Oregon Health Policy Board AGENDA February 3, 2014 OHSU Center for Health & Healing 3303 SW Bond Ave, 3 rd floor Rm. #4 8:30 a.m. to 11:30 a.m.

Transcription

1 Oregon Health Policy Board AGENDA February 3, 2014 OHSU Center for Health & Healing 3303 SW Bond Ave, 3 rd floor Rm. #4 8:30 a.m. to 11:30 a.m. Live web streamed at: OHPB Live Web Streaming # Time Item Presenter Action Item 1 8:30 Welcome, call to order and roll Zeke Smith, Chair 2 8:35 Director s report Lynne Saxton, Director, OHA 3 9:00 Legislative update Courtney Westling, OHA 4 9:15 Review of OHPB January planning session summary and next steps Action Item: Approval of 1/6/15 Summary Leslie Clement, OHA Diana Bianco, Artemis Consulting X 5 10:00 Break Chair 6 10:15 Health System Transformation report Lori Coyner, OHA Lillian Shirley, OHA Pam Martin, OHA 7 11:15 Public testimony Chair 8 11:30 Adjourn Chair Next meeting: March 3, 2014 OHSU Center for Health & Healing 3303 SW Bond Ave, 3 rd floor Rm. #4 8:30 a.m. to 12:00 p.m.

2 Oregon Health Authority 2015 Legislative Agenda HB 2419 (LC 473) OHA Housekeeping This measure amends or repeals statutes to align new statutory language as well as reflect current organizational structure and allow flexibility at the Oregon Health Authority (OHA). Changes Oregon Health Policy and Research (OHPR) to Oregon Health Authority (OHA) throughout statutes. Deletes references to OHPR Advisory Committee because it referred to when OHPR was outside of OHA/DHS. Expands the qualifications and experience that would qualify someone to be appointed as the State Public Health Officer (Public Health Division) Modifies definition of health care interpreter and revises membership of Oregon Council on Health Care Interpreters to better align with current business practice within OHA and those that govern CCOs. Removes all statutory references to Blue Mountain Recovery Center in ORS and ORS (Addictions and Mental Health Division) Aligns references relating to screening interviews and treatment programs for alcohol and drug diversion programs. Removes reference to prescription drugs and replaces the current definition of illegal drugs with the definition used in the Americans with Disabilities Act, allowing for people to be evicted if they have relapsed on alcohol or another controlled substance in residential treatment. SB 227 (LC 474) TBI Registry The measure amends the statute that established the Oregon Trauma Registry (OTR) to allow the state to create a Traumatic Brain Injury Registry, utilizing OTR data. The state will compile a case list from the Trauma Registry of persons who experienced a traumatic brain injury (TBI). The compiled case list would be shared with the Department of Human Services (DHS), Seniors and People with Disabilities program. DHS staff would use the case list information for services planning and to conduct outreach and follow up with people with TBI. The measure amends the Trauma Registry statute to allow data from the Trauma Registry to be used for public health epidemiologic studies that will support overall system improvement and prevention of injuries. The Trauma Registry was enacted in SB 228 (LC 475) RPS Fees RPS programs are 100% user-fee supported and are used to recover the direct costs of Radiation Protection Services (RPS) operations and administrative functions relating to the regulation of radiation. RPS is requesting a fee adjustment through statute to increase X-ray and tanning device registration fees and increase the radioactive material licensing fee cap. This will allow the RPS program to maintain fiscal solvency, and avoid staff reductions which could result in inadequate regulatory oversight. SB 229 (LC 476) Travel Stipend This concept will permit members of the Oregon Consumer Advisory Council (OCAC) to receive a stipend and travel reimbursement. This will align the compensation and expense reimbursement for members of OCAC with other AMH Advisory Councils Legislative Agenda

