Focus Area 3: Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings

Defining the Problem

Delivery of high-quality chronic disease preventive care and management can prevent much of the burden of chronic disease or avoid many related complications.23,24 Many of these services have been shown to be cost-effective or even cost-saving.25 However, many New Yorkers do not receive the recommended preventive care and management that include screening tests, counseling, immunizations or medications used to prevent disease, detect health problems early, and prevent disease progression and complications.23,24,25

For example, cancer screening rates in New York State should increase. The NYS Behavioral Risk Factor Surveillance System indicates that breast cancer screening has remained stable between 2000 and 2010. In 2010, 80.6 percent of women 50 years and older reported having a mammogram in the past two years. Cervical cancer screening rates have also remained stable between 2000 and 2010. In 2010, 88.6 percent of women 21-65 years of age reported having a Pap test in the past three years. In contrast, although colorectal cancer screening rates have increased during the past decade, in 2010 only 69.2 percent of adults 50-75 years old reported having a blood stool test in the last year or lower endoscopy in the past ten years. There are some subpopulations that are less likely to be screened for breast, cervical or colorectal cancer, including individuals with disabilities, lower incomes and those without health insurance.26

New York State data also show that individuals with diabetes are not receiving recommended preventive care services. Despite quality improvement efforts, in 2007 only half of Medicaid managed care enrollees with diabetes (49%) received all four recommended clinical preventive care services (HbA1c test, lipid profile, nephropathy screening and eye exam) based on national guidelines for diabetes management.27

Finally, many New York State adults have more than one chronic disease. The number of Americans living with two or more chronic conditions increased from 24 percent in 2001 to 28 percent in 2006.28 In 2009, 58 percent of adult New Yorkers reported having one or more chronic conditions.29 Individuals with multiple chronic conditions require a coordinated, comprehensive approach to their care.

A combination of clinical and community preventive services (i.e., policies, laws, programs and initiatives, education programs and health system interventions) are needed to promote healthy behaviors, increase use of clinical preventive services and to help individuals with one or more chronic diseases manage their chronic conditions and improve their quality of life.30 Logistical, financial, cultural and health literacy barriers to care need to be removed. Information and clinical supports need to be made available to clinicians. Patients need to be supported by a multidisciplinary team of lifestyle, clinical and behavioral experts to optimally manage their disease/condition(s).

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Goals, Objectives and Interventions

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Goal #3.1: Increase screening rates for cardiovascular disease, diabetes and breast, cervical and colorectal cancers, especially among disparate populations.

Objective 3.1.1:
By December 31, 2017, increase the percentage of women aged 50-74 years with an income of < $25,000 who receive breast cancer screening, based on the most recent clinical guidelines (mammography within the past two years), by 5% from 76.7% (2010) to 80.5%.
(Data Source: NYS BRFSS) (Health Disparities Indicator)
(Also, see: Focus Area - Preconception and Reproductive Health)
Objective 3.1.2:
By December 31, 2017, increase the percentage of women aged 21-65 years with an income of < $25,000 who receive a cervical cancer screening, based on the most recent clinical guidelines (Pap test within the past three years), by 5% from 83.8% (2010) to 88.0%.
(Data Source: NYS BRFSS) (Health Disparities Indicator)
(Also, see: Focus Area - Preconception and Reproductive Health)
Objective 3.1.3:
By December 31, 2017, increase the percentage of adults (50-75 years) who receive a colorectal cancer screening based on the most recent guidelines (blood stool test in the past year or sigmoidoscopy in the past 5 years and a blood stool test in the past years or a colonoscopy in the past 10 years):
  • By 5% from 68.0% (2010) to 71.4% for all adults.
  • By 10% from 59.4% to 65.4% for adults with an income <$25,000.
(Data Source: NYS BRFSS) (PA Tracking Indicator; Health Disparities Indicator)
Objective 3.1.4:
By December 31, 2017, increase the percentage of adults 18 years and older who had a test for high blood sugar or diabetes within the past three years by 5% from 58.8% (2011) to 61.7%.
(Data Source: NYS BRFSS)

Interventions for Consideration

  1. Use media and health communications to build public awareness and demand. (Guide to Community Preventive Services [Community Guide])
  2. Foster collaboration among community-based organizations, the education and faith-based sectors, independent living centers, businesses and clinicians to identify underserved groups and implement programs to improve access to preventive services. (National Prevention Strategy)
  3. Establish training programs across the health professional spectrum, to include enhancement of patient-centered skills, disability literacy and providers' cultural competence. (Community Guide)
  4. Ensure consumer access to and coverage for preventive services, and enhance reimbursement and incentive models. (Community Guide; National Prevention Strategy)
  5. Expand use of health information technology to remind, provide feedback and incentivize clinicians and health care systems. (Community Guide; National Prevention Strategy)

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Goal #3.2: Promote use of evidence-based care to manage chronic diseases.

