[This Transcript Is Unedited]

National Committee on Vital and Health Statistics

Population Health Subcommittee Workshop:

“Advancing Community-Level Core Measurement: Proposing a Roadmap for HHS”

November 17, 2015

National Center for Health Statistics
3311 Toledo Road
Hyattsville, MD 20782


  • Welcome – Bruce Cohen, PhD and Bill Stead, MD, NCVHS Co-Leads for Population Health
  • Workshop Purpose and the Opportunity
  • Agenda and Expectations for the Day – Monte Roulier, Facilitator
  • Introduction of Emerging Domains – Denise Koo, MD, MPH, HHS/OASH, Dave Ross, ScD, Public Health Informatics Institute And NCVHS Committee Member
  • What’s the Big Opportunity: Charge to Meeting Participants – Bruce Cohen, PhD, Bill Stead, MD, Monte Roulier
  • Panel A: Perspectives from Community and State Change Makers
    • Marissa Levine, MD, Virginia Department of Health
    • Amy Rohling McGee, MSW, Health Policy, Institute of Ohio
    • Andy Allen, City of Baton Rouge, Baton Rouge, LA
    • Ray King, PhD, MPH, Community Health Record Project, Shelby County, TN
  • Panel B: Perspectives from Thought Leaders and National Initiatives
    • Pat Remington, MD, MPH, University of Wisconsin- Madison
    • Carolyn Miller, MS, Robert Wood Johnson Foundation
    • Gib Parrish, MD, Consultant
    • Bechara Choucair, MD, MS, Trinity Health
  • Advancing Domains of Measurement That Will Make a Difference
  • Reflections from the Federal Perspective
  • Working Session: Drilling Down
  • Report Outs: Filling in Roadmap Ideas
  • Final Reflection and Next Steps


Agenda Item: Welcome

DR. COHEN: As I have said before, there are plenty of tables around. I would really appreciate if folks who are sitting in the back row sort of come on in. Be part of the conversation. Join us at open tables. Thank you for modeling. Come on the rest of you guys. Come to the tables because the day is going to be very interactive. As folks come in, you might have assigned tables, but we are done with that. Please find your seat.

My name is Bruce Cohen. I am a member of the National Committee on Vital and Health Statistics. Along with my colleague, Bill Stead, we are co-facilitating this with Monte Roulier, who you will meet in a second. Welcome everyone. This is a really exciting day. We are very happy that you could all make it. This is going to be one phenomenal large discussion and many small ones.

Bill, do you want to introduce yourself? Some of you may not know anything about the National Committee. I have a two-minute presentation on how we got to this place.

DR. STEAD: I am Bill Stead, Vanderbilt University, and Bruce’s partner in crime as co-chair of Population Health. Welcome.

Agenda Item: Workshop Purpose and the Opportunity

DR. COHEN: That was good modeling. That is about as long as we want each person to speak. Let’s see if I can pay attention. The National Committee is one of the oldest federal advisory boards. I think it was founded in 1949. We focus on a variety of health data and health policy issues. We provide advice to the secretary and to a variety of federal organizations. Today, the fourth bullet is most germane. We are serving as a forum for an interaction for ideas.

There are four basic areas that NCVHS operates in. Standards. We have a new Data Access and Use group that Dr. Vickie Mays chairs. She is around here today. Bill and I co-chair the Population Health for NCVHS and we do a lot of work on Privacy, Confidentiality, and Security.

This is a seminal – you probably cannot see this. We will get back to this. We don’t really need to focus on that right now, but later we might need to. I am going to really be talking a little bit about the population health track for NCVHS. This document was developed by Gib Parrish, who is here today and we will be sharing it more with Dan Friedman. I think for the last 10 to 15 years, we have been slowly and increasing our focus on population health related issues. And in particular, focusing on moving more towards looking at the role of the federal government and helping to promote community health. For us, our focus really is on data. It is using data to promote community health.

Of course, there are many definitions of what a community is. For those of you who cannot see this, we define community as an interdependent of people who share a set of characteristics and are joined over time by a sense that what happens to one member affects many or all the others in the group.

Today, we are going to be talking about several themes and certainly one of them is how the federal government can support community health by providing access to more data for community use.

Some of our early work. This was from a report about four years ago. Health is a Community Affair. Getting data into the hands of communities and ensuring they have tools and capacities to use them could move the nation forward. Essentially, that is the theme that we will be promoting.

For us, this is the continuation of a journey. This report, Community as a Learning System using local health data, came out in 2011 and set us on this course and today is the next step in this journey.

Last year we had a roundtable that brought together community leaders, health data connectors, and health data suppliers to identify major lessons and gaps for community data. This is the report. I suggest if you are interested, going online and finding a copy of this.

One of the ways we communicate our ideas is to write letters of recommendation to the Secretary of Health and Human Services. The most striking finding of last year’s roundtable was the theme concerned with expanding the drive for health equity at the community level. The federal government has done a phenomenal job of generating national statistics, but we feel now as we have the opportunity to work with different agencies, not just Health and Human Services to focus on communities at a much lower level of aggregation, not only geographically, but for subpopulations as well.

Some of the recommendations to the secretary include creating a virtual home for community data work, developing a Strategic Community Health Data Plan, and really trying to think about health more broadly rather than the absence of disease and access to high-quality medical services, but really think more holistically about population health and public health. That is our goal today.

I think that was my last slide. I will turn it over to Monte to continue introducing what we will be doing today.

Agenda Item: Agenda and Expectations for the Day

MR. ROULIER: Thanks Bruce. Good morning everyone. My name is Monte Roulier. I help lead a group called Community Initiatives as well as the Community Commons and have the privilege to really serve as your facilitator today, which is mostly making sure that we maximize our time together and hopefully start to tap into the collective wisdom that is present in this room. I know there is really an extraordinary mix of perspectives here.

Maybe before I jump into the agenda, I just give you a flavor of the extraordinary mix. I just want to get a sense of the types of organizations that are here. We have a number of federal leaders here. Maybe if you could just wave a hand and then actually call some out. Folks from CMS that are here. CDC? Department of Justice? Anybody here from the Department of Justice? Wonderful. How about HUD? Anybody from HUD yet? I think some folks from HUD are going to be coming. EPA as well. Wonderful. How about HRSA? Folks from HRSA. AHRQ? OASH? I am not going to read out every acronym. We probably should here in a moment. What other kind of federal perspectives do we have here that I may have missed? ASPE.

We have a number of associations as well. I think we have some folks from NACCHO. And the Public Health Accreditation Board. Over here. Wonderful. How about National Association of Medical Directors I think may be here at some point. Not yet. What other associations do we have? ASTHO. Academy Health. NAPHSIS. NAHDO. Catholic Health Association. Wonderful. What else do we have in this room? Major kind of perspectives that are being represented?

PARTICIPANT: Academia. I also work with Montgomery County on these issues.

DR. ROULIER: Wonderful. Thanks for being here. Health Systems. Trinity Health. The Public Health Institute. National Quality Forum. Beaumont Foundation. I think we may have some folks from RWJ coming as well. State government and health information exchange. Consulting firms. Local government. County health rankings. County health department. A broad range. I am hoping that you will take advantage of both some small table time. Any other big perspectives that you want to surface? We will have a chance to interact to make sure we get to know each other a little better. Some of you know each quite well.

But actually just having all of you show up and to agree to spend the better part of a day together holds enormous promise. I just want to spend a moment kind of orienting you to what I hope you showed up to do. You have an agenda in front of you. I am just going to give a high-level walk through on the agenda.

The meeting objectives, as Bruce alluded to earlier on, are really to identify a balance and parsimonious set of domains, really aimed at supporting multi-sector partnerships to better assess, to measure, and ultimately improve health and well-being. There are some caveats around what are assumptions or what would make a strong set of domains. Dr. Denise Koo is going to talk about that momentarily.

And also this notion of giving input into or drafting a roadmap to figure out how we get from the conceptual areas to not only rounding out domains, but starting to come up with some measures and ultimately move this forward to the point where HHS with support of others can help make sure that we have greater availability and use of data within communities. Bill is going to actually talk a little bit about the roadmap. Those are our two overarching meeting objectives.

The agenda for the day I think hopefully is fairly straightforward. We are going to get a chance to hear a little bit around how we arrived at the straw domains and a little bit on the opportunity. But at 9:45, we are going to have a chance to hear from some local and state community leaders that have been using measures to drive improvement and assessment work. After a break at 11 o’clock, we are going to have a chance to hear from, as it says here, some thought leaders and national initiatives that have been doing work in related areas and hear about the broader ecosystem.

Hopefully, this morning is really about getting smarter together and making sure we have a shared context so that after lunch, we can start to dive into together around how might we advance our thinking around shaping these domains whether we collapse, add to those domains. We are going to have a chance to step back and a hear a little bit more about some federal perspectives and how they hear how this is bubbling up from their perspective as well as how they are seeing their role in this work.

And then towards the end of the afternoon, we are going to mostly be spending our time trying to figure out how we might advance these roadmap concepts. How do we take this from concept to actually putting some of these ideas into motion? We have deliberately left the afternoon somewhat flexible just so we can take advantage of what seems to be emergent, where we might be most productive. Take this agenda as a little bit of a guide. We are going to use it to make sure we maximize our time, but we are not going to be wed to it necessarily particularly in the afternoon.

Does the agenda generally make sense to you? Is it what you thought you showed up to do? I hope. Again, really delighted that you all are going to be here.

I don’t know if there are a couple of slides that we had just a kind of quick reminder on some working agreements. If not, I will just name some working agreements. One, I just want to make sure that we honor our time, start and end on time. This is absolutely the place to test and share some new ideas. There is a reason why we are calling these straw domains. We are going to have a couple of formal breaks, but we want to try to keep this large room. I know that we are tight in here, but make sure that this is a pretty informal atmosphere.

If you all need to use the restroom and stand up because your back is bothering you, just make sure you meet your needs. We have this backwards in our country sometimes I think, which is this idea of being gentle on people. We all care a lot about these issues that we are going to be talking about today, but rigorous in ideas. This is absolutely the space where we can push back and make sure that we are challenging each other’s thinking in some positive ways and on that note, kind of learn through the spirit of dialogue.

We are in the political season, which means that we don’t see a lot of dialogue. The next slide may show a dialogue coming up here. It is not coming up, but that is fine. Dialogue is really the art of thinking together. Debate is when you are assuming that there is one right answer and you have it. Dialogue is realizing that we are going to benefit from having a lot of different perspectives and we are going to be spending some time really thinking about common ground.

When I am in a debate mode, I am mostly listening to where there are weaknesses in somebody else’s point of view versus really thinking about where there might be some strengths. When we are in dialogue, we are holding this space, which I think is really important given the expertise in this room, which is bringing what you really understand and know from experience, but also being open, having some inquiry, balancing those and being prepared to be changed. As we say a lot of times with dialogue, come as you are, but don’t leave as you come. That is when we know that we are going to be in dialogue and it takes a little bit more energy. That is the spirit. I hope that we can generate and be in the rest of the day.

Any other thoughts or ideas around working agreements today? I am going to come back up and share some ideas around how we are going to use some of the wall charts and how we are going to operate the different segments today.

Next up I would like to actually have Dr. Denise Koo who many of you know to just anchor us because a lot of the data is going to be centered on the straw domains and share how we arrived at. I am saying we. I did not have anything to do with it. But Denise obviously spearheaded this on how we arrived at the straw domains. Denise, I will let you take it away.

Agenda Item: Introduction of Emerging Domains

DR. KOO: Great. Thank you so much, Monte. It is really great to be here and thank you all for coming. I am going to talk a little bit about the work I have been doing with Karen DeSalvo, the Acting Assistant Secretary for Health. I am on a part-time assignment with Dr. DeSalvo. My day job is actually with CDC. I raised my hand twice when we did the raising of hands. It has really been great to work with NCVHS because I think this is a great opportunity to leverage both what HHS wants to do and this advisory body, the National Committee on Vital and Health Statistics, to give us advice. I see this very much in the spirit of what Monte just said as sort of a peer review, testing out these ideas, how we got to where we are and seeing what a whole bunch of bright, engaged people in the room can help us with.

I don’t need to repeat this for this audience. Now is the time. We have passed the Affordable Care Act. There is hopefully increasing and potentially universal access to care. But we all know and the reason we are here is that health care alone is not enough. It is certainly not sufficient to ensure health. We want to have the broader discussions about what really makes health and how do we measure success if we are working for health. Dr. DeSalvo is very interested in supporting multi-sectorial community-driven strategies to improve health. She is very interested in strengthening the public health system and this is a concept that she calls Public Health 3.0.

I, myself, recently led the development at CDC of the CDC Community Health Improvement Navigator, which includes this infographic, which we think is pretty cool. It has actually been downloaded an average of 150 times a week since we went live, again, emphasizing, as you see here on the upper left, what affects health. It is more than just health care. This is, of course, the percentages that are adapted from the work at University of Wisconsin. You will see that graphic here in a second where to focus on areas of greatest need, sort of the 80-20 rule where you will have the biggest impact is the areas with greatest disparities.

Who collaborates with others to maximize your efforts? We can have a greater collective impact if we work together. And then of course how. Use a balanced portfolio to maximize impact. A balanced portfolio, not just clinical care, but affecting health behaviors, the physical environment, socioeconomic factors.