3 Oregon Health Authority 2015 Legislative Agenda HB 2420 (LC 477) 370 Evaluations This concept will require individuals charged with a misdemeanor or Class C felony and unable to aid and assist in their own defense due to a mental illness to be interviewed by the Community Mental Health Program Director or designee. The interview is to determine if the services, supports and supervision are available in the community to divert the individual from the state hospital to the community for restoration. HB 2421 (LC 480) MH Drugs to CCOs This measure would transfer the responsibility for management of all mental health drugs from FFS to CCOs and shift the associated dollars spent on these drugs from FFS to CCOs. This will allow the CCOs to coordinate all health delivery costs for their mental health clients. SB 230 (LC 481) Healthcare Workforce Information Collection This measure requires all health care regulatory boards to participate in the Oregon Healthcare Workforce Database, created by HB 2009 in Expanded data collection will allow the Legislature, OHA, and other industry and education stakeholders to better understand Oregon s current health care workforce and plan for future needs. SB 231 (LC 483) Primary Care Transformation Initiative This concept establishes an initiative that will strengthen investment and infrastructure for Oregon s primary care delivery system. Specifically, it would formalize a multi-payer primary care collaborative in statute and direct the group to design an initiative in which payers: a) pilot a small number of alternative primary care payments and develop benchmarks for success that would trigger continuation of the initiative past pilot phase; and b) make equitable investments in primary care transformation assistance. Contact: Courtney Westling, Director of Legislative and Government Affairs, Oregon Health Authority, , courtney.c.westling@state.or.us 2015 Legislative Agenda

4 Oregon Health Policy Board Planning Session January 6, 2015 SUMMARY On January 6, 2015, the Oregon Health Policy Board held a planning session to: Review and affirm the role of the OHPB; Reach a shared understanding of the OHPB s priorities over the next 1-3 years; Discuss and reach agreement on the how the board will work together to accomplish its goals All current Board members were present for the session. Priorities from the Governor Sean Kolmer, Health Policy Advisor to Governor Kitzhaber, shared the following priority areas that the Governor would like the Board to engage in over the coming year: 1. Integration of mental health and physical health systems. 2. Highlighting the success of PEBB (and soon, OEBB) in adopting the coordinated care model 3. Support in improving the behavioral health system and the community mental health system (both issues will be seen in the legislative session). OHPB Role The Board discussed its role and scope of its responsibilities. The Board is the policy-making and oversight body for the Oregon Health Authority. Through its policy-making role, the Board identifies and focuses on high-priority issues that require review, direction and insight. The board will seek to focus on issues of significant scope, magnitude and impact ( biggest worst first and burning platform ). The board s oversight role is focused on accountability to determine, for example, whether policies are moving in the intended direction; to ensure that systems or programs are coordinating or aligned whenever possible; and that CCOs continue to make progress. The oversight and policy-making roles are connected through a cycle of action. The Board first focuses on a priority issue, then initiates the policy-making process, which leads to the need for oversight and monitoring during development and implementation of that policy. The oversight that the Board provides allows for adjusting policies or programs midstream (e.g., providing feedback to staff or identifying potential areas of concern), as well as assessing the results of a fully implemented policy and identifying next steps (potentially restarting the cycle of action). To bolster its effectiveness and focus, the Board will continuously strengthen relationships with the Director of the Oregon Health Authority, the Governor s office, and the Legislature in order to ensure alignment, coordination, efficiency and accountability. Draft 1/28/15

5 2015 Board Meetings Staff will work with the Board to organize meetings that highlight questions for discussion and problemsolving on high priority issues. Presentations to the Board will be formatted for efficiency and timeliness, and will: Frame the question, challenge, or problem for the Board; Articulate the pros and cons of recommendations; Be transparent about point-of-view/position; Highlight the connections between different areas of work across the state and agency; Include information about other advisory or stakeholder groups working on the issue, and how Board consideration or action would contribute uniquely. The Board also may identify issues that potentially warrant the Board s attention and ask staff for additional information. Issue Prioritization In order to determine a work plan for 2015 (and for the future), the Board identified a number of principles to guide the prioritization process. When presented with an issue, risk, or challenge to potentially address, the Board will consider: The Triple Aim: How does this issue impact Oregon s goal of better health, better care, and lower costs? The governor s agenda: Does this align with the governor s priorities? Urgency and impact: What is the scope, magnitude, and timeliness of this issue? Is it a significant barrier to health care transformation? Does this issue affect a substantial number of Oregonians? Unique role: Are there other groups, agencies, or organizations already addressing this issue, or will the Board be able to offer a unique perspective? Oregon Health Policy Board 2015 Priorities The Board identified three overarching priorities for 2015: 1. Health System Transformation Monitoring The Board will continue to monitor and track the successes and challenges of CCO implementation. In the coming year, efforts such as integration of behavioral health, oral health and physical health systems in CCOs and the implementation of alternative payment methodologies will possibly be a focus. Additionally, the Board will continue to support the spread of the coordinated care model principles into PEBB, OEBB, and the commercial market. Relevant work groups: Coordinated Care Model Alignment work group; Sustainable Health Expenditures work group (SHEW), All Payer All Claims Technical Advisory Group 2. Behavioral Health Ongoing discussions about the behavioral health system in Oregon may lead to a variety of opportunities for the Board to engage, including integration efforts, enhanced community- Draft 1/28/15

