# Presentation: 714743

## The Vermont Blueprint for Health:An Integrated Approach to Chronic Disease Prevention and Care

- Vermont Department of Health
- Ellen B. Thompson, MS
- Sharon Moffatt, RN, MSN
- Paul Jarris, MD, MBA
- Eileen Girling, RN, MPH

**Notes:**
Thanks to Sharon et al

Share how we have taken a systems approach to prevention of chronic disease

How we have “divided up” the work between various components of the systems

Leave you with a sense of the possibilities of multi-stakeholder participation

## Vermont

- Population: 620,000
- 18 US Cities are larger
- 90 US Counties are larger
- Ranked 2nd healthiest State in 2005
- 90 % insured
- 59 %  Private (3 carriers)
- 370,000 lives
- 15 %  Medicaid
- 15 %  Medicare
- Adequate to good access to primary care

## Why the Blueprint?

- More than 1⁄2 of adult Vermonters have a chronic condition—88% of those over age 65
- Inefficiency in the system: people don’t get the care they need 1⁄2 the time (national data)
- “System” is set up to be responsive-not proactive: good doctors and good patients can’t overcome system problems
- Increasing cost of health care: 8.7% increase in 2003 (U.S. 7.7%)

**Notes:**
Same reasons you are all working to improve chronic care....

High prevalence

Inadequate response

High costs

## Blueprint Vision

- Vermont will have a statewide system of care that improves the lives of individuals with and at risk for chronic conditions.
- Goals:
- Better Outcomes
- Lower prevalence of chronic conditions
- Better health for people with chronic conditions
- Improved quality of life
- Moderation in costs

## Our travel plan

- Link prevention and treatment
- Work with key players to promote change
- Patients, families and friends
- Health care team
- Communities: geographic, faith, social, work, school
- Create coordinated, supportive infrastructure
- Health “system”
- Public health and public policy “system”

## The Continuum of Chronic Disease

- Healthy
- “Normal”

- “Pre-disease”
- Or High Risk

- Uncomplicated
- Disease

**Onset**

**Recovery**

- 50 % of
- population

- Est. 40 % of pop.

- 10 % of pop.

- Primary

- Care
- Management

- Prevention type:

- Complicated
- Disease

**Progression**

**Improvement**

**Death**

- Secondary

**Onset**

**50%**

**10%**

**100%**

- Tertiary

**Notes:**
Why complicate our lives by integrating prevention and care?
This is not really a choice

Chronic disease is a continuum—not stepping stones
Many interventions are the same—more a matter of degree and intensity

Concept—Different types and degree of intervention at various points.

It’s all prevention—at least until disease has become very complicated
Preventing 	onset
	complications
	slowing progression

## Reducing diabetes deaths

**Deaths Per Thousand Adults**

- 2.50

- 2.25

- 2.00

- 1.75

- 1.50

- 1.25

- 1980

- 1990

- 2000

- 2010

- 2020

- 2030

- 2040

- 2050

- Time (Year)

** ****Do Nothing**

** ****Obesity **
** ****Prevention**

** ****Better Care**

- Reducing diabetes deaths

** ****Both**

**Notes:**
Example—modeling diabetes deaths under different scenario’s
No change in interventions (Blue line)
By 2050, Death rate is 55 % higher than at baseline
Primary driver is increased prevalence of diabetes
Better Health Care
Very rapid pay off with leveling of death rate for several years
Increased prevalence off-sets those gains and rate of death begins to increase
By 2050, Death rate is 37 % higher than at baseline
Reduced prevalence of obesity leading to lower prevalence of diabetes (green line)
Little change in death rate seen for several years, then slow rise
By 2050, Death rate is 26 % higher than at baseline
Both Obesity Prevention and Better Care
Advantage of both
Early response, and actual decrease in mortality (because weight loss in people who already have diabetes improves outcomes)
By 2050 mortality rate is only 12.7 % over baseline

## Blueprint Care and Prevention Model

**Improved Outcomes-Healthier People**

**Productive**
**Interactions**

**Self-****Management ****Support**

**Delivery****System**
**Design**

**Decision**
**Support **

** ****Clinical****Information****Systems**

**Health System**

**Health Care Organization**

**Community **

**Resources and Policies**

**Public Health**
**Policies, Systems, Environment**** **

**Supportive Environment**

**Informed,**
**Activated**
**Patient**

**Prepared,**
**Proactive**
**Practice Team**

- Adapted from the chronic care model
-  which is used by permission of
-  “Effective Clinical Practice.”

**Notes:**
Started with the CCM
Model developed and mostly used in closed systems—HMO/ CHC 
Not tested in a mixed insurance market
Not tested with independent practitioners
Not tried within a public health model

 Added Public Health
Bring the population/environment approach to change—
Apply what we’ve learned with tobacco
“Neutral” party to convene multiple stakeholders
Resources via the administration and legislature/grantsmanship

## The Model Reconstructed

**Provider **
**Team**
- Practice standards
- Info. Systems
- Decision support
- Office systems
- Self mgmt. coaching

**Community**
- Built environment
- Programs and  services
- Health awareness
- Healthy options
- Modeling
- Policies

**Public Health**
- Public Policy
- Infrastructure
- Financing
- Social change
- Environmental change
- Regulation
- Evaluation

**Health Systems**
- System policy
- Quality care
- Reimbursement
- Financing
- Services
- Continuity
- Coordination

**Individuals**
** ****and Families**
- Health  knowledge
- Self-management  skill
- Health behaviors
- Supportive home
- environment

**Environment**
**Infrastructure**
**Support**

**Improved Outcomes-Healthier People**

**Notes:**
Relationships also viewed differently within the model
Start where all the action takes place—in the home and community
Begin with the people (not patients) with the most to gain, and the most to change to meet the goals
most strongly supported, to change or not, by their families and friends
Implemented “Healthier Living” program (Stanford) to focus on skills rather than knowledge
Encourage family/support person participation
trained instructors, mostly lay leaders
pay for a part-time coordinator in each community
Will develop/offer options for skill development in future

Next—the practice team who uses the same tools as in the CCM to proactively manage care—help guide individuals in the changes they need to make—within the context of about 1 hour per year!
Next speaker will talk more about how practices can change
Major difference in VT is that we have purchased a chronic disease management system with a patient registry that can be used by all practices—decision support tools included, adaptable to office systems

## BlueprintSuccesses

- 10/20/2006

**Self Management**
- 7 Master Trainers
- 81 Instructors
- >250 participants
- 15 towns

**Health Systems**
- Payer/regulator engagement
- Disease Management Report
- Pay 4 Performance
- Agreement on standards

**Provider Practice**
- 2 Service Areas-2005
- 19 Practices
- 45 Providers
- 1200 patients
- Training
- Evaluation plan
- 4 Service Areas-2006

**Public Policy**
- Mainstreamed Debate
- Governors priority
- Legislation
- Public Funding
- Press Coverage
- National recognition

**Community Services**
- 12 Local Health Districts
- >37 towns-physical activity
- VT-211 statewide
- Built Environment Assessment

**Information**
**Systems**
- Software purchase
- Interim registry
- RHIO contract
- Practice needs
- Analysis

## Blueprint Sites

**2005—providers**

**2006—providers**

**Self Management**
**&/or Physical Activity**

## Next steps

- Continue to expand communities and conditions
- Promote entrepreneurship
- Fully engage Vermonters in the endeavor
- Gain Medicare participation
- Keep learning

## Thank you

- Ellen Thompson
- Vermont Department of Health
- _[ethomps@vdh.state.vt.us](mailto:ethomps@vdh.state.vt.us)_
- 802-863-7279