Dr. DeSalvo asks, as part of my assignment, what is a healthy, safe, and thriving community and how do we measure such. And what she said is she would like to ideally have a set of 10 to 12 domains. We started with metrics, but in a short assignment and given the amount of work that would get to for vetting a set of metrics as well as the fact that communities actually have to decide on their own metrics. We went up a level to domains that advance and promote multi-sectoral collaborations to improve community health and well-being. Ten to twelve because she wanted it to be sort of and I know this term is popular right now, a sort of vital signs, something that people could actually remember. We have too many metrics. People would get lost in that. We discussed it and said wouldn’t it be great if they were actually, roughly proportionate to the contribution to health outcomes.

In order to think about what is proportionate to health outcomes, not because I am going to do a whole literature search again. That is why you have these folks like you in the room and some of the sources I looked at in terms of coming up with these 12 domains as you have seen.

Again, hopefully, these graphics are somewhat familiar to people. But for those who are new to this area or maybe some of our non-health colleagues, this is a health impact pyramid that comes from our boss, Dr. Frieden, the CDC director. As you see, you can see the health impact pyramid. The smallest impact is those at the top of the pyramid, which are individually focused or trying to change people’s behavior. His point is do we want to change the context, make the default choice a healthy one. And of course, some of the hardest things to impact, but could have the biggest long-term impact. Of course, socioeconomic factors.

This is a graphic you may see a couple of times today. This comes from our colleagues at the University of Wisconsin, Pat Remington is here in the audience, where they took a look at what really impacts health and really categorized it and put some percentages around it in terms of health behaviors, clinical care, social and economic factors, and physical environment and have various examples of interventions or behaviors in those areas. You can see here sort of the logic model, if you will, to getting to health outcomes.

We chose to use that kind of approach when we are looking at the 12 domains to think about health outcomes in terms of mortality and quality of life and then health behaviors and have it be roughly proportionate too. One for mortality or related morbidity and then the other ten proportionate to these category areas that they have at University of Wisconsin, the County Health Rankings.

One of the other things that I did and Dr. Teutsch is in the room. He pointed me toward this IOM report on quality measures. I decided to focus a little further downstream. Too difficult quite frankly. Too variable to look at resources and capacity and interventions especially again if we are focusing on 12 domains. Focus more again on healthy conditions and healthy outcomes.

Again, poor person’s way to approach this on a short-term, part-time detail, not a lot of time and a lot of great thinking had already gone into this. I don’t need to reinvent the wheel. We don’t need to reinvent the wheel. The poor person’s approach is a pseudo meta-analysis was to look for health metric sources where people had already looked at these issues where they had health as a primary goal or focus, not just health care, where they had a cross-cutting focus beyond health care and with inclusion of other sectors with some explicit inclusion of social determinants. They had to be focused on population and national scope because actually you could go on and on. There are so many great efforts at the state level. We decided it would be easier to at least stay at the national level for now.

These are the major cross-cutting health metrics efforts that I looked at, looked across them, did multiple charts so you know what metrics do they have, what domains do they have, how is it meant to the University of Wisconsin categories. Obviously, Healthy People 2020. The leading health indictors, again, are trying to focus. I was not going to be able to look at all 1400 Healthy People indicators. The National Prevention Strategy, America’s Health Rankings, County Health Rankings, Community Health Status Indicators, the recent Institute of Medicine Core Metrics or Vital Signs and the Robert Wood Johnson Foundation Culture of Health.

After I waved my hands and looked at these and did chart after chart, I came up with these particular 12 domains that we are putting forth here sort of a straw proposal and I certainly would be very interested in feedback. As you can imagine, I had some determined debates about these, but they are in your document. I am not going to go over them. This is hopefully what you have read. I tried to put some definitions on them, again, using things like Kindig or New South Wales, et cetera, but just to let people know what it was that I was thinking about or that I derived from these various sources.

Just a couple other sources to let you know about that I sort of used as a secondary validation. They did not necessarily fit the criteria of what I was looking for or they were in other fields. But I thought it was very interesting and validating to see the IOM report on capturing social and behavioral domains in measures in EHRs that they also covered many of the same domains.

I don’t know if our HUD colleague got here yet, but they are doing some fantastic work on Healthy Communities Index and a healthy communities assessment tool. Here are the primary domains in their tool: environmental hazards, health systems and public safety, neighborhood characteristics, transportation, natural areas, housing, employment opportunities, educational opportunities, social cohesion, and economic health. It looks relatively familiar.

They also had work with the DOT and EPA on a Sustainable Communities Index. Again, relatively familiar. The categories. I am not going to read them actually because they really are very well aligned with what we have and what you have in front of you.

And then recently released at the APHA meeting is a new tool from the Department of Transportation in collaboration with APHA and CDC, a Transportation and Health Tool. Very similar once again and very nice tool with some evidence-based strategies.

Also, CDC worked with AARP on this Livability Index for Quality of Life in Communities. Again, somewhat similar. Very validating. Environment, transportation, housing, et cetera. It seemed like where we are starting makes a lot of sense. It seems very reasonable based on what else we have seen.

I am going to stop this part of the conversation with just a few considerations again on how we thought about this. We want population health and population health the way many of us would define it. Total population health, population health of the jurisdiction, not just a patient panel, et cetera. I would be very interested in the discussions of other good sources of cross-cutting metrics efforts that maybe we should look at. Although, again, they seem to very much converge on the similar domains.

One thing I did consider was something that was easily understood and applied. We thought that it would be really important especially when you are talking to non-health folks or non-technical folks, communities, mayors, et cetera, things that immediately they found easy to grasp.

We did try to seek a balance of actions, process and outcomes. You will see in the definitions of the domains that because of the fact that there was a variety in how some of these metrics were defined and also I was very influenced by some of the work of the Public Health Accreditation Board that when you look at tobacco, for instance, you could end up with 35 or 40 different metrics depending on where the community is focusing their efforts, whether furthest upstream, downstream. In the definition of the domains and again staying at the domain level, it is kind of well it can be anywhere from upstream policy, downstream depending on where your community might want to focus. Part of that is to balance local flexibility and ownership. But we really want to think about national comparability. How can we use these sorts of metrics to help decide funding, directions, et cetera?

And of course the issue that we are not going to be dealing with today, but might influence this sort of decision or influence efforts is what about the timeliness and the availability at the local level for people to take action. I am going to go ahead and stop there.

Monte, I don’t know whether you have questions, comments?

MR. ROULIER: Just maybe real quickly. As we were having a chance to talk a little bit on our way over here. I think you were talking about some insights as you looked across all the range of these sources, some observations that you had.

DR. KOO: I thought it was interesting. If you look at a lot of these sources, you hear a lot about America’s Health Rankings. Obviously, County Health Rankings and the County Health Status Indicators are health focused. But I was interested to see that even our Healthy People Leading Indicators and the National Prevention Strategy and America’s Health Rankings, the IOM reports still surprisingly clinically focused more from a health care lens than I expected them to be. That was one thing.

The other thing, again, this audience is probably not surprised that the data sources and the data availability or the usability was more at a national or state, maybe a county level. Some of them, very few of them were actually available at the local level for action, which was a bit of a challenge I think.

And the other thing that was interesting looking across is they did not all use – maybe this is not a surprise for all of us. They don’t use the same definition or metric or data source. Funny how that works.

MR. ROULIER: Bill, great for you to come up here in just a moment. I think one other thing you briefly touched on is how you were anticipating this would get used.

DR. KOO: The idea of course is that this can be a message to folks. Lots of counties, states, organizations, mayors around the country already get it and they are really trying to bring sectors together. But the idea is to say what makes your community healthy, thriving, economically vital is a combination of different things, different sectors are going to have to come together and maybe it will help facilitate some dialogue at least at the federal level and hopefully at multiple levels about how do we come together. How can we work together to potentially pool, combine, leverage different resources from different sectors for the greatest impact on health?

MR. ROULIER: Denise, thanks. I know there is going to be a chance. You are going to be around all day today and particularly as we start to drill into the afternoon. There may be some other contextual pieces that you could add to. How about a round of applause for Denise?

If there are really any pressing questions, it would be great. And then we are going to have a chance to do it a little bit later in the morning. Share your name.

DR. ALLEYNE: Good morning. My name is Dr. Oscar Alleyne. I am with NACCHO, the National Association of County and City Health Officials. Denise’s question or my question to Denise actually revolves – you made a lot of comments. One of the concerns I guess my question is the challenge around the fact that your data sets still stay at a level that is not usable for local communities. Being a local health epidemiologist for 15 years, I can tell you that the County Heath Rankings, America’s Health Rankings – they are based off of population sets or sample sizes that are not reflective of my population and therefore I am making policy decisions on a sample that is predominately women who answer, for example, the BRFSS, the hard line folks.

If we are looking towards this framework, as you mentioned, to really do community level stuff, to really have that process and outcomes of those measures, how are we really getting to that if we are still at the ceiling that is not necessarily reflective of what our community needs are?

DR. KOO: It is very valid question, Oscar. I think this was discussed at the NCVHS meeting in September when we first started having this discussion. This can also be a broader discussion with some of the feds. It is part of why there are other federal government agencies here.

The idea I think now is to talk a little bit about what is important, what is needed, and to hopefully help drive potentially interest change increased availability. Maybe those – recommendations for the level at which the data needs are available. I think you will not find, I don’t get the sense just watching the nods in the room also, any dissent on that issue, the data needing to be more granular, more locally available, more timely for decision making.

But I think my understanding of what Bill and Bruce and the group wanted to discuss here today is the important areas, recognizing that there are definitely gaps in the data, the availability of the timeline and the granularity.

DR. COHEN: Hopefully, by the end of the day, we could be developing actionable recommendations to the federal government about how they could be more involved either in direct measurement, figuring out the resources to provide to communities to do their own work or developing other kinds of approaches so that we can help communities with their —

DR. ALLEYNE: I appreciate. Because I have to leave later, I won’t be here for all of it. My colleague is here. But my one quick comment is perhaps including local health epidemiologists or local health on your committee.

MR. ROULIER: Oscar, thanks for asking that. As a reminder, the microphones are going to pick up so if you all could just leave the microphones wherever they are placed. Oscar, I think your question is really a crux question that I hope we will continue to explore throughout the day.

Bill, do you want to share a little bit about the roadmap? I think it actually picks up on Oscar’s questions in some ways.

Agenda Item: What’s the Big Opportunity, Charge to Meeting Participants

DR. STEAD: I will. You should each have at your table a picture of the draft roadmap and we will bring it up on the screen. With the roadmap, we are trying to communicate a series of things. The time is now. We need to get started. Yet this is a journey, not a destination or not an event at least.

The question of how do we get our hands around, working locally in ways that roll up to national-level change. That is the fundamental challenge. As we have tried to make a schematic of the roadmap, we need to start today by asking one important question. When we come out of this afternoon, will there be general consensus that we need a core set of domains and that we are roughly in the right lake with this idea of a balanced set that reflect the determinants of health, the contribution to the determinants of health? If we don’t have consensus or something close to consensus on that, then we need to go back and put another loop at the front of the roadmap. We are here today on the assumption that there has been enough discussion over now truly decades. There has been enough successful action at the community level that now is the time to act. One thing we have to know is are we there or not.

If we are then the next idea is that we would build a menu of metrics that support the domains. We are not talking about agreeing on individual measures that everybody would use. We are talking about a balanced score card of domains that would mean that a multi-sector or local collaboration would take the type of balanced approach it takes to truly move the bar on health.

The actual measures would need to be appropriate to an individual community’s concerns, resources, and interests. This idea that there would be a menu of metrics, not 12 metrics. There would be a menu of metrics that would be relevant to each of the domains. And then a community would then say given my interest, I want to focus on this metric and this domain and we would want one metric in each domain. It would be the idea, but that obviously would still be their choice.

If you are picking a menu of a community, you would not be starting with a blank slate. You would be able to say given my problems, these are the things that people have proven have worked. I will pick this one and I will use it in association with others to build this balanced metric.

We are going to discover as we try to build that menu, that there are gaps. This roadmap is built a little bit like we were on a path in a zoo. When we discover a gap, you may end up having to go around the measurement development plain where we would have a number of cycles, really developed measures that filled in gaps in the menu.

We would then – if we understood the metrics we were trying to be able to measure then the question is how can we either collect that data or estimate it at the very local community level. We are going to discover gaps there and we are going to end up with another method development. Actually I had my plain and valley mixed up, but that is okay. You can get the idea. To build out methods. And the question then is what is the role of a federal government in helping us do both the measurement development and the method development to enable communities to either capture or to estimate data. That is the kind of journey that we think we are on.

We are talking about a roadmap. We are not talking about a Microsoft PERT chart. We are talking about what is the sequence of steps that we would take both as a country and as local communities in a very actionable way move to where we can assess these domains.

Is that clear enough, Bruce? Back to Monte.

MR. ROULIER: I was just going to get you all thinking. I am going to borrow a little bit of time, a couple of minutes from the panel because we actually have some flexibility. I am sure that all of you have different ranges of enthusiasm. We are completely there. This is absolutely where we want to go. Maybe reservations about how we might get through some of these hoops and gaps.

Let’s imagine that at some level we are successful. I look for you to just grab one of the stickies on your own for a moment and imagine what brought you to this table. What is the one impact or change you think having core community-level measures might enable and that excites you? What is the impact or result that going in this direction would enable us that is not happening otherwise? I would like you to just take a minute or two, maybe just a minute on your own to just jot down that note. And then I am going to encourage you in pairs to just share that. What impact or change do you hope that this endeavor would lead to if we were successful? I know those are small stickies so you cannot write a chapter on that.

DR. COHEN: Also, for folks who come in later, there are seats at the table if you want to come and join us at the table. That would be great.