6 based services and supports, barriers that impede care coordination, performance oversight informed by data,, workforce issues, and legislation. Relevant advisory groups: Addictions and Mental Health Planning and Advisory Council, Children s Services Advisory Council, Oregon Consumer Advisory Council, and other ad hoc groups as convened by the Governor s office and OHA. 3. Public Health The Public Health Modernization process will be addressed during the 2015 legislative session. The Board will follow the legislation and be ready to act accordingly. Population health issues will be routinely included in relevant health system discussions. In addition to these three priorities, the Board will continue to: Next Steps Oversee alignment and integration between health care system transformation and early learning system transformation via the Early Learning Council/OHPB Joint subcommittee; Identify ways in which the Workforce Committee can support work in the priority areas; Monitor the implementation of health information technology and movement on the HITOC legislation. Staff will gather information that pertains to the role of the Board in relation to the behavioral health and public health systems in the state for future discussion, including: o Funding streams at the federal, state, and local levels; o Articulation of a specific role that the Board can play in each arena; o Expected or ideal timeline for achieving milestones or addressing issues; o Specific ask for a concrete list of current challenges in each area; o Definitions (e.g., integration ); Staff will connect with the Governor s office to further clarify ways in which the Board might be involved in conversations related to the spread of the coordinated care model. Further Board discussion at February meeting will center on: o Board decision-making process; o Advisory panels or subject matter expertise. Draft 1/28/15

7 Health System Transformation 2014 Mid-Year Performance Report Oregon Health Policy Board February 3, 2015 Lori Coyner Director of Health Analytics Game Plan 1. What have we learned about the ACA population? 2. What are we learning about the Coordinated Care Model? 3. What can we learn about areas within Behavioral Health and Public Health? 4. Summary 2 1

8 Oregon Health Authority accountability Core Performance Measures Included in Oregon's 1115 demonstration waiver - some focus on population health There are no financial incentives or penalties associated with them State Performance Measures Annual assessment of statewide performance on 33 measures. Financial penalties to the state if quality goals are not achieved. CCO Incentive Measures Annual assessment of CCO performance on 17 measures. Quality pool paid to CCOs for performance. Compare 2013 performance to 2011 baseline Mid-Year Performance Report State and CCO progress is reported for July 1, 2013 through June 30, 2014; compared with calendar 2013 and baseline year No quality pool payments were made based on this data, or included in this report

9 2014 Mid-Year Performance Report: What s New? Core Performance Measures: Population health measures reported to CMS each year as part of Oregon s 1115 waiver. Expansion Population: Data on key measures for the 380,000+ Oregonians who enrolled in the Oregon Health Plan since the ACA took effect January 1, Enhanced Financial Data: New visualizations and drill-downs for cost and utilization. 5 ACA EXPANSION IN OREGON 3

10 Oregon Health Plan: Changing Demographics 7 Oregon Health Plan: Changing Demographics 8 4

11 ED Utilization since January 1, 2014 See similar pattern for avoidable ED visits. 9 What next? Monitor ED visit use and outpatient visits with a full year of data. Work to understand more about the new members are they relatively healthy or is the decrease in ED use the result of a change in health care delivery? Examine access to care over time 10 5

12 COORDINATED CARE MODEL 11 ED visits decreased 21 percent since 2011, despite an influx of 20 percent new enrollment from ACA expansion. 12 6

13 Emergency Department Costs Decreased by 20% 13 PCPCH Enrollment Increased by 55% since 2012 Q1 78.6% 79.6% 76.9% 80.4% 51.8% Q Q Q3 CCOs N = 528, , , ,

14 Outpatient Costs Overall PMPM outpatient costs have decreased. Primary care spending has increased 15 What are we learning about the Coordinated Care Model? 16 8

15 17 Incentives promote change 18 9

16 How Are We Doing? Incentive Metrics: Statewide improvement on all nine of the incentive metrics (compare 2011 to mid-year 2014) State Performance Metrics: statewide improvements on 10 of the 14 state performance metrics (compare 2011 to mid-year 2014) Core Performance Metrics: Statewide progress was mixed first time reporting 19 More work is needed Child and adolescent access to primary care providers Access declined for all age groups at the statewide level (results were not reported at the CCO level). Initiation and engagement of alcohol or other drug treatment (engagement phase) Nine of 16 CCOs declined on this measure. Tobacco use prevalence Nine of 16 CCOs declined on this measure, and none have reached the benchmark

