determinants of health in Oklahoma County residents.7 Schools located in the lowest health ranking zip codes were considered for inclusion into the initial program and associated evaluation.  Comprehensive school health teams conducted a baseline assessment with schools to assure they are willing to participate and implement strategies across the model.  Each activity undertakes an assessment on effectiveness through the conduct of a pre/post survey and observational data collection measures collected on each event.  At the completion of the 12 month training provided to each school a close out survey will be collected from participants in the project implementation strategies within the year. Additionally, one on one stakeholder interviews will be conducted to assess the effectiveness of program implementation and sustainability of implemented programs. In addition to the qualitative data collection described here, baseline data including student weight and general perception of health, most recent year academic data and historical and on-going absenteeism will also be collected.  Multivariate analysis will be conducted to determine the impact of programming strategies on reduction of total proportion of students moving from unhealthy to healthy weight categories, improved perception of overall health, and reduction in student absenteeism. 
The OCCHD and Wellness Now coalition is committed to developing and implementing strategies that have long term impact and sustainability for the community.  The integrated and strategic delivery of program interventions was critical to community-wide health improvement realized by Oklahoma City and Oklahoma County from 2010 through 2012.  The innovative practice described in this application reflects the lessons learned from those efforts, and the development of the technical package that is implemented in the framework using a combination of training and technical assistance, policy implementation and health service delivery integration.  To maintain these strategies and the long term impact for improved health outcomes, Interventions must focus on multi-generational, and place-driven.  Engaging partners and program implementation staff in program design was critical not only to successful implementation but to program sustainability.  These efforts have been undertaken with the idea that effective change comes at the helm of a shift in the community's culture.  OCCHD and Wellness Now have been at the forefront of the effort in Oklahoma City and believe strongly that these efforts represent a promising practice for the design, implementation and evaluation of public health practice.
Colleague in my LHD|E-Mail from NACCHO
 
Processing...


Driving Walking/Biking Public Transit  Get Directions