MR. ROULIER: The question again. What impact or change do you hope this could lead to having core community-level measures? What most excites you? Not the right answer for the rest of the audience, but what possibility here most excites you? Take just a couple more seconds.

I would like you to actually not as a table, but just for a moment in pairs, somebody to your right or your left, just explain what you have just written on your stickie. What is the big opportunity, if you will, in your mind? Just take a minute with a pair and share your idea.

May I ask for your attention? Just when you started getting going. Maybe just to give us a quick flavor so we would illustrate. What were the things that started to pop out in your conversations? What is the big opportunity? What did you talk about?

MR. HOMER: My name is Charlie Homer. I am from ASPE. What I am really excited about is the opportunity to get society to focus more intently on addressing the underlying poverty that drives health and community outcomes and well-being.

DR. STOTO: I am Mike Stoto from Georgetown University. What I have been thinking about here a lot is about community health needs assessments and now required of all nonprofit hospitals. I think they are a real opportunity to get hospitals and health departments and others in the community to collaborate. But one of the things that has prevented them from working as effectively as possible is a lack of a set of common measures.

MR. ROULIER: So really helping the CHNA processes.

DR. ALLEYNE: There are some states where local health departments have been doing the community health needs assessments for probably decades. In some states like New York, they are actually required to do it in conjunction with the hospitals. I think it is best to identify some of these best practices and utilize that in the framework of what was just said to really help and engage the work that has really been done in the field.

MS. GOSS: We had three that kind of all worked together. We talked about the clarity on the data needs, informing better standards and how to really get the data flowing to benefit the community needs, kind of building on Oscar’s prior comment. But also that if you have the better standards, you also to get people sharing and you need to break down that cultural barrier to data exchange and that may be benefited by aligned funding – cross sectors.

MR. ROULIER: We are going to continue to circle around to what end? What results? What is the opportunity? Clearly, there is a smattering. There are a number of potential benefits of opportunities of being able to do this and to do it well. This will not be the first time that you get a chance to address this question and again particularly in the afternoon, we are going to go a little bit deeper.

But I wanted to just draw your attention this wall chart. As you might want to add your stickie as you are thinking about the big opportunity that might change over the course of the morning and afternoon. If you have some ideas and some language you would like to put up there, add to this to the wall chart.

All of the domains are along the wall up here. This is not a place where we are going to go into great detail about every measure, every resource, but we really want to capture those. Throughout the day, if you have some ideas on a particular domain and say here is a measure, an indicator, a resource, a tool that we want to make sure is on our radar screen, put it on a stickie note and set it up here.

This afternoon we are going to also have a chance as small groups in a more continued way to say are there ways that we want to collapse, add to, change the domains. But if you have some ideas around other domains you would like to consider and just have that on a stickie note. Put that down and we will capture it on the wall chart. I am going to really encourage you to do that so that we can capture some of the expertise because we are going to have limited time to make sure that is all heard in this larger group.

Let’s pivot into hearing some experiences of some peers. If the panel that has agreed to participate. Marissa Levine, I think, is here. Ray King and Andy Allen are here in person. We also have Amy. Is that right? Amy Rohling McGee from Ohio. Is she on the phone?

The planning group thought it would be helpful to kick off. Here are some actual experiences rooted in folks that are doing work at the community and state levels around and kind of ask them a couple of questions. How would you characterize your current community or state efforts as you are using data to both assess and drive performance? Going into this question of what you see is the real potential benefit. They are each going to share a little bit of their background in a few minutes and answer those couple of questions and then we might have a moment to reflect on some domains.

I am going to ask you all to be listening for the same things. What are your observations as you have seen this at local and state levels? We are going to actually pull this into your small group dialogue here in a moment.

I think we are going to start with Marissa and then we are going to go to Amy, who is on the phone. Marissa, please.

Agenda Item: Panel A: Perspectives from Community and State Change Makers

DR. LEVINE: Good morning everyone. I am the Virginia State Health Commissioner. Just a quick background on Virginia. As a public health entity, we are an integrated system with 34 local health districts. Most of those are actually part of the state system, but two of them are locally administered yet contracted. Just keep that in mind as I talk.

We have been on quite a journey for the past two years related to this activity. I am having a little bit of a déjà vu experience because Monte and I know each other from a long time ago when I was doing community health work at the local level in Pennsylvania. I feel like we are re-circling back on these issues. A lot of what I am interested in is more urgent action and fortunately we had about a year and a half ago a request from our legislature to create population health metrics for Virginia. This was before – much of the other work that was done and we also received a state innovation model design grant from CMS earlier this year and activated that. Those two activities plus, as you have all talked about, the window being open, but perhaps not for too long an opportunity. Put us in a good position along with the leadership of our governor and the administration to really move and look at the issue around metrics.

We took it this way. We said there is an urgency here because people are dying prematurely and burden of disease. There are huge disparities across Virginia. It is obvious at the state level, but it is also existing at the local level even in our most prosperous jurisdictions. We did not have metrics to help guide us, but we had to put those metrics into context.

One thing I asked my folks to do was to consider how are we doing in Virginia compared to other states? Who is doing best in whatever metric? It actually forced us to look at many of the rankings that exist including the County Health Rankings, America’s Health Rankings. Virginia sits in the middle and it sits in the middle because of the disparity issue. Quite frankly when we looked at 20 years’ worth of data, many of the metrics never changed. It hit us that metrics are important, but you also have to know where you want to go and you have to have a process for improvement. We are looking at this really as a statewide, local and regional continuous improvement process.

The metrics for us were critical to get some agreement at a high level of what might be important for population health improvement that we could use at state, regional, and local levels. We actually took it by saying this is not about health care. This is actually about health and well-being. When we step back, what would we want to create in terms of big domains and potential metrics around what I am calling person-oriented outcomes that actually matter to people, not institutions, not providers, and you take a whole different perspective.

When we did that, I also realized that I had to challenge our folks with a sense of urgency. Virginia ranks top ten in per capita income. We are in the middle for health outcomes. What would it look like if we were going to be the healthiest state in the nation that is measurable? We can say where we are, where we could be if we were healthiest. That gives us significant insights into our gaps.

That perspective drove us to create a few domains and about two dozen high-level metrics. I will just give you a quick thumbnail of what it looks like today. It is still evolving. We are wrapping that into a framework of state population health improvement plan that we are calling a plan for well-being using the term well-being specifically so that it is bigger than health and health care.

I would like you to think about the metaphor of the tree and start with the roots. The roots to us are the community. We call this domain healthy connected community. And the concept is that the community is where through built design, through policy, through social engagement, we basically set the conditions and increase or decrease opportunity, if you will.

We have created a health opportunity index in Virginia that allows us to begin to look down to the census track level. And the way I describe this and I would be happy to share more on it is it is an index of about 13 indices that cover really all the social determinants of health. It is giving us a good picture of what communities look like down to the local level. I describe it to people that we have areas where opportunities are higher and areas where opportunities are lower. Those lower opportunity areas are like holes, if you will. They are big ditches. And when people are born or grow up there, it takes a lot of energy to get out of there. Some people may be able to do it on their own, but many need help. And then how well you can get out is determined to some degree the conditions you grow in, i.e. the community and the opportunity.

We said we have to deal with the burden of issues at the same time as we have to think about how we fill the hole and increase opportunity for all. Otherwise, the disparities will continue.

In that vein, we realize we need a system of care, a system of health care for people who are burdened with issues, with health issues, much better than we have now where the community builds support so that people get what they need just in time and prevent them from getting into crisis, i.e. readmissions, mental health crises, et cetera.

At the same time, if we don’t do something about the generational continuation of that burden, i.e. unhealthy children, we will just continue. Basically, we will go broke and we will have a very unhealthy population. We are dealing with the burden through a system of care and we are dealing with children. We call it a strong start for children, looking at milestone sections along the way and helping us know if we are investing and actually making a change. I would put to you that we have to think about this longitudinally because we not only need metrics that help us know how we are doing now, but are we investing appropriately.

We also separated out preventive actions, more of that culture of health concept because prevention often occurs outside the health care. And then all of that together ultimately allows us to have a population that is more well. And we also factored in the concept of aging while in there. We have created metrics in all of those arenas.

I would say we are getting traction around both the health opportunity index where people are interested or what does my community look like and around the strong start, which is a little less political because most people want to invest in children. We have used some of the metrics just to close out around that in terms of milestones. They are not health metrics. They are not educational attainment metrics so kindergarten readiness, third grade reading level, which are really good. We still have metrics around infant mortality although we are trying to turn it to the positive and talking about more thriving infants. I will just close by saying we ought to think about our metrics in the positive sense because we see better engagement with the public as we do that. A lot of good work that is going on. I will stop there. I would be happy to expand on anything.

MR. ROULIER: Let’s get all the voices on the panel. I think Amy is on the line. Amy, can you hear us?

MS. MCGEE: Yes, can you hear me?

MR. ROULIER: Yes, you are in a room full of folks that are very attentive and excited to hear what you have to say. I think you have some slides as well that we might be walking through.

MS. MCGEE: Great. Good morning. About a year ago, the Health Policy Institute of Ohio released our health – this was our first – is to provide the – unbiased and nonpartisan information analysis – particularly one is to provide – policymakers. We developed a Dashboard so that policymakers would have a tool for setting state health policy priorities and tracking progress over time. We have been very pleased with how receptive our state policymakers both in the executive branch and the legislative branch have been to the data that we provided through the Dashboard. Our intention is to update the data and the Dashboard every two years. A year from now, we will release the next iteration of the Dashboard.

In responding to the question of what has worked well in terms of how we have used the Health Value Dashboard to improve health value. Number one, we started with a collaborative process. We brought together a diverse group of stakeholders – metrics and advise the creation of the Dashboard. And then we also started with the end in mind considering three questions. What problems do we want to address? What metrics should we all be paying attention to? And how will we know if we are successful? We knew, as all of you know, that the primary problem was not a lack of data necessarily, but the ability to extract key pieces of data to inform policy making.

The third strategy that has worked well for us in terms of gaining traction is working from a conceptual framework. In building our framework, we recognize that advancing population health is a goal that many share. We also know that the amount we spend on health care is a concern for policymakers, for businesses and for consumers. We included health care costs as another domain. We view health value as the intersection of population health outcomes and health care costs.

Given that we know that our health is influenced by a number of modifiable factors and that we spend much more on clinical care than on prevention in public health, we kept that in mind as we created the conceptual framework. This is the framework from which we build the rest of the Dashboard. You will not that we have seven domains. Improve population health. Sustainable health cost on the right hand side. That is the end goal. You can kind of think of this as the logic model. And then all of the systems and environments that affect health are to the left hand side.

We asked our stakeholder groups to work with us to select the most relevant metrics from publicly available sources. We ended up with 106 metrics, roughly 15 in each of these domains. That was a parsimonious list of metrics. A lot of times people think it is still too many, but really we called it down from a lot more available.

The Dashboard that helped the Policy Institute of Ohio produce is the first in the nation to include this concept of health value, placing equal emphasis on population health outcomes and heath care costs. You can see here that we cross walked many of the existing scorecards and dashboards that are available.

I want to note that we did prioritize metrics that are also available in County Health Rankings. We knew that legislators and others working at the local level would be interested in obtaining county-level data when possible. We wanted to incorporate those metrics in the scorecard as well.

The fourth way that the Dashboard has been working in terms of getting traction is that we created graphics that tell a story about the data. Even though we have a full version of the Dashboard with all 106 metrics included that is not typically what we share with most state policymakers. We have a four-page version, which I think may have been provided to all of you that we use to engage legislators in conversation. This is one of the tools that is in the four-page document.

This often catches policymakers’ attention too. Here you have the states that are green, which are high-value states, meaning that they have good population health outcomes and low costs. And on the other side of the spectrum, you have the red states, which are poor health outcomes and high cost. And Ohio is one of the red states, which brings me to the challenges.

One of Ohio’s challenges is that we have a lot of challenges. This is another page in the four-page version of the Dashboard that we share with policymakers. Figuring out at least for Ohio where to start and where to focus in terms of making improvements is difficult because there are so many challenges.

Another challenge we experience in the creation of the Dashboard and all of the work of the work that we have been engaged in, this is really for the Dashboard, is that there really are very few metrics that link clinical outcomes to population health outcomes. And even on the clinical outcome side, as we dove deeper into the data, we also think that there is a lack of true outcome measures on that side as well. I will say too that we did not allow ourselves to get caught up too much and that they over process an outcome metrics in this first iteration of the Dashboard because we just wanted to get started. I think that was one of the introductory remarks that were made this morning that I wholeheartedly agree with is that you can spend hours and hours debating that. But beginning somewhere makes sense and then figure out where you need to improve the kinds of metrics that are collected is the second step.

Our third challenge has been making the data actionable. The policymakers almost immediately ask what can be done about these challenges, which is great. That is exactly what we would want them to be asking. But we then need to be prepared to provide technical assistance and drive them to evidence-based policies and evidence-based strategies that could mitigate these challenges.

Our fourth challenge has been getting everyone so all of the sectors that are involved in health and health care rowing in the same direction. We believe that that is critically important, but also very hard. In recent months, we have been under contracts by our state to convene state and local stakeholders around alignment of population health planning activities, primarily focused on the community health improvement processes that local health departments have to conduct for accreditation and the community health needs assessments that hospitals have to conduct. Looking at ways to align those processes locally and to align them between the state and the local level as well. We will be providing recommendations to the state in the next month or so. But getting to greater alignment is no easy feat. That has been another challenge.