17 21 BEHAVIORAL HEALTH WHAT CAN WE LEARN Continued improvement over 2011 baseline. Modified measure specifications allow community providers to complete follow-up, promoting behavioral and physical health care integration

18 Progress on SBIRT

19 Inpatient Costs Inpatient PMPM costs have declined 5.7 percent since Greatest declines were in mental health and maternity. 25 Outpatient Costs Overall PMPM outpatient costs have decreased. Spending for mental health ahs remained roughly the same 26 13

20 27 PUBLIC HEALTH WHAT CAN WE LEARN Children on OHP have about the same proportion of completed immunizations as all children in Oregon 14

21 Lagging behind the benchmark Core Performance: Tobacco Prevalence Tobacco use among all Oregonians is 16% 30 15

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23 Main messages Incentive measures get the attention -- $$ drives improvements Progress in some areas appears to be accelerated for Medicaid when compared to other payers Measures show progress and some challenges for improving behavioral health and population health 33 CCO Incentive Metrics for 2015 Retired: Early elective delivery Follow-after medication for ADHD Added: Modified: Dental sealants for children Effective contraceptive use among women at risk of unintended pregnancy SBIRT for adolescents Dental health assessments for children in foster care Challenge pool metrics: SBIRT Depression screening and follow-up Diabetes HbA1c poor control Developmental screening 34 17

24 Next Progress Report Will be published late June Metrics calculated for calendar year Will include CY 2014 quality pool distribution. Will have expanded cost and utilization information. 35 For More Information The 2014 Mid Year Performance Report and all technical specifications are posted online at health.oregon.gov Contact Lori Coyner, MA Director of Health Analytics 36 18

25 Public health work supporting health system transformation performance measures February 2015 The Oregon Health Authority s Public Health Division (PHD) focuses work on policies and programs that promote healthy environments while protecting the public from harmful diseases and conditions. A significant part of this role is focused on the collection of population level data. PHD operates many registries, databases and surveys which are used to create public reports and inform policy and program efforts. PHD also uses data to identify health disparities that require focused efforts to mitigate. Measure INCENTIVE MEASURES Adolescent well-child visits Alcohol and other substance misuse (SBIRT) Colorectal cancer screening Controlling high blood pressure Current Public Health Division efforts PHD supports a network of certified school-based health centers, which are able to provide adolescent well-child visits and other services. PHD also provides guidance to school-based health centers, pediatric and primary care practices on how to provide high quality adolescent well-child visits. PHD has been working with stakeholders across OHA and the Insurance Division to assess policy issues related to the provision of confidential services and the impact of confidentiality on the adolescent well-child visit and other measures (i.e. SBIRT, depression screening, chlamydia screening and effective contraception use). PHD is collaborating with the Addictions and Mental Health Division on a quality improvement project aimed at integrating SBIRT and depression screening in adolescent well-child visits. PHD participates in the Addictions and Mental Health Division s Strategic Prevention Framework-State Incentive Grant (SPF-SIG) Advisory Group. In addition, PHD manages a school-based health center mental health expansion grant aimed at increasing access to mental health care for children and adolescents. PHD s Oregon MothersCare and nurse home visiting programs provide alcohol screening for pregnant women. PHD s colorectal cancer program operates the Cancer You Can Prevent media campaign to promote uptake of colorectal cancer screening. PHD s WISEWOMAN and heart disease and stroke prevention programs promote the use of clinical guidelines to monitor and control high blood pressure. PHD provides access to several chronic disease self-management programs, including the Stanford Chronic Disease Self-Management Program and Walk with Ease, which provide individuals with the skills necessary to manage their ongoing health conditions. Oregon Health Authority, Public Health Division 1