Objective 3.2.1:
By December 31, 2017, reduce the asthma emergency department visit rate:
  • By 10% from 218.3 per 10,000 (2007-2009) to 156.9 per 10,000 for residents ages 0-4 years.
  • By 10% from 81.6 per 10,000 (2007-2009) to 65.4 per 10,000 for residents ages 5-64 years.
  • By 10% from 31.4 per 10,000 (2007-2009) to 22.3 per 10,000 for residents ages 65 years and older.
  • By 10% from 83.4 per 10,000 (2007-2009) to 75.1 per 10,000 for residents of all ages.
(Data Source: SPARCS) (PA Tracking Indicator; Health Disparities Indicator)
Objective 3.2.2:
By December 31, 2017, reduce the asthma hospital discharge rate:
  • By 35% from 58.8 per 10,000 (2007-2009) to 38.5 per 10,000 for residents ages 0-4 years.
  • By 23% from 15.5 per 10,000 (2007-2009) to 11.9 per 10,000 for residents ages 5-64 years.
  • By 17% from 31.2 per 10,000 (2007-2009) to 25.8 per 10,000 for residents ages 65 years and older.
(Data Source: SPARCS)
Objective 3.2.3:
By December 31, 2017, increase the percentage of members 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate asthma controller medications for at least 50% of the treatment period:
  • By 12% from 58% (2012) to 65% among residents enrolled in NYS Government sponsored managed care health insurance (Medicaid or Child Health Plus).
  • By 10% from 65% (2012) to 71.5% among residents enrolled in commercial managed care health insurance.
(Data Source: NYS QARR)
Objective 3.2.4:
By December 31, 2017, increase the percentage of health plan members, ages 18-85 years, with hypertension who have controlled their blood pressure (below 140/90):
  • By 10% from 63% (2011) to 69.3% for residents enrolled in commercial managed care health insurance.
  • B 7% from 67% (2011) to 72% for residents enrolled in Medicaid Managed CareB.
  • By 15% among black adults enrolled in Medicaid Managed Care from 58% (2011) to 66.7%.
(Data Source: NYS QARR) (PA Tracking Indicator; Health Disparities Indicator)
Objective 3.2.5:
By December 31, 2017, reduce the age-adjusted hospitalization rate for heart attack by 10% from 15.5 per 10,000 residents (2010) to 14.0 per 10,000 residents of all ages.
(Data Source: SPARCS) (PA Tracking Indicator)
Objective 3.2.6:
By December 31, 2017, increase the percentage of adult health plan members with diabetes whose blood glucose is in good control (hemoglobin A1C less than 8%):
  • By 7% from 58% (2011) to 62% for residents enrolled in Medicaid Managed Care.
  • By 10% from 55% (2011) to 60.5% for residents enrolled in commercial managed care insurance.
  • By 10% from 56% (2011) to 62% for black adults enrolled in Medicaid Managed Care.
(Data Source: NYS QARR) (PA Tracking Indicator; Health Disparities Indicator)
Objective 3.2.7:
By December 31, 2017, increase the percentage of Medicaid managed care plan members who received all four screening tests for diabetes (HbA1c testing, lipid profile, dilated eye exam and nephropathy monitoring):
  • By 5% from 50% (2009) to 52.5% among all adults with diabetes.
  • By 10% from 45% (2009) to 49.5% among Black adults with diabetes.
  • By 10% from 46% (2009) to 50.6% among non-Hispanic white adults with diabetes.
(Data Source: NYS QARR) (Health Disparities Indicator)
Objective 3.2.8:
By December 31, 2017, reduce the rate of hospitalizations for short-term diabetes complications:
  • By 10% from 3.4 per 10,000 (2007-2009) to 3.06 per 10,000 for residents ages 6-17 years.
  • By 10% from 5.4 per 10,000 (2007-2009) to 4.86 per 10,000 for residents 18 years and older.
(Data Source: SPARCS) (PA Tracking Indicator)