We see our State Innovation Model’s initiative as a great opportunity to align around a core set of metrics that encourage multiple systems to go upstream to improve population health. Even though, as I said, this is a very hard exercise, we think that SIM provides a unique opportunity to get the right players to the table. We think that the federal government along with state and private payers with key partners can use this leverage to get stakeholders from health and health care and even sectors outside of health and health care like housing and transportation to the table around alignment, around metric selection and the implementation of evidence-based strategies.

Having access to a comprehensive parsimonious list of core metrics would be helpful. I think it could have saved us some time here at the state level. We, as you see, agree with the idea of including multiple domains. We have a few less than I think have been proposed in the straw person, but we have sub-domains under some of those main domains. I think we have most of the categories captured.

We believe that the process that we engaged in bringing together all of these stakeholders and the processes that we have been engaged in since we released the Dashboard is important in and of itself. I think having a list of core metrics is great, but it really needs to be the state and the local levels that then uses that list of metrics to decide what is most relevant or important in that particular state or in that particular community for additional focus and action. Thank you.

MR. ROULIER: Thanks so much, Amy. Really super helpful. I wish you could be here, but you were very clear and added a lot to the day. I know you actually need to run. You are welcome to listen in. Again, we are going to have a chance to ask some questions and reflect. But I think we have next is – Andy was going to go next.

MR. ALLEN: My name is Andy Allen. I am the outreach officer for the mayor’s office in Baton Rouge, which is a big of a departure from the doctors and the wonderful people sitting next to me. I hope that we can provide a perspective of on the ground. We are building the plane as we are flying it.

I think just to give some context in Amy’s presentation, it was not unfamiliar for me to see Louisiana highlighted in red. We are used to that. We have some really distressing health outcomes locally and some even more troubling health disparities within the community that we work with.

The reason that I think we are here and we are optimistic about the future in Baton Rouge is because and I know it has been mentioned by the professor from Georgetown back there. The work we have been able to do at the community health needs assessment and our state department of health. We have brought together the five acute care hospitals in Baton Rouge to do a joint community health needs assessment. Three years ago, we did a collaborative assessment, which was wonderful. It gave great alignment to the work we were doing.

In this go around, we have done a joint needs assessment, the difference being that in the collaborative assessment, you basically take the bones of the document and you adjust them to your facility and technically submit a separate one, but the bones are the same. In this go around, we just have one document that all hospitals will submit. We have one community implementation plan that follows from that that will go on the schedule. That has given us great alignment in the big players in the community that are working together on this.

The reason that this work that you all are doing and the data is so important is because that is the key to the is it working question. We would like to think that this is the strategy moving forward and that other cities and places will look to do work like this in bringing together not only your health care partners, but your public agencies and your community organizations. We have more than 70 partners who are part of this effort and who ascribe to this one needs assessment and plan. But being able to answer that is it working question is key.

We have used a lot of the data sources reference particularly the Robert Wood Johnson Rankings have been helpful. We have worked with them to identify what is relevant to the priorities we have identified and put in there. That year-to-year benchmark is interesting and certainly we could do it better with better access to data and particularly Oscar’s point about being able to hone in on specific pieces of the community would be really a groundbreaking development for us because we know those issues exist. They are educated guesses that we are making on where we are delivering services and targeting that, but really to be able to target that more specifically and then coming on the back end and look at whether the difference was made would be very important.

We have also been using some data sources that I have not seen mentioned that are more on the socioeconomic side, trying to bring in all the social determinants of health, which was a big push in this latest assessment. We wanted to be much more inclusive of that realizing that if that was not part of the plan then we were not going to see the results at the end of the day that we wanted to see.

The other way that I think that this data could be particularly helpful for us on a local level is that we have been pushing really hard at the city level to get our different departments and agencies to work together to target specific underserved communities holistically whether those are programs in violence elimination, neighborhood revitalization and blight and health, putting them all focused together and trying to lift up historically underserved communities. Again, the targeting of that could be greatly improved with better data and coming back and seeing how it is evaluated.

I heard another question or comment in Amy’s presentation about how they are working with the assessments that public health agencies have to do, which are on a five-year cycle, I believe, whereas the hospitals are on a three-cycle cycle. Just the policy issues there provide some difficulties in getting alignment. We have been working over the last year with the Department of Health and Hospitals in Louisiana to make sure that their assessment for our region mirrors the assessment that we have gone through. Even though they cannot technically be the same document because of the way that it works, they can at least talk and cooperate with one another.

As far as these domains go, one of the issues that we have run into –- we don’t have – we are the largest metro area in the country. It does not have a local public health department, which is why I am sitting here talking to you and not our public health director because they don’t exist. We have a Mayor’s Healthy City Initiative that tries to fill some of that gap, but the entire staff of that initiative is also sitting at this table. It is a little bit challenging.

The prioritization on the local level has been huge. I see we have all these domains as wonderful. We certainly try and look at each of them in the assessment and say this may be a particular challenge for us, but is it a priority area that the communities can address, not this go around because we don’t have the resources and the time. Maybe if there was some way to use these domains and to help communities narrow down what their focus areas ought to be, we have largely again built that plane as we are flying with the hospitals and other stakeholders and generate our own process. But if there was a way for communities to have an easier way to go through that and come out at the end with here are the four or five things that we really want to work on and the metrics we are going to look at to benchmark and track progress there. I guess I have some thoughts on the domain, but I think that is question three we were asked to address. I am going to hold off for now.

MR. ROULIER: Perfect. Thank you so much.

DR. KING: Thank you, everyone. I appreciate the opportunity to speak to you guys today. I am thrilled to be here. My name is Ray King. I am an epidemiologist and informaticist in the Division for Heart Disease and Stroke Prevention at CDC. But more importantly, I represent the Memphis and Shelby County community that I have been working with these four stakeholders, one being Shelby County Health Department, whose chief epidemiologist is here in the front. The Methodist Le Bonheur Healthcare, the Common Table Health Alliance as well as the Tennessee Department of Health. We have been working together for four years on this project.

Also, with the current ask and with our current expansion of the project into these determinants of health domains, we reached out and we spoke to groups working in Memphis, which included the HUD, the Department of Education, the Memphis Housing Authority, and some other collaborators at Lake Forest as well as I should say the Division of Nutrition and Physical Activity and Obesity at CDC.

I have talked to all of these groups. I recognize some of my comments into what is working and what is not working are going to reflect some of the previous committee meetings. As I tried to bring them back to the measures and domains, every one of these groups said the major issue is information access. And that they want information access at the sub-county level to drive action. Without that, a list of domains, a list of measures they felt was just another list. Unless they can have timely access to this, it is kind of I don’t want to say irrelevant, but just another problem to their plate.

Part of that is – Andy mentioned and the community health needs assessments. I learned everyone has one. The hospital has one. HUD has one. Public health has one. And then for them to find that data, to find that information is taking 12 to 18 months or they have to conduct one-off surveys, which are not standardized, which cannot be integrated and used for other things. They really were interested in all these different groups.

Multi-sector data and system integration and kind of more of the secondary use of data such as EHRs and what not to populate these domains and these measures. Of course, they do have comments on domains. They want more asset-based as Marissa mentioned. They find that that is more actionable and more positive for the community to benefit from as well as some prevalence data on core chronic disease. I don’t want to get into a bunch of outcomes, but maybe three or four. And of course nutrition and physical activity wants walkability. To have those measures accessible is very important.

In terms of what is beginning to work. It is gaining traction and we have been working on this for several years with funding, without funding. And without funding perhaps has been the most interesting because the community and state took it over. Instead of it dying, they saw the value and really started pushing it forward. It is this idea of a community health record and they are now calling it the Tennessee health record. And we have defined it both as a framework to guide multi-sector collaboration and information exchanges as well as the system to actually make that happen, to integrate and transform that data into actionable information.

I am not going to go through the framework, but just to point out two quick points. If you see on the left, there is data, information, and knowledge going up the side. In the informatics world – Dave, who could not be here I think would be happy. But this is kind of the way we think about this. As we talk about these measures and domains, it is just to recognize to go from data to information, information being the measures that we want to capture and knowledge is when we actually use those measures to intervene, which all of these stakeholders show was vital. If we are not going to use them to take action then they did not see them as necessarily helpful.

But also to recognize to get there that it is a multi-sector, at least in Tennessee, effort that involves a lot of social aspects as well as the technology and the social perhaps being more important to the technology. For FY, we are currently at the transitioning from the capacity and pilots to the new business processes, tools, and information flows in Tennessee.

This is kind of a cartoon of what we see as the community health record system. I just want to point out a couple of quick things. If you notice on the left, we have data sources. And of course we have health care and public health, which we are trying to integrate and pushing very hard. As we are here today and recognizing these determinants of health and these domains, you will see at the bottom other sectors. This to us in Tennessee is very important to garner some of this data so we don’t have to do a lot of these surveys and go out and hunt and find these data sources.

And then we have the Tennessee Data Warehouse and I should say multi-sector data warehouse because it also includes the other sectors. An interesting point here – the chief public health informatics officer for the State of Tennessee, a guy by the name of Jeffrey Kriseman, who was a CDC branch chief, just last week was appointed in pitching this idea as well as other ideas, who was just appointed to be the informatics officer across all sectors for the State of Tennessee. We feel like we are getting some traction there. The government in Tennessee sees the value of integrating all of this information. And the key is to provide these end users and providers of data in Tennessee in terms of providing these measures that they want to drive action to make sure that if public health wants transportation data that we are providing value back to transportation. Without that win-win, we are finding in Tennessee that we get no traction. It just does not happen. Across all sectors we want to make that happen.

The next slide I think was just my address. I did not go a lot into the measures and the domains. We do have a lot of comments regarding that in the third question. But I will just leave it at that for now.

MR. ROULIER: That sounds great. Thank you. I am thinking that maybe we will loop back on your reflections on the domains because you have shared so much information and I think some really rich ideas and to give you all a moment in small groups. I am going to give you about ten minutes. I think there is a slide with some questions on that. In essence, just give you a chance to – how does what you have started to hear fit with your own experiences and observations at whatever level and what didn’t you hear that you would want to add based on your experiences. Again, I am going to encourage you to have that across your whole table. How does it fit with your experiences? What other experiences – observations? Again, we had a chance to hear about some other benefits. Continue to loop back. Other benefits, ways that you are thinking about that based on what you have heard. About ten minutes on your small groups and then we will bring it back to a large group and have a chance to reflect on domains.

(Pause for Group Discussion)

MR. ROULIER: Maybe just take one more minute. We are going to take this back to the large group. Wherever you are is just fine. More intentional and kind of how we are capturing feedback and making some specific proposals. This morning we are just trying to create some shared ideas, some shared context. We will capture as much as we can, but mostly just want to hear – what are some of the significant nuggets that came out of your small group conversation? We don’t need a formal report out for this. What was most significant? I am going to come back to your question in just a moment. What came out of your table conversations?

MS. LOVE: We don’t have a system and what systems we have are broken. I don’t want to say we are doomed, but the infrastructure is just pretty shaky.

MR. ROULIER: When you say we don’t have a system, can you talk a little more specific?

MS. LOVE: System is the wrong word. We just have a lot of data, but we are not sharing and proprietary concerns and small numbers and no uniform linkage numbers. What did I miss? And poor data policies are inconsistent and data policies and lack of will to enforce data policies that we have. We could go on.

MR. ROULIER: It sounds like a positive conversation. I appreciate it. We are realists here. No systems across the board at all levels. I appreciate you putting that out there. What else came out of your conversations? Experiences, observations?

MR. SWEAT: I am David Sweat from the Shelby County Tennessee Memphis work on that project. I just shared with the table. Basically, we have spent the last four years gathering data and pulling it together and putting it together in an analyzable format that is common for 33 zip codes. It should not take anybody four years to pull all the data together and get it all formulated in a way that it can now finally be shown to people, which we are beginning to do. But there are 3500 counties across America that are all struggling with the same stuff. What we have been trying to focus on is building a methodology, which I shared with the table about how we go about doing it.

But the key take-a-way for the group is we need to get data down at a sub-county level. Local mayors, local county commissions, local health care systems cannot do anything with a single number that is supposed to be the number for the whole county. You have to do as Virginia is talking about. You have to keep pushing deeper and get down to Census tracks, zip codes, get down to something with the data so that people can make resource allocation decisions and work with communities on designing interventions that might make a difference for that community. It is pushing the data down one more level.

MR. ROULIER: Thank you for that. It seems like a common theme that has been bubbling up, maybe not surprisingly. What other insights, things that jumped out at you for your table? How about as you talked about experiences, observations as you are kind of hearing some of your peers share their stories, things that you jumped on or observed or excited you perhaps?

PARTICIPANT: I thought that one of the main drivers is purpose and the reason you are collecting data. We really heard a diversity of purposes across the panel from local needs to a statewide initiative. I think we have to remember that when we are talking about metrics even the source, the number, the domains. It always should drive back to the purpose.

My other comment is that the roadmap – it is as if we want to get to the pot of gold at the end, but I think what we heard was that people actually – four years is a long time to be on the road, but that it is a process. And maybe the process within communities is as important as the product that don’t necessarily assume that we in this room could come up with a product and deliver it that you may deliver a roadmap and a process.

MR. ROULIER: It seems like this is a really interesting kind of created a tension around what do we create that would be accessible potentially across the country and to what end and how much flexibility is there really and being able to tailor that and have groups as you all described and really take ownership for this at multiple levels.

DR. WOOLF: Steve Woolf, Virginia Commonwealth University. I just wanted to raise another tension, which is this argument about parsimony because I think we all value parsimony. But I wonder whether that is really going to be as helpful depending on what the goal of the effort is. If you think about America’s Health Rankings, County Health Rankings and so forth, they have already done the parsimony thing. They have a parsimonious list of indicators that you can look at and have been available for many years that you can look at the state level, county level and so forth.