26 Dental sealants on permanent molars for children Depression screening Developmental screening Diabetes HbA1c poor control Effective contraceptive use PHD s oral health program provides dental sealants in schools where at least 50% of students are eligible for the Federal free and reduced lunch program. PHD also provides school-based dental sealant training and certification programs. PHD is collaborating with the Addictions and Mental Health Division on a quality improvement project aimed at integrating SBIRT and depression screening in adolescent well-child visits. Statecertified school-based health centers across the state are focused on increasing depression screening and follow up via a mental health expansion grant aimed at increasing access to mental health care for children and adolescents. PHD s nurse home visiting program provides depressing screening services for pregnant and postpartum women. PHD provides funding to local health departments for maternal and child health services and nurse home visiting programs; these programs offer developmental screening for the parents of infants and young children. Nurse home visitors support families in engaging with preventive health care services. PHD also manages a grant program to CCO and local public health partnerships; Eastern Oregon CCO and the 12 counties in their service region are focused on improving developmental screening rates through partnership with primary care and early learning providers. PHD s WISEWOMAN and diabetes programs promote the use of clinical guidelines to monitor and control high blood pressure. PHD provides access to several chronic disease self-management programs, including the Stanford Chronic Disease Self-Management Program and Walk with Ease, which provide individuals with the skills necessary to manage their ongoing health conditions. PHD administers Oregon s Title X grant and Oregon ContraceptiveCare, a Medicaid family planning waiver, through a statewide network of contracted family planning providers. This network of family planning providers receives resources, including training, best practice recommendations and technical assistance to deliver high quality reproductive health services. PHD convenes the Oregon Preventive Reproductive Health Advisory Council (OPRHAC), a statewide group of experts tasked with developing standards for primary care and family planning providers regarding the provision of contraceptive services. PHD also partners with the Oregon Foundation for Reproductive Health to promote the One Key Question intervention. PHD s nurse home visiting program provides contraceptive screening services and utilizes the One Key Question intervention. As part of the grant program listed under developmental screening, AllCare, Jackson Care Connect and PrimaryHealth of Josephine County CCOs and Jackson and Josephine County Health Departments are working together to implement One Key Question in primary care, WIC and family planning offices across the region. Oregon Health Authority, Public Health Division 2

27 Electronic health record adoption Follow-up after hospitalization for mental illness Mental and physical health assessments for children in DHS custody Patient-centered primary care home enrollment Timeliness of prenatal care CORE MEASURES All-cause readmissions Ambulatory care: avoidable emergency department utilization Ambulatory care: emergency department utilization Ambulatory care: outpatient utilization Initiation and engagement of alcohol or other drug treatment Low birth weight prevalence Obesity prevalence PHD has released funding opportunities for local health departments to adopt, implement, and/or enhance their electronic health record systems and capacity. PHD also promotes Meaningful Use of electronic health information to improve preventive health screenings and care. PHD and the Addictions and Mental Health Division partner on strategies to reduce suicide in Oregon, including follow up services after a suicide attempt. PHD provides funding to local health departments for the provision of public health nurse home visiting services. Public health nurse home visitors can refer and support mental and physical health assessments for infants and young children. PHD also manages the school-based health center program; school-based health centers can provide services to support children and families. PHD operates the school-based health center program, which recently provided innovation grants to centers wishing to pursue patient-centered primary care home tier status. PHD s Oregon MothersCare program supports pregnant women with health insurance enrollment and connection to health care and social services in a timely manner. PHD s health care associated infections program works with hospitals and providers to implement and monitor appropriate protocols to prevent the spread of health care associated infections. PHD operates the senior falls prevention program, which provides educational programs such as Tai Chi: Moving for Better Balance, Stepping On and Otago to providers, community members and their families to reduce the risk of falls and fall-related injuries. PHD promotes several chronic disease self-management programs, including the Stanford Chronic Disease Self-Management Program, Walk with Ease and the National Diabetes Prevention Program, which provide individuals with the skills necessary to manage their ongoing health conditions and utilize health care resources appropriately. PHD s maternal and child health program provides support to families so they can access behavioral health resources in the community. PHD s promotion of SBIRT screening within the context of an adolescent well-child visit can also promote initiation and engagement of youth in treatment. PHD addresses low birth weight in its tobacco control efforts, through the WIC supplemental nutrition program and through its maternal and child health programs, which includes efforts to ensure early access to prenatal care and public health nurse home visiting services. Public health nurse home visitors promote healthy birth outcomes for their pregnant clients and appropriate weight for infants and young children. PHD s obesity prevention efforts are focused on increasing physical activity and access to healthy foods in child care, schools, worksites, hospitals and health clinics. PHD provides grants to local Oregon Health Authority, Public Health Division 3