Interventions for Consideration

  1. Support the adoption and use of electronic health records. (Community Guide)
  2. Promote the inclusion of decision support tools/reminder system modules in the basic electronic medical record packages offered by vendors. (Community Guide)
  3. Adopt medical home or team-based care models, especially in practices that serve disparate communities. (Community Guide)
  4. Provide technical assistance and quality improvement training to health care organizations and providers, especially those serving disparate communities. (NYSDOH Chronic Disease Program Goal)

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Goal #3.3: Promote culturally relevant chronic disease self-management education.

Objective 3.3.1:
By December 31, 2017, increase by at least 5% the percentage of adults with arthritis, asthma, cardiovascular disease, or diabetes who have taken a course or class to learn how to manage their condition. (Data Source: BRFSS; annual measure, beginning 2013)
Objective 3.3.2:
By December 31, 2017, increase by 38% the percentage of adults with current asthma who have received a written asthma action plan from their health care provider from 29% (2010) to 40%. (Data Source: BRFSS)

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Interventions for Consideration

  1. Implement policies to support coverage of chronic disease self-management programs. (NYSDOH Chronic Disease Program Goal)
  2. Develop a sustainable infrastructure for widely accessible, readily available self-management interventions that link community and clinical settings and make use of lifestyle intervention professionals such as registered dietitians, exercise physiologists and social workers. (NYSDOH Chronic Disease Program Goal)
  3. Develop a sustainable infrastructure for widely accessible, readily available self-management interventions linked to the clinical setting. (NYSDOH Chronic Disease Program Goal)
  4. Establish clinical-community linkages that connect patients to self-management education and community resources, such as the NYS Smokers' Quitline. (NYSDOH Chronic Disease Program Goal)
  5. Use health information technology to support a clinical referral/recommendation system that links patients to community-based resources. (National Prevention Strategy)

Interventions by Level of Health Impact Pyramid

Focus Area 3: Increase access to high-quality chronic disease preventive care and management in clinical and community settings.
Levels of Health Impact Pyramid*Interventions
Counseling and Education
  • Use media and health communications to build public awareness about and demand for chronic disease prevention and management programs.
  • Establish training programs across the health professional spectrum, to include enhancement of patient-centered skills and providers' cultural competence.
  • Provide technical assistance and quality improvement training to health care organizations and providers.
Clinical Interventions
  • Foster collaboration among community-based organizations, the education and faith-based sectors, businesses and clinicians to identify underserved groups and implement programs to improve access to preventive health care.
  • Expand use of health information technology to remind, provide feedback and incentivize clinicians and health care systems.
  • Support the meaningful use of electronic health records in improving prevention and control of chronic diseases.
  • Promote the inclusion of decision support tools/reminder system modules in vendors' basic electronic medical record packages.
  • Use health information technology to support a clinical referral/recommendation system that links patients to community-based resources.
Long-Lasting Protective Interventions
  • Establish clinical-community linkages that connect patients to self-management education and community resources, such as the NYS Smokers' Quitline.
Changing the Context to Make Individuals' Decisions Healthy
  • Ensure consumer access and coverage for preventive services, and enhance reimbursement and incentive models.
  • Adopt medical home or team-based care models.
  • Implement policies to support coverage of chronic disease self-management programs
  • Develop a sustainable infrastructure for widely accessible, readily available self-management interventions linked to the clinical setting.
Socioeconomic Factors
  • Develop and implement community-led, place-based interventions targeted to address the social determinants of health in high-priority vulnerable communities

* Frieden T., "A Framework for Public Health Action: The Health Impact Pyramid". American Journal of Public Health. 2010; 100(4): 590-595

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Interventions and Activities by Sector

Changes can be made across all sectors to increase access to high-quality chronic disease preventive care and management in clinical and community settings. Below are examples of how your sector can make a difference.