If the goal is to try to reach out to stakeholders across sectors and help them see themselves as being relevant to the health issues, the whole health in all policies notion, the problem with parsimony is that your list already has excluded many of the sectors. If I am in transportation and I look at the straw list right now, I don’t see myself there. If I am working on early childhood trauma, I don’t see myself there. If I am working in mental health, I don’t see myself there because your parsimonious list does not have space to include them. If that is the agenda then maybe the parsimonious list is not going to full succeed.

If the agenda is to try to help policymakers who are sort of past that point and want to address the kinds of decisions that Pat just mentioned and others, folks who want to have the local level information at the sub-county level to make decisions or researchers like myself who are interested in doing big data analytics. Here at the National Center for Health Statistics is the place where there is an opportunity to respond to the big data movement and get a richer set of community-level data that are not parsimonious, but take a deeper dive into all the sectors that we know matter. I just wonder whether coming up with a parsimonious list of 12 domains is really going to be moving us as far down field as we would like.

MR. ROULIER: Really again I think an essential question. I think for us to really start to drill into a little bit particularly after lunch and those kinds of creative tensions. Thank you so much. That is great.

Your team started asking a similar question.

PARTICIPANT: A question that came up – actually, it kind of builds on both what Pat and Steve were saying. But the question for me is I really appreciate all of the background about the different frameworks and that is absolutely the right place to start. But what I am not understanding is what is it about what we are trying to do today that is different from each of those other frameworks. Why is it that we need to create something new? It gets at what Pat is saying about purpose. What is the essential purpose here that is different from the purposes of all of those other initiatives?

DR. REMINGTON: I had a chance to work on many of these processes that we have just been talking about, County Health Rankings, State Health Rankings, the IOM committee, dealing with all these domains. Obviously, we are trying to get a lot of very complex concepts down into a few, small little areas. It strikes me that in many other areas they don’t try to do that. They actually try to come up with some broader metrics that embody a lot of the detail. When you look at the gross national product, you cannot see if you work for a port or a local business, but you know that it is in there somewhere. And then you can break it down. But we have these broader concepts. When I see these domains, I don’t see an overall measure of social development or environment. We looked at the index. It said air quality improvement. That is important, but where is water – where is climate change? Where are ecosystems? Having a broader environmental measure that allows us then to here is the broad concept. Here is where we are. Now you local – you just have to go down and say what is your issue. Maybe you have brown fields. Maybe you have drought.

I think we may want to think about and some of these things in a slightly different ways so we can get to a more inclusive, broader set of concepts.

MR. ROULIER: Great. It seems like some thoughts that are being built upon one another. Right after lunch, just to give heads up, we are going to ask you all in small groups to actually propose what that might look like. What are those either broader sets of domains? How do we deal with the complexity and the level of parsimony or not? Again, to what purpose? What is possible or not?

PARTICIPANT: We don’t need to get to 100 percent correct solution. We need to get to about 80 percent mark. The truth of the matter is we need to do something. We are spending a whole lot of time over the last thousand years spinning our wheels doing absolutely nothing, but talking about it. And the truth of the matter is that every one of us who has a Smart Phone has an app that is not perfect. And every day as annoying as it is your app gets updated with something that is better. And that is exactly the same mindset we ought to take with this. We ought to put something out there. We ought to work on it. We ought to improve it over time. Because the real task here is getting people into making data-driven decisions. That is the ultimate goal. That is the only goal we have. Put out something we want to do. Measure it. Improve the health. Fix it because it won’t be perfect and move on. That is what this will hopefully get us to and I think that ought to be our task.

PARTICIPANT: Good morning. Our group was actually thinking about some of the data access and use at the community level. We talked about the use of standard metrics at the local level and the appropriateness of that.

The other thing that we talked about was really the data availability and building capacity at community levels to actually utilize and access data that is available and thinking about are there ways that we can expand some of the data that might be available. We have a colleague here from the Census Bureau in thinking about the American Community Survey. Are there ways for us to perhaps collect additional data using the ACS model that is more health relevant?

We started thinking about data collection and moving from not just data collection and also like the types of estimation that we would be able to do from the data that we would have access to, but the importance of investing in capacity building at the community level in order to access and utilize data.

MR. ROULIER: Thank you. Some good ideas for where we might do some drill downs a little bit later.

DR. HOLVE: Erin Holve from AcademyHealth. Our group had general support for the domains work that has been put on the table today. We did, however, talk about a lot of the data needs that are currently unmet and ways to leverage current opportunities around payment reform to try and actually collect some of that data, given the incentives that a lot of local institutions have to do that work including information coming out of electronic health records and other sources of information including apps. Of course, there are a lot of governance considerations there that we really need to address. Many have been raised previously.

MR. ROULIER: Make this the last comment here and then I am going to bring it back to the panel to make a final thought.

DR. MAYS: One of the issues that I raised when our group was talking about taking so long and what it requires is trying to make sure that we are really going to address the health of the people who often are most in need. And what we are not getting is the granular level of the data in terms of racial and ethnic minorities. We all know that place matters and that has come up quite a bit. I think that that is what we are solving in terms of the level.

But what we are not solving are the unique cultural and some of the differences that people bring with them particularly when they are immigrants, et cetera. Because when we are bringing this data down, the problem is and I am going to address this particularly at the federal level. The data we give away at the federal level often is not necessarily broken down fine enough.

I am a little concerned about the rush to do something because what happens is that the something to solve the problems of the people who are trying to solve is what ends up not happening. And then we are told we have just spent all this money and we will jury rig it and do something else to try and get there. I really would hope that part of what we are going to do is to try and solve that problem of addressing those with some of the greatest needs with specifics for their health that they can then take to their community. We can design interventions until we are blue in the face. If the community does not take them and use them and implement them and keep them sustained then we have wasted our money.

MR. ROULIER: Thanks for that caveat. I think it is an important reminder as we try to figure out and how best to move forward.

In just a couple of minutes, we are going to take a break. I know we were going to reflect a little bit on the domains. I am going to give you a chance if you want to just one or two big comments for you either on the domains or any other things that you want to respond to.

DR. LEVINE: Lots of great thoughts. Thank you for your input. I would just say that as I look at the domains, I am trying to think about does this tell us if a community is competent to do what we are talking about. I am not comfortable that we are when we look at this. When I go around Virginia and talk to providers, I tell them that as a physician we have come from the individual provider competence to the team to the institution. And now what we are really talking about is in order for a provider to be successful to get to that system, we have to build a community competence. I look at this to say how are we measuring whether we have a competent community that is able to do that.

The other thing that is happening in another sector in the public safety sector is community resilience. I would ask us perhaps to connect the dots here because I think they are going on a parallel track and there are lots of important connections there that might inform this process too.

And the last thing I would just say is the data to me is not just a statistic. When I go around as a commissioner, I tell folks that my job is to tell the story of people of the Virginia and I see the data as the story to the point that was just made. I think we need to be sure that the data is the story is reflecting the people whose story needs to be told.

With that, I would just be cautious that the way we do geographic data identifies people in a very static manner. We know that people move around and particularly many of the people who are most vulnerable move even more. How do we build a dynamic component to this too?

And then my closing comment gets me back to what I said before. We have to think horizons. The short horizon around the burden. The long horizon. How do we break this cycle?

DR. KING: Question 3 was kind of our initial reflections on the domain and talking about the stakeholders. They had lots of comments, but in the short time. Some of the additions. They felt life expectancy and well-being was great. They do want a couple of prevalence indicators, maybe some notifiable chronic diseases just three. Cancer, diabetes, cardiovascular disease, maybe hypertension. They want obesity moved up to an outcome. BMI.

They were really big on community assets and also a new paper that one of the stakeholders is putting out with IOM on the leading causes of health and that gets back to what Marissa was saying as kind of the positive indicators and driving change because communities are very receptive to that.

And then also to think of cross-cutting domains. I don’t know if you have a cross-cutting domain, but you have to recognize that in Memphis, a beautiful green park is not enough. It has to be a safe park. You have to merge safety in green space. You have to merge all of these different indicators to recognize whether it is being used is possible.

And then another thing was in the last and I will conclude is access indicators. They felt they were hardest to come by. The access to fruits and vegetables, access to health care, access to everything. But then they went further to say that the problem with that is that they really don’t want access. They want utilization because – to think of others – secondary uses of data so market scan type data. We cannot tell if they are eating the fruits and vegetables, but at least are they buying the fruits and vegetables if you put a grocery store in that neighborhood. To think in terms of that. It gets back to thinking in terms of what the population wants and what the locals in the community want.

And just one other comment. We tried to think of – there was a comment about big data. In Shelby County, we try to think about small data because a lot of the data goes locally. It aggregates up to big data, but never stops at the local level. We would like to start framing it in terms of starting small and then using it and then it can aggregate up to big data, but not skipping the local community on the way.

MR. ALLEN: This has been a fascinating discussion to listen to. I cannot echo from our perspectives strong enough what Dr. Sweat said about sub-county level data. That would be a complete game changer for us.

I also think from our perspective as I look at the domains and think about what we have identified as priorities and want to work on locally, I don’t necessarily see some of those represented. I heard mental health. For us, a big challenge is sexual health, HIV, and other STIs. I don’t see that particularly on here. I would hate for communities to look at the domains and say I don’t know if I can identify my priorities as a part of that. How do I use this would be my comment.

MR. ROULIER: Thank you. Let’s give a hand to the panel. Two things. You all some great ideas and just to model since you have already been great models. Any of the ideas that you had around cross-cutting domains or concepts that you want to put in there. I would just invite you and everybody else to continue to put some of those ideas on there so we can also be grabbing those that don’t come out of the small groups.

Let’s take a ten-minute break and then we are going to be ready for Panel B. Coffee on the right and then restrooms on the left.


Agenda Item: Panel B: Perspectives from Thought Leaders and National Initiatives

MR. ROULIER: We had a great conversation. We are going to have a chance to layer on this conversation with the second panel here. We have a number of folks that are going to share some expertise here. Those of you who are following along with the agenda, we have Carolyn Miller with the Robert Wood Johnson Foundation. We have Gib Parrish who is a consultant and has a lot of expertise in a couple of these areas around measurement and estimation and then Pat Remington, who you all have been hearing about, with the University of Wisconsin County Health Rankings, and Bechara Choucair, who is going to actually maybe kick us off. Is that right? Actually, we had Pat going first.

Again, a few minutes on their organization, what they are up to, how this is connected to this effort, and some insights that they have in doing this work.

DR. REMINGTON: Thanks so much for inviting me. It is a pleasure for me to be here. I learn more than I suspect that I can contribute. First of all, I just need to thank everybody along the way who helped us at the University of Wisconsin develop the County Health Rankings. My experience at CDC working with Steve Teutsch when together we ranked states based on cardiovascular mortality and nearly lost our jobs because the health officer reported up to the senator who threatened funding for CDC if we ever ranked states again. I sort of parked that in the back of my mind. When I went to Wisconsin, I wrote a grant back to CDC and I want to thank an anonymous reviewer. In the early ‘90s who criticized my proposal to do Wisconsin County Health Rankings and I quote. “I found the pink sheets just last year.” Rankings may be “quite counterproductive.” They often incite great resistance. We did not get the grant. It wasn’t until I got to the university that I had a little extra money and some graduate students to then do the County Health Rankings.

Dave Kindig provided me with those resources and also with the concept of the model of population health. Obviously, without the Robert Wood Johnson Foundation and our advisors, many of whom are in this room, we would not be where we are today in the County Health Rankings.

I reflect on a couple of things with respect to the opportunity before us. First of all, I think it is a great idea to talk about data and to try and get back to the question of what is our purpose. I do think, as I mentioned, the process is often the product. My experience having worked with communities in Wisconsin where we did the rankings for six years, we spent a lot of time with communities with their data, getting them to understand their own data and getting them to use the data to move toward action. In fact, our project before County Health Rankings was called MATCH, Mobilizing Action Toward Community Health, and the data was just a little part of that, the goal of which was to mobilize communities to think broadly about population health, come together with other stakeholders and do good things. I think that remains an important purpose for data, but it is just one purpose.

I will just close with a couple of comments. I do think that we can do a better job of measuring what we are doing. Juneau County, which ranked last in our state and became quite a famous story when I was called to testify at Juneau County. Actually, it was in the court room and I had to sit in the witness stand. Rather than being charged with a data crime and reporting the data, they actually said they would like to change the conversation from the health problems because the rankings were accurate and they knew they had health problems. They wanted to change the conversation to what they are doing. They thought as a community they were doing the right things. They were dealt a bad hand, but they were playing the cards they were dealt as well as they could. I would push us to think about how we can think about measuring what communities are doing.

In our County Health Rankings, it is the orange box. Do you notice? The orange box has nothing to the right. We don’t have measures there. We just say do good things, but we don’t really measure what people are doing. I think the collective wisdom in this room could help us measure a few things. Some have said that access to health care is something you can do through policy change. That actually might be a metric that you could move down into the programs and policies.

Because Juneau County as a result of this ranking, actually started doing things. They provided universal access. The hospital health system, Mile Bluff Clinic said it will provide care to anybody on a sliding scale. If they don’t have resources, they won’t pay. I would give them a gold star or number one ranking for doing something good in health care access. They banned smoking in their community, which was one of the first communities in the state to do that. They should get credit for doing the right thing. Even though they had one of the highest rates of smoking, highest rate of lung cancer, shortest life expectancy in the state, they should get credit for doing. Again, back to the robust measures, a dozen or so that we could come up with. It would be nice to have something in the domain of inputs.