28 Tobacco use prevalence STATE PERFORMANCE MEASURES Appropriate testing for children with pharyngitis Cervical cancer screening Child and adolescent access to primary care providers Childhood immunization status health departments that focus on obesity prevention. PHD also supports the National Diabetes Prevention Program, which prevents Type II diabetes through weight management. PHD s WIC program supports access to healthy foods for families and promotes breastfeeding through peer counseling and support. PHD funds a tobacco prevention and education program in every Oregon county and federallyrecognized Tribe in Oregon. Comprehensive tobacco prevention and education programs enforce the Indoor Clean Air Act, work with health care providers to promote tobacco cessation and promote the adoption of local tobacco control policies such as tobacco-free college and community college campuses, multi-unit housing, parks and fairs. The PHD tobacco prevention and education program also implements a tobacco media campaign, funds the Oregon Tobacco Quit Line and provides tobacco cessation training to CCOs, providers, community health workers and residential treatment facility staff. PHD s maternal and child health, nurse home visiting and Oregon MothersCare programs assist pregnant women in quitting tobacco. PHD s antibiotic resistance program offers training and materials to patients and providers focused on appropriate antibiotic use; these materials stress the importance of appropriate testing for children with pharyngitis before antibiotics are administered. PHD provides access to free screening services for uninsured individuals through its breast and cervical cancer program. PHD s network of breast and cervical cancer screening providers also receive education on clinical guidelines and best practices which they can apply to their entire panel of patients. PHD s school-based health center program provides children, adolescents and families with access to primary care services. PHD s maternal and child health program also assists families with connecting to primary care providers. PHD operates the Vaccines for Children program, which is designed to improve access to child vaccines. PHD supports provider improvement in vaccine practices and coverage through the AFIX program. PHD also focuses efforts on policies to ensure more children are vaccinated and in compliance with Oregon s school entry policies. Public health nurse home visitors monitor immunization status for infants and young children that they are serving. PHD operates the ALERT immunization registry, which allows providers to access a patient s vaccination history and access tools for clinical decision-making. Oregon Health Authority, Public Health Division 4

29 Chlamydia screening in women Comprehensive diabetes care: LDL-C screening Comprehensive diabetes care: HbA1c testing Follow-up for children prescribed ADHD medication Immunizations for adolescents Medical assistance with smoking Diabetes short-term complication admission rate Chronic obstructive pulmonary disease or asthma admission rate Congestive heart failure admission rate Adult asthma admission rate PHD s reproductive health program provides access to family planning and STD screening services through a network of contracted providers. PHD s STD prevention program includes a team of disease investigation specialists, which help providers track individuals who have tested positive for an STD along with their partners, in order to engage individuals in appropriate STD treatment. PHD s diabetes program promotes the use of clinical guidelines for diabetes care. PHD promotes several chronic disease self-management programs, including the Stanford Chronic Disease Self- Management Program and Walk with Ease, which provide individuals with the skills necessary to manage their ongoing health conditions and utilize health care resources appropriately. PHD provides funding to local health departments for the provision of nurse home visiting services. PHD also manages the school-based health center program which includes the mental health expansion initiative. PHD operates the Vaccines for Children program, which is designed to improve access to child vaccines. PHD supports provider improvement in vaccine practices and coverage through the AFIX program. PHD also focuses efforts on policies to ensure more children are vaccinated and in compliance with Oregon s school entry policies. PHD operates the ALERT immunization registry, which allows providers to access a patient s vaccination history and tools for decision-making. PHD s tobacco prevention and education program operates the Oregon Tobacco Quit Line, which providers can offer to patients seeking assistance with quitting tobacco. The tobacco prevention and education program provides information related to comprehensive tobacco cessation benefit design and offers tobacco cessation counseling training to CCOs, providers, community health workers, residential treatment facility staff and others. Both the PHD WIC and maternal and child health programs focus on screening and referring women who smoke to the Oregon Tobacco Quit Line. PHD promotes several chronic disease self-management programs, including the Stanford Chronic Disease Self-Management Program and Walk with Ease which provide individuals with the skills necessary to manage their ongoing health conditions and utilize health care resources appropriately. PHD also works to prevent tobacco use and obesity (see tobacco use prevalence and obesity prevalence above). Oregon Health Authority, Public Health Division 5

30 Adapted from Frieden, T. (2010). A framework for public health action: The health impact pyramid. American Journal of Public Health, 100(4): Smallest Impact Factors that affect health Counseling & Education Clinical Interventions Examples Advice to quit smoking, eat healthy, get vaccinated Rx for high blood pressure, cholesterol, diabetes Largest Impact Long-lasting Protective Interventions Changing the Context to make individuals default decisions healthy Socioeconomic Factors Immunizations; tobacco cessation interventions Tobacco-free policies; low-cost, healthy foods; school entry policies Poverty, education, housing, inequality