Healthcare Delivery System

  • Establish or enhance reimbursement and incentive models to increase delivery of high-quality chronic disease prevention and management services.
  • Offer recommended clinical preventive services and connect patients to community-based preventive service resources.
  • Incorporate Prevention Agenda goals and objectives into hospital Community Service Plans, and coordinate implementation with local health departments and other community partners.
  • Adopt and use certified electronic health records, especially those with clinical decision supports and registry functionality. Send reminders to patients for preventive and follow-up care, and identify community resources available to patients to support disease self-management.
  • Adopt medical home or team-based care models.
  • Create linkages with and connect patients to community preventive resources.
  • Provide feedback to clinicians around clinical benchmarks and incentivize quality improvement efforts.
  • Reduce or eliminate out-of-pocket costs for clinical and community preventive services.
  • Educate and encourage enrollees to access clinical and community preventive services.
  • Coordinate with clinicians to establish and implement patient reminder systems for preventive and follow-up care.

Employers, Businesses, and Unions

  • Offer health coverage that provides employees and their families with access to preventive services with no or reduced out-of-pocket costs.
  • Provide incentives for employees and their families to access clinical and community preventive services.
  • Give employees time off or flextime to access preventive services and to attend community programs aimed at disease self-management.
  • Provide employees with comprehensive wellness programs.

Media

  • Coordinate health-related messaging with local health care systems and public health agencies.
  • Promote awareness of and demand for community preventive services.
  • Highlight community needs and communicate disease burden to engage consumers, communities and relevant stakeholders.
  • Support local community initiatives that increase access to high-quality chronic disease preventive care and management services.

Academia

  • Provide health care organizations and clinicians with trainings related to quality improvement and the use of health information technology to increase the use of clinical preventive services and disease management.
  • Train community volunteers to become community health workers or patient navigators.
  • Promote the use of preventive services within their own health service provisions.
  • Engage in research and research translation to inform the evidence-base for chronic disease prevention and management.

Community-Based Health and Human Service Agencies

  • Inform people about the range of preventive services they should receive and their benefits.
  • Create linkages with local health care systems to connect patients to community preventive resources.
  • Support use of alternative locations to deliver preventive services.
  • Expand public-private partnerships to implement community preventive services.
  • Support training and use of community health workers and patient navigators.

Other Government Agencies

  • Promote the use of preventive services within their own health service networks.
  • Expand the use of community health workers and patient navigators.
  • Adopt a "health in all policies" approach to regulation and policy development and implementation.
  • Revise regulations to allow reimbursement for services provided by non-licensed professionals who receive formal training and certification in the delivery of preventive services (e.g., community health workers, lactation consultants).
  • Incorporate Prevention Agenda goals and objectives in county health planning initiatives.

Governmental (G) and Non-Governmental (NG) Public Health

  • Increase delivery of preventive services by Medicaid and other public insurance program providers. (G)
  • Improve monitoring capacity for quality and performance of recommended clinical preventive services Statewide and provide resources to improve monitoring capacity at the local level. (G) (NG)
  • Educate clinicians and the public about coverage improvements for clinical preventive services as outlined in the Affordable Care Act. (G) (NG)
  • Support adoption of certified electronic health records that meet federal "meaningful use" criteria.
  • Expand use of patient-centered medical home models. (G) (NG)
  • Identify high-priority clinical and community preventive services and test innovative strategies. (G) (NG)
  • Foster collaboration among traditional and non-traditional community partners to improve access to clinical and community preventive services. (G) (NG)

Policymakers and Elected Officials

  • Promote awareness of and demand for clinical and community preventive services.
  • Support adequate funding for evidence-based projects focusing on increasing awareness of and access to clinical and community preventive services.
  • Support adequate government reimbursement for preventive services and expanded access to insurance coverage that includes preventive care benefits.
  • Support a "health in all policies" approach to legislation.
  • Participate in/lend support to local community initiatives that increase access to high-quality chronic disease prevention and management services.

Communities

  • Encourage individuals and families to visit health care providers to receive clinical preventive services.
  • Advocate for improved access to and delivery of quality clinical and community preventive services.
  • Raise funds and promote awareness of clinical and community preventive services.

Philanthropy

  • Provide resources to communities for initiatives that increase access to high-quality chronic disease preventive care and management services (e.g., community health workers, chronic disease self-management programs).
  • Convene relevant stakeholders to coordinate efforts aimed at increasing access to and provision of high-quality chronic disease prevention and management services.
  • Provide scholarships to address health care workforce shortages.
  • Support research efforts aimed at informing the evidence base for chronic disease prevention and management.

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