And the final thing. I echo Steve Woolf’s comments. Steve is a visionary as far as getting data to be useful. The maps that you are producing are wonderful. They are not conventional because people who make maps don’t think about communications as much as just making maps. In our own Dane County, which is the home of Madison and what used to be a progressive state government. Sorry, I had to get that in there. I don’t need to be careful. Did somebody say I need to be careful? We produced a report, actually a local advocacy group. A council on children and families produced a report. Somebody sat down. The students sat down and looked at the Census data, which is free, accessible, and never used, hardly ever used locally. They looked at Census indicators by race. They were astounded. Here in Madison, Wisconsin, the disparities for the measures of social determinants available in the Census, never looked at, were striking.

They prepared a report called The Race to Equity report. It has changed business in Dane County. The government, the health department, the schools are coming together. This is now a crisis within Dane County. If we simply use the County Health Rankings or other standard metrics that have a certain purpose, if we simply held to what other people do, this report would not have galvanized community.

Again, I go back to the point that – think about the purpose and if the purpose is comparing across counties and across time, County Health Rankings do a pretty good job of that, but that is only one purpose. I encourage us to think more broadly about what these metrics could be used for.

MR. ROULIER: Thank you, Pat.

MS. MILLER: Hello everyone. I am Carolyn Miller. I am a senior program officer in the Research Evaluation and Learning unit at the Robert Wood Johnson Foundation. As many of you in the room know, I am sure, over the last couple of years, the foundation has been working on our new vision and operationalizing that vision and building a culture of health in the country. I was on the team with Plough and a team of researchers from the Rand Corporation to develop and operationalize that vision. We developed an action framework.

There were some key questions that we considered as we operationalized our vision for building culture of health. How will we as a nation know if we are achieving a culture of health? What areas of action should Americans work toward and how do our actions connect with one another? Most importantly, how can we starting points that speak to many different actors within a community? And then what specific measures would be a signal of improvement?

This is the action framework that I think you have probably all seen. You should have a handout that shows all the action areas. Those are making health a shared value, fostering cross-sector collaboration to improve well-being, creating healthier, more equitable communities, and then the outcomes area of improve population health, well-being, and equity.

Each of these action areas includes three drivers and then is accompanied by a set of national, evidence-based measures that were rigorously selected as points of assessment and engagement.

I want to note a few things about the action framework and the 41 national measures. The four action areas and the drivers within each are what we hope will endure and be most relevant for communities. The 41 measures that we actually selected provided a national-level picture of our progress toward building a culture of health. We imagine that these measures are likely to evolve over time as progress is made, as more data become available. We view these measures as version 1.0.

I also wanted to note that the framework was really meant to complement and not duplicate other existing robust sets of measures like County Health Rankings, the vital signs, and the prevention strategy.

I also wanted to call out that we talk about this as an action framework, not a model. We believe that a model implies something more formulaic, fixed, and final and a blueprint that should be emulated. And what we are really hoping to do with this framework is we hope that it speaks to a built-in fluidity and an opportunity to utilize this structure and then to personalize it and to run with it. We really want the framework to provide these entry points that resonate with the goals and values of many different individuals, communities, and organizations.

I don’t have time to go through all of the – to the action areas and the drivers, but again, you have this handout.

Here are just some of the criteria that we used. It is important to share with you the constraints and the criteria for selecting the culture of health measures. As you see on this slide, the measures were selected based on the availability of national data. Remember, these are our national level picture. These measures are the national level picture of how we are making progress toward building a culture of health. Application across the entire lifespan and health span and representation of these upstream drivers and broad determinants. Ability to engage audiences beyond our usual suspects and an overarching concern with equity.

I was also asked to talk a little bit about some of the activities that we have going on at the foundation that are more relevant to the community level. First, our sentinel community project. This is a new effort that will inform the implementation and the evaluation of the culture of health framework at the local level. We are really viewing this as a proof of concept of a culture of health framework.

Our goal with this project is to provide a rich narrative of the development of a culture of health at a more localized level in 30 diverse communities around the country. We have just finalized and announced our 30 communities, which include major metropolitan areas, rural, counties, entire states, a tribal nation, and each as approaching community health and well-being from a different perspective. We don’t believe there is any one right way to build a culture of health and we really want to try and learn from different approaches and see how these communities are moving toward improving health and well-being in their communities.

We will be employing mixed methods of data collection and monitoring the communities, but it is not the implementation of a program intervention or the provision of technical assistance. This is really a surveillance project where we are watching these communities. We will be making information about these communities available on our cultureofhealth.org website where you can also find the action framework and the 41 measures. And we are really hoping that by telling a detailed story of these communities and how they are approaching and using this framework and what kinds of measure they decide to use as they relate to the different action areas and drivers. We are hoping that this will help other communities find themselves in this, see a community that we are observing say we are like that community. They are doing interesting things. Reach out. We are hoping that we will learn from that.

We are going to be doing many other community-level efforts that do involve funding for implementation and research. Some of those other activities are the culture of health prize communities that you may have heard about are DASH, Data Across Sectors for Health. It is selecting communities where they are really doing innovative new things to connect different sectors, health care, public health, social service, community organizations, connecting data and using data.

And then we are also – a last project I will mention is developing high-quality, small area health data to improve outcomes for residents in the nation’s 50 largest cities. This is a project with the CDC foundation. We will be identifying, analyzing, and reporting on Census track-level data and using an interactive city health indicator website. This project is up and running and starting to get underway I believe. Those are just some of the activities.

I am happy to talk more about the action framework, but I feel as though, recognizing many in the audience, that a lot of people probably know about it already and I did not want to take up any more time going through the specifics of it.

MR. ROULIER: This was a perfect start. Thank you for that.

DR. PARRISH: Gib Parrish. I am a consultant. I am going to show you four things. There is a drawing. I am going to talk about a program. I am going to talk about a book and a survey. The drawing – Bruce in his opening comments showed this slide. This is from NCVHS in 2002. I just wanted to point out that NCVHS has been in the area of looking at domains for a long time. As a part of a report that Ed Hunter, Dan Friedman and I prepared for NCVHS back then, we actually came up with this particular perspective on influences on population health. As you go from the outside to the inside, it goes from the most general place in time into the context, the natural environment, culture as Vickie Mays was talking about, which is very important, the political context in which different communities operate into the actual community attributes themselves and then in the middle is the population health.

And then this fills out areas under those domains that were developed at that time. Ultimately, the measures are sitting in that little box over there on the right, population’s health, in terms of disease, functional status, well-being, level, and then the distribution within the population. That is the first thing.

Here is the report from ten years ago. The second thing is I want to talk about a program. CDC from 1992 until about 2007 had a program called the Assessment Initiative. Some of you may be familiar with it. Some of you may not. Some of you may have even gotten money from it. In fact, I see Bruce Cohen over here from Massachusetts. They did. Utah. There were about 20 or 25 states that were funded through that project.

NCHS first ran it at CDC. It then moved to an office known as EPO and then eventually ended up in I think OSTLTS. Those are old acronyms.

But this was a program that was founded in 1988 Institute of Medicine report on the future of public health. It was trying to in fact provide CDC support to state and local folks to do community health assessment. It actually funded states. Each cycle funded roughly 10 to 12 states to do community health assessment. They could pick an area that they thought was in fact what they wanted to work on. Some people worked on training materials for their county folks to do community health assessment. Some worked on the visualization of data so that they could actually make the data accessible to the local folks because that is a big issue when you get down to the local level. Others worked on other aspects of this. But that program continued for a number of years. Ultimately, it was ended for lack of funding.

One of my pleas is that the federal government might reconsider reinvigorating something like that again. It was actually quite an interesting and very useful program. There was an annual conference each year to bring people together to discuss practices on community health assessment and what different people learned from that. That is the program I wanted to mention.

The book. Mike Stoto is sitting back there and he was in fact the principal author of a book in 1997, which many of you I am sure are familiar with. Improving Health in the Community: The Role for Performance Monitoring in which they put forward, in fact, a community health profile, a set of basic metrics that would be used in all communities. They used that as a model for a national set of metrics that could be used for comparing across communities. But then the model, which they developed the community health improvement plan, in fact had under it another cycle. There was an initial assessment cycle. And under it is actually doing something and at that point, individual performance indicators would be developed for strong needs identified in those communities, but then performance indicators to actually look at specific areas that were community specific that were not wide.

As we go through this exercise here, yes, it is important to have a parsimonious group of indicators, but when you get down to the local level, they are going to need a lot more flexibility in terms of what they are trying to measure. I like Pat’s thing about talking about various policy things at the local level and that those can be used also to indicate progress.

Finally, on my yellow slip of paper at the beginning, the one thing we thought about, the one thing I wrote down was the American Community Survey. This echoes what Pat said. There is out there data at the block level from the American Community Survey. If you ever looked at this, it is impossible to actually look at American FactFinder and find anything. But if, in fact, somebody, Census, CDC, NCHS could work with that data to make it accessible to people at the local level, they could do what Dane County did. It is an incredible amount of data and it covers most of the domains here. It does not cover health although there are six disability questions, two of which in fact touch on well-being, sort of that idea of functional ability. It is a gold mine out there that needs to be mined and good maps made, et cetera. Those were my things I wanted to talk about.

DR. CHOUCAIR: I am assuming it is going to be my turn and I will move the slides forward for us. I am Bechara Choucair and I serve – for the last ten months, I have been serving as the senior vice president for Community Health at Trinity Health. And five years prior to that, I served as the health commissioner for the City of Chicago as part of Rahm Emanuel’s administration.

You might be asking yourself what is a health system. Why would a health system be interested in these types of community health and well-being metrics and development of domains and all of that? Honestly, as a system, we don’t necessarily have the expertise in developing domains. But what I was hoping from my short presentation here is to share with you why we are interested in using those metrics and how we have been thinking about the space. As you are developing these metrics, keep that in mind. I think that would be tremendously helpful.

Trinity Health. We are one of the largest health care systems in this country. We are in 21 states. We have 121,000 colleagues working on providing health care services, 88 hospitals, large number of network of outpatient, inpatient, continuing care facilities. Traditionally, health systems have been focusing on episodic health care and hospital delivery services. Over the last few years, there has been a lot of push on population health management initiative. And for the folks who are not part of health systems, population health management has a different perspective and we look at it very differently from a health system. This is really focusing on the attributed lives within our system. We have been building a lot of accountable care organizations, Medicare shared savings programs, NextGen, ACO, all the fun stuff.

But our system just recently a year and a half ago or so said that we really need to be focusing on community health and well-being. That needs to be an equally as important part of our business. What does that mean? That is when Rick Gilfillan, who many of you might know as the founder of CMMI became our CEO and asked me to come into the system and really focus on community health and well-being as part of our strategy.

When you think about why we are interested in community health and well-being and why we would want to transform communities, we think about it in three different buckets. The first piece of transforming communities focuses on clinical services for people living in poverty: all folks on Medicaid, uninsured, dual eligible patients. How do we make sure that we make sure that we are providing them with clinical services?

But we know that these folks are going to be needing a lot more than just clinical services. They need a lot of the wrap-around services. How do we make sure that we are optimizing their care by ensuring they have access to housing, transportation, food, all of these other aspects of the economic and social determinants of health?

But we also realize that if we want to be truly transformative in our communities as a health system, we have to be thinking about community transformation and we really have to be thinking about efforts like policy systems and environmental changes and take a step back to think of upstream interventions.

When you think about metrics for each one of these buckets on the clinical side, we have obviously at a point where we are querying our electronic health record systems fairly quickly. We have an HIE for our system where we have the electronic health records of over 12 million lives throughout our system. We could get at these types of reports very easily and those are reports that usually get updated daily, hourly, weekly, monthly. We can get them updated as quickly as we want and as often as we want. When I go to the board and share with them clinical data, that is the level of sophistication of our clinical data that we can get from our HIE that would allow me to share clinical data up to the minute of issuing that report of the 12 million lives that we have in our HIE.

When you think about the community engagement piece and you start thinking about our attributable lives within our accountable care organizations and we are trying to think about what can we do for these folks when it comes to the social determinants of health. I can also go through the use of community health workers or whatever efforts we have to optimize the care of these patients by looking at our data that comes from our accountable care organizations, using claims data, using clinical data, using data from CMS. I could get these data updated on a quarterly basis and I could be able to tell. Are we making a difference for these lives who are attributable to us when it comes to the social determinants of health?

Now when it comes to that third part, which is around community transformation, we are really interested because we truly believe that there are a lot of impact and focusing on the social determinants of health and looking at cross sectors, really looking at housing, economic development, transportation. We are really interested in playing in that space.

As a system, we invest every year around a billion dollars in community benefits. Every year, a billion dollars in community benefits. We are making a commitment to start taking some of these dollars and start thinking more about investing upstream. The challenge would be how do I get to make sure that these dollars that I am investing are making a difference.

Just last Tuesday we have made an announcement of investing $80 million over the next five years in six communities where we have Trinity Health clinical services to really focus on these upstream interventions. We have national partners who are helping us with this effort, really focusing on the use of community health workers, but also focusing on upstream interventions on tobacco and obesity. We are also making $40 million available in no interest or low interest loans for communities to focus on mixed income housing, early childhood education, things that might be of interest to that community. The way we are investing these dollars is by asking our community partners, our hospitals, and their local health departments to come together and tell us how they would like to use those dollars.

When we started thinking about this type of intervention, I think there are a lot of opportunities as we start leveraging our community benefit dollars to make these types of efforts. We would like to be able to measure the impact for that type of effort and that is where the challenge is.

When we started thinking about a community health and well-being dashboard that is as robust as our clinical dashboard, we are not nearly there. Most of the data that we are looking at those domains that we are thinking about incorporating comes from 2011 data, 2012 data, 2013 data. You could think about when I am going to the board and saying I would like to use a billion dollars or $100 million or $20 million or $50 million more to make a difference on these metrics and really looking at data from 2010 and 2011 at the same time I have clinical data that goes to last month or last week, it is really a big challenge. As you are thinking about developing these metrics, please keep this perspective in mind.

Health systems at least our health system is very interested in being part of community transformation. We would like to take our community benefit dollars and invest them more upstream, but we are going to need real help in trying to think more robust data, more out of the box thinking about data that touches all these other domains. I will stop here and apologies for the little hiccup in the start of those slides.

MR. ROULIER: Thank you. I had a couple of drill down questions, but I am actually going to flip it and maybe just allow those of you out here because I think there is a lot of pregnant questions to put out there.

But before I do, one other perspective that was going maybe be on this panel was Matt Stiefel from Kaiser Permanente and Soma Stout with the 100 Million Healthier Lives Campaign who have been doing some work on related areas. We realize that Brita Roy was actually part of the metrics team. I wanted to just give you a moment to share one other kind of perspective that is worth knowing about.

PARTICIPANT: I have been fortunate to be part of the 100 Million Healthier Lives Metrics Team. We also through a parallel process over this past year have been thinking really hard about how do we measure healthier lives and how do we assess the well-being of communities. I am actually really excited to say that our overall assessment, our overall primary outcome is very similar to what you come up with and that we are looking at well-being and life expectancy and have come up with this term of a well-being adjusted life expectancy as a primary outcome or a WALE if you will. And to measure well-being, we have actually come up with a seven-item instrument that is doing really well in 18 years and older in multiple communities around the country that we have piloted. Happy to share that.

But in addition, the other domains that we have come up with are also similar to what is here. But what is not there is really a measure of community. I guess we would argue that community is different than population and many of the communities that we are working with really want to know how well their communities are doing. How healthy is their community? Are there social connections? Are the organizations within the community working together? That might be one additional domain we would suggest.

But as I am talking with each individual community around the country, they are trying to measure each of these things. And the challenge is they don’t have the capacity, but they are trying to do the same things as all these other communities are doing. Having a nice streamlined process that is working either at the national government or state or more local government level to be able to provide this information to the communities so that they can actually themselves have the ability to create the change that they want for themselves. As was brought up before, making it possible for each community to tailor to what they need I think is the main thing. Even if we have these broad categories up front, if they are drilled down to where each community can specify what is important to them in an obesity-related measure, I think that would be really useful.

MR. ROULIER: Actually today as an aside, I think Matt Stiefel and others are actually designing a menu set so that it would allow that is really geared towards these end users of communities to do this work around data collection and reporting that really adds value to local improvement efforts. I think Soma and others and obviously Kaiser who is here with Walter is really interested in making a lot of those tools publicly available across the board. They are excited about being a part of this effort in some way.

We have just a little bit of time before lunch even though I know you were teased by the slides. I am going to just open it up to you all around big strategic questions. Insights you would love to hear this panel’s reflections on.

DR. WOOLF: Steve Woolf again. I had a question for Dr. Choucair. Can you articulate the business case for why in your case Trinity Healthy System wants to put $80 million into this? I am delighted. I think I know the answer, but I am just curious how you would articulate it.

DR. CHOUCAIR: As we continue with our journey from getting reimbursed for volume to getting reimbursed for value, we are realizing very quickly that actually investing in the social determinants of health is something good for us, not just from a mission perspective as a faith-based organization or from a moral perspective, but really good for a business perspective. The challenge is going to be how do we measure that and how do we make sure that this is really making a difference. I am hoping that the outcome of today would allow me to make a better business case to our board as we continue to invest our community benefit dollars more upstream rather than our cooking classes and smoking classes and our health fairs.

DR. LEVINE: To follow up on that, one of the perspectives I think we need to be thinking about is that the people who work in your facilities and for all employers come from the community. As we look at these domains, figuring out how we capture and how we make it relevant. I think health care facilities have maybe been the most blind to that issue because many other big employers have taken a wellness approach. But this is something I am particularly interested in the state level because I think there is a business case to develop for employers to be involved in this process.

DR. STOTO: I want to pick up the endorsement from Gib, but first say it was actually an Institutes of Medicine report, not just me. But I think that really there was a lot there that is relevant today to the issues that came up. In particular, the two cycles that Gib described. The first one was about identifying the problems in the community and the kind of measures you would need for that.

The other one was how do you actually measure what organizations do to address those problems, which is what Pat was asking about. I think it is really important to recognize there are two very different needs when you are coming up with the kind of measures. And the second one needs to be tailored to what the community strategy is and the hospital strategies are and so on. The first one needs to be comparable so you can benchmark.

DR. COHEN: I had a question for the panel. First of all, I want to thank Gib for the shout out for the assessment initiative. We developed a web-based query system and a lot of other states did that provided simple, interactive access to data at the community level. If the federal government could reinvigorate the program to do these web-based data query systems that people at their desk tops, there are still about 20 to 30 of them across the country. That would be a phenomenal value for all.

But the question I wanted to pose to the panel was there was some discussion earlier about cumulative indices that combined a lot of these domains. I just wanted to get your thought on what your sense of how valuable they at the community level.

DR. REMINGTON: I think my answer is it depends on the question. When you are measuring across communities or states, I think, as you pointed out, comparability is important. Mike’s cycle or the IOM cycle, footnote Mike Stoto, is I think really valuable. That first cycle where you are identifying problems. One way to identify a problem is comparative analysis. You need comparable metrics.

Again, for this process, I think there is a time and a place for using the same exact measures and some re-measures. I think the deep dive is really important and it depends on what you are doing.

The paper in the National Academy of Sciences that just came out. I am sure you have heard out, the Case and Deaton paper. That simply did what – introductory, epidemiology course would teach, which is stratifying the analysis of trends for whites by education and well done, well written. It kind of shocked the world as to what is happening – the BBC covered it of what is happening to poor whites in America. And then stratified – so diving deeper, looking at leading causes of death in that group and trends for suicide, for accidental poisonings and liver disease related to hepatitis C and alcohol abuse. Wow. That tells a powerful story about America.

Now if we just use summary indices and common metrics across counties, we never would have seen this. I frankly am surprised that we have not talked about this issue about being poor and white in America in the middle ages and the effects of the economic recession and the policies of the 1990s.

To me, that is an example of a deep dive that a Nobel Laureate or actually a wife and her spouse Nobel Laureate did. I think we need both. I think we need the comparable measures across time and place that are not that useful really for the deep dive. And then you need to go deep into the data and learn from it, but also monitor it to see whether what you are doing is having an effect.

MS. MILLER: When we were talking about the action framework and creating our national level measures, we talked about and thought about creating one index of a culture of health and decided against doing that. I think it speaks directly to Pat’s point that it depends on the purpose and the purpose of our action framework and the action areas and the drivers is really to start a conversation and to bring people into this conversation about health who maybe have not been thinking about their work as being part of health. We have very different kinds of measures. We have transportation-related measures, housing-related measures. We have voter participation. We have early childhood education.

There is such a wide variety of measures that we hope it – it is not that we think a community is going to pick up all those measures or pick up those measures because they are this national level picture, but we hope that it provides this model and framework of the different people to include in the conversation, the different areas you might want to be looking at when you are thinking about community health and start that conversation. I am just supporting Pat’s point that it really does I think depend on what the purpose of your model of your framework is.

DR. PARRISH: I am going to put in a very quick plug in for the summary measures of population health. There was a lot of work done in the late ‘90s and early 2000s in looking at composite measures of life expectancy typically well-being as sometimes functional status. NCHS, in fact, did an extensive report on those in 2002 as a part of the Healthy People process. They are interesting because in fact life expectancy is in some ways a composite measure. Essentially, it is all the causes put together. It takes into account all. And then it can be causally decomposed. You can look back just like Pat was saying into what is feeding into that in terms of increasing life expectancy, for example.

MR. HUNTER: This trip down memory lane with Gib and updated with Bechara’s three categories. Ed Hunter, by the way. It makes me go back to what is the big opportunity. In some ways, we have had the opportunity to define these kinds of domains for 20 or 30 years of this. The question to me is what is different now and what is the motivation behind coming up with these kind of indicators now. And the culture of health indicators I think working towards some of this. To me, it is to signal what is different about our expectations for a health system or a social system or a health-generating system today than it might have been when we worked on that chart before where we were still working on specific medical models or separate public health interventions or a whole variety of categorical approaches.

To me, when we think about these domains and they are actually fine domains. We were having a little sidebar in our group and at the break. But the thing that you want to do with these is to signal what it is we think is different. What is the change? What is the health system, social system, however you define it, we are trying to move towards? Rather, for example, than thinking of access to care as a separate domain and Pat kind of mentioned maybe move it. I think there is a question of what do we want to provide access to or coverage for as a community that is different than just medical care. There is a category or a cluster of things where we want to provide the things that only a public health agency can provide. There are some protective services. There is emergency response. There is preparedness. There is environmental protection. There is tobacco cessation, tobacco control, secondhand smoke protection. Then there are personal behavioral choices that one can make that may be enabled by that and maybe separate from that. There is medical care system and it is supported domains.

But I think in thinking through do we go with disease categories and then subsume what you can do about them under them or do you think of the things that we as a community ought to be saying these are the things we need to call attention to, focus on, and then find ways to measure whether communities are doing those things. You can actually turn this and say if tobacco is an issue, are the communities doing the evidence-based things we know are effective in tobacco or are they doing things that are providing coverage or support or connectedness within their systems. And then you can kind of parse these out into diseases as examples.

To me, this panel crystallized for me the opportunity is to really show we are not just talking about diseases and systems and health care and insurance. We are talking about what it is we owe people that live in these communities, what the community can do together, and what the pieces of the puzzle might be.

DR. CHOUCAIR: Thank you. Can I follow up on what Ed was mentioning about what is new now? I think with a lot of data liberation that we are seeing from local governments, state governments, federal government, there is a huge opportunity for us to start thinking more out of the box on a lot of the metrics that we really need to measure.

In our community health and well-being dashboard that we are putting together for our Trinity Health Communities, we are trying to figure out police reports that are being posted on the city websites as a proxy for public safety. And even doing my work at the health department in Chicago, we were looking at the building’s department reports on modifications and remodeling of homes to let us do a better work on lead poisoning prevention. We were looking at tweets that come out from Chicago that referenced food poisoning and through machine learning. We are trying to figure out how to target our inspection of reports and interfacing with people on Twitter to really go do inspections of restaurants posted online and link it back to the person who originated the random tweet about getting food poisoning in restaurants.

I think it is really time to start thinking very aggressively and out of the box on the set of the data basis that we are looking at to develop our metrics. Unless we get to a point where we have robust, up to the minute data that really allows us to look at these metrics, in my mind we are way behind. If we can get it on the clinical side, there is no reason why we cannot get it on the community health side. If we can get it for sales of cars, if we can get it in every one of the industries, there is no reason why we don’t get it in this industry. It is really time to think out of the box on these metrics.

MR. ROULIER: One more question and then want to give you all one more chance particularly on this kind of stream of thought if you want to jump on what is different now.

DR. LEVINE: If I could follow up on the “out of the box thinking”, I think there has been some really good work done in retrospect. What I worry about and I would ask the group to consider is that if we follow where we have been, we are probably going to end up in the same place that we are now. I really worry about the disease-specific approach. I am also very concerned that if the goal and I heard this often as health equity and increasing health opportunity for all. A lot of what we have done over the years is about incremental improvements. I have challenged my own folks and people in Virginia to think about what would be different if we really stepped away from the incremental improvement and wanted to make change for all. At least get everybody to a comparable level. How would it look differently and how would the systems look differently? We heard the comment that the systems are broken or don’t exist. I think we have to challenge ourselves.

We can use some of the wisdom of the past, but I am very concerned that the focus on individual diseases without thinking about the system pieces and what is common systematically for obesity and tobacco. We need to focus on those common system changes and begin to think differently and avoid the pitfall of where we have been. Just a caution.

MR. ROULIER: Any kind of final thoughts for many of you.

DR. REMINGTON: I would just conclude by reminding folks about Sutton’s law, not about banks, but about the health care system. Why should we work in public health with the health care system? It is where the money is. If you can combine money and mission, public health has a mission, but not the money, and with leaders like Choucair, I think you can make a real change.

I am interested in the fact they used to call it the electronic medical record. Then somebody changed it to EHR. But I don’t think they changed it. I just think they changed the name and not the record. It is not really a health record. It is a medical record. Could we take the electronic health record and turn it into the Behavioral Risk Factor Surveillance System input, which would be not from random digit dial telephone surveys, which by the way I worked on back at CDC many years ago. It is not very good. In fact, it is worse than not very good. But we have an opportunity. Within the electronic health record, maybe it should be electronic community health record that begins with people and then moves up to system and to community. It is where the money is. If we just have the mission and leaders like yourself in health care, I think public health has a great future in population health data.

MS. MILLER: I would just end with one of the areas that we really focus on in action framework although they are all equal is action area one, which is making health a shared value. In that, we have drivers of mind set and expectation, sense of community and civic engagement. We really feel like even though this area is one in which we know there is not a lot of data availability, we think that is a really important piece of this community health, building community health and population health is to understand what the landscape in a community in terms of willingness and the buy in to health interdependence and the value of raising the health of everybody in the community. We really highlight that as an area we think is really important for communities to work in.

DR. PARRISH: My last thought is a question for you guys. How many of you have ever looked at the community health needs assessment website. It is chna.org. A handful of you have. It was actually put together as a joint project between public health and the health care providers and health care organizations and in fact several organizations that participated are here in this room.

I say it just because it is an interesting site to look at and it puts you into a community. The first thing it does is it talks about vulnerable populations. It tries to actually look at those places. And the data is some of it is at census track level. Some of it is at county level. It is perhaps a way of beginning to think towards a future in a tiny step, but of how things might be visualized in the future to think of a more holistic approach. I am thinking of the comments from Virginia there about the need to look at all the underlying factors. But you might go take a look at that and see what you think.

MR. ROULIER: Just as an aside, that is the system that actually IHI and Kaiser are going to be building on a little bit over together. It is on the commons and CHNA and generously publicly accessible.

DR. CHOUCAIR: I am going to echo what my colleagues here have said. The health care system is 17 percent of our GDP. It is a huge amount of resources. We are in that journey where we are transitioning from getting paid for volume to getting paid for value. This journey is not going to end. We are moving down that path very quickly and we are no longer going to be getting paid down the line based on the number of cat scans that we offer, but based on how we are keeping people healthy in our communities. I couldn’t think of a better time for alignment between public health and health system. My career has been mostly in the public health side and now that I am in the health system side, this is the best time to think about that.

As you are thinking about metrics, three quick things. Let’s make sure that those metrics are pragmatic. We can use them in a way that really makes a difference. Let’s think outside the box when it comes to the data sources and let’s make sure that the data is timely. I think those would be the key messages that I will have. Thank you for having me.

DR. CHANDERRAJ: I just want to conclude by saying that there is an excellent article in the The New England Journal in October, putting the public health in perspective. If you look at the public health as a pyramid. The bottom of the pyramid has social economic factors where insurance coverage and teen pregnancy is important in quality levels. The second level is the individual’s default and decisions that make healthy life, such as clean water and other things. Lasting protective interventions such as immunizations is the third level, which is immunizations that would take (indiscernible).

The fourth level is the clinical interventions such as controlling of hypertension, which is the most important factor in reducing stroke and heart attacks immediately(?). And the fifth level is counseling and education.

If you put all of these metrics into this pyramid, I think it would make a wonderful union of path processes and get public health moving in the right direction.

MR. ROULIER: Thank you for that. That was one of the NCVHS community members. Raj. A great morning. I think we laid the foundation. A reminder that we are in some ways not in new territories. Some of these conversations and contributions have been going on for decades around aspirations and challenges. We are also reminded that we are actually at a very different time. The strong felt needs in different areas for a diversity of purposes. I think particularly this panel. We need to start thinking in some fresh ways about how we might move forward. There is enormous amount to build on. Different states. Some of these frameworks with RWJ and county health rankings.

My hope is after lunch we don’t have just another conversation, but we actually figure out where is the energy. What would be unique? What would make this different? How would we move this forward? What is the unique contribution given everything else that is going on right now? That is the conversation we want to be having after lunch.

The way that lunch is going to work. I think Janine was going to share this.

MS. MTUI: I just wanted to share the options that are available. There are several options including Qdoba, Carolina Kitchen, Five Guys, coffee shop, pizza, and a deli all out of the building, not this exit, which leads you to the garage but opposite. Go out the door and turn left. They are all within one minute walking distance. You should be able to be served and be back in time.

In addition, if anyone needs ground transportation to your destination and/or back to the Sheraton Silver Spring Hotel, please let us know at the registration desk.

MR. ROULIER: Start making your way back so you could be here at 1:15 if possible. I appreciate you being efficient on that front. Have a good lunch.

(Lunch Break)


Agenda Item: Advancing Domains of Measurement That Will Make a Difference

MR. ROULIER: Welcome back. I suspect that – we will have a couple of colleagues that continue to make their way in, but again I appreciate you all making it back. It is not easy to grab lunch in such a short period of time.

Again, really wonderful foundation that was set this morning that I am optimistic that we can build on. I am going to actually hand some work over to you because we are going to move it into what are some things that we could move forward. What are some strategic guidance that we can give to NCVHS, HHS, and others around how we could move this forward in some unique ways?

Bill and I were talking over lunch. He thought it might be helpful to set a little additional context and some assumptions before we move into some small work groups in a moment. Bill, take it away.

DR. STEAD: I thought first to try to provide my lens on what the unique thing we might be trying to accomplish now is, given the multitude of efforts that we have heard about. I would just summarize it. We are trying to enable multi-sector collaboration at the neighborhood level to support assessment, selection of interventions, and monitoring of progress. That is what we are really trying to do.

A lot of the discussion about this tension between parsimony on one hand and depth and local importance on the other. I think it might be helpful to think of the core domains as broad areas that contribute to community well-being. They need to be considered collectively to have the optimal effect on community well-being. The thing that is important about the domains is to think about them as a collection that needs to be considered together. They are not in fact at the measurement level. But we then would have a set or a menu of metrics for each of the core domains. Anybody that is interested in improving community well-being ought to easily see themselves in the metrics amongst one or more domains. It may not be seeing themselves in the domain that is the broader category.

Our thought would be that we would have metrics under each domain, some of which would apply to the assessment phase of activity, some of which would apply to the choices and design around the interventions, others that would apply to ongoing monitoring. As a community, once you knew your area of a focus depending on what phase of that improvement work you were engaged in, you would be picking the appropriate measures from the metric set.

Another thing we are struggling with is this tension between are we working at the community level or the national level. And in my purpose, I made clear that at least from my perch, we are trying to support action at the neighborhood level. With that said, if we can support that action with a common menu of metrics then it should be easy for two communities that are working on the same problem to talk in the same language and to then locate each other and work together. It should also be easier for us to aggregate some of that information at the national level so that we can look at it from both perspectives. But that is just some sort of clarifying context if that is helpful. Did I get that right, Monte and Bruce?

MR. ROULIER: I think that is what we talked about. Is that helpful? A little reminder of where we are going to dig in. Thanks Bill. I think we may have a slide coming up here in a moment.

We wanted to turn this back over to you. Bill kind of reiterated it at a high level kind of what is the unique purpose particularly given what time we are in right now. Advancing the measurement. What is our unique purpose and opportunity here particularly given the federal representation that this brings, not trying to supplant or change another model and all the good work that is already going on out there? What is the unique purpose and opportunity here? Bill kind of reiterated a version of that. I wanted you all to consider that.

And then secondly to kind of jump into again proposing some specific enhancements to the domains. We are not going to be looking for really crystal clear consensus because I think we will have dimensioning returns. But there are some fresh ways of maybe looking at the domains. A couple of ideas came out around transportation and sense of community as possible domains. We want to allow you at a smaller level to wrestle with are there ideas around collapse, remove, add, clarify the existing domains or new ways and fresh ways to thinking about it. I want to give you about 25 minutes in your small groups to play around with both these concepts and just see where we land. Make sense? Go for it and we will just kind of touch base. We are not going to do a formal report out, but we will definitely be wanting to hear your insights as it relates to both of those questions.

(Pause for Group Discussion)

MR. ROULIER: Which group has it all figured out? Just so you don’t think that those of us who are helping to plan and facilitate naively thought that you were going to figure this out in a small group in a short period of time. I know your imagining lots of complexity. But I think it is really helpful to even hear some of your gut instincts around this. We certainly want to hear where you are wrestling with some ambiguity and where you were not able to resolve some tensions.

I would like to start with where you have some clarity. What are the things that we could actually build on? Whether you figured out how to do it, but where the real areas of clarity, particularly as it starts back on this kind of area around our unique purpose and opportunity.

DR. LINDE: My name is Sarah Linde. I am the chief public health office at HRSA, one of the HHS agencies. I represent the red group. We wanted to notice our unique opportunity here today that I don’t think we have availed ourselves of at all is hearing from EPA, HUD, and whatever the non-HHS, non-health people are who are here today. I think a lot of the discussion and presenters have been folks in the health domain. I think we would be remiss if we did not ask them what they talk about at these meetings with their people. That is number one.

Number two. Propose specific enhancement to the domains.

MR. ROULIER: Can we hold on that? I want to come back to you. I just want to focus real quickly on the purpose for a moment. If you don’t mind, can we come back to you on that?

By the way, have folks from HUD and EPA, anybody else, arrive? I know there was a HUD meeting. EPA. Terrific. I guess your underlying point was really that we have this enormous opportunity really with some of the non-health specific sectors given the work that they are doing. We actually thought when we hear from the fed perspective coming up at this break that you all might be able to speak into that a little bit, not that you cannot speak now.

How about purpose? Pieces that you were starting to get clear on? What is the unique opportunity? Are there any thoughts on that?

MR. SMITH: We were talking about data. It would be useful to – it would probably have to be federal – an agency like HHS to fund research into what are the data elements especially below the state level that exist in the various domains we choose and like who is collecting what. I don’t even know what the state, the lay of the land is in terms of – are people already collecting police records? Are they collecting built environment things? What is available? We also talked about private issues. That is something that seems it would be at a federal level where you could get funding to do that.

MR. ROULIER: What is available? What do we know about those that are evidence base? What kind of the nature of those particularly at a sub-county level? One of the unique purposes of this group that might perform.

Any other thoughts on unique opportunity purpose as we continue to circle around this?

DR. COHEN: One issue that was brought up earlier was there are existing data sources that have not been adequately mined. I think it is an extension of what was just said. We need to figure out how we can use the data that exists already more effectively and efficiently at the local level.

PARTICIPANT: There are also issues in how you conceptualize all of this. For instance, these domains don’t have equity obviously in them. We can do things with them too. Look at equity, but it does not come front and center. It also uses a determinant’s framework – a life course framework. It is not obvious that there are – there is a lot of emphasis on children and critical periods. I am not saying that they are right or wrong, but intrinsically in some of this, there is an implicit determinant’s approach as oppose to other ways to think about some of these issues.

MR. ROULIER: Probably not one right way, but there are clearly some tradeoffs by going in this direction.

PARTICIPANT: You may want to add some domains that begin to capture some things that you think are critical that are outside the determinant’s framework.

MR. ROULIER: Great. Let’s actually go there. By the way, I have noticed this and I encourage you may be over break to look at some of the notes that are getting populated up here and actually continue to do that yourselves, but obviously a real emphasis on equity on a lot of the comments here around other domains or dimensions.

PARTICIPANT: If I could just fill in what Steve said. Thinking about how you conceptualize it. One of the discussions in our group was let’s say you and your family are thinking of moving to any community you can in the country and you want to know is this a good place to live. What are the things that you are thinking about to define why would you choose to live here rather than there. One certainty is. Is this a place where my kids can grow up? I am getting into question two a little bit about what the domains could be. If the focus is figuring out what a thriving community is, as Denise said –- can I go into question two?

MR. ROULIER: Yes, please.

PARTICIPANT: Denise’s slide in her opening remarks about what transportation uses as their domains so to speak. Health was one thing, but there was economic well-being. There is housing. There is transportation, public safety, education, all of those things. I think if we are focusing on what makes a community thriving, those are the things. Within health, the health domain, we could put some of these things that people think that yes, obesity is one of the most important things that communities should focus on. But what if in my community we don’t have a problem with obesity? That does not appeal to me. But in my community if there is a lot of suicide, mental behavioral health or substance abuse, that may be an issue. I think some of these domains could be collapsed in a health domain and then expand some of the others. That list that you had, Denise, I thought there it is right there. You are done.

MR. ROULIER: Collapse some. You named some that I think outside of transportation I think are some of the domains if I followed your point. Housing and some of these others up here.

PARTICIPANT: For example, I completely agree with an earlier comment or we agreed of things like air quality. That is not necessarily the right domain. It is environment. But whatever that list was. I don’t know if the slide person could go back and find that particular slide. I think that that had all the essential elements or we could work from that. Do you know which one I am talking about?

MR. ROULIER: I am not sure which one you are talking about, but thank you for clarifying. Gib, maybe it was the slide that you had. I am not sure.

DR. PARRISH: I was going to further comment on her thing. I, in preparation for this, went and looked on the Internet for best places to live. Actually, it is exactly what you said. There was one from money, livability and 24/7 Wall Street. Let me just read you the list of their domains. There is amenities, crime, demography, ease of living, the economy, education, environment, health and health care which are smooshed together. Housing, jobs, leisure, social and civic capital, transportation and then other infrastructure. It gives you a sense. Health is one of those pieces. It is not like this where it is all broken out, but it is one piece among many in terms of overall community and vigor and livability.

The health was typically measured in those three sites in terms of health care and in terms of either number of hospitals in the community or numbers of physicians, that kind of thing.

MR. ROULIER: For you, what is the implication for this in terms of this particular endeavor around domains or thinking about conceptualizing domains?

PARTICIPANT: Some of us at this table we were talking about adopting the county health ranking domains as the domains for this activity as well. I think they would be a lot better than the ones you said. I think maybe the ones you are referring to. They are not perfect, but as a set of domains, I think they are pretty good and they have passed the test of time at least being useful for a couple of different purposes.

MR. ROULIER: One proposal. Again, I don’t think we are going to try to get to come to consensus on that, but just to put that idea in existing framework out there. Other thoughts? Let us open this up.

DR. MAYS: I just want to talk a little bit about – and this is in response to when Bill started and he was saying what level are we talking about. I am going to bring this down to the level of talking about it at actual counties and cities kind of thing.

One of the things that is happening is that – and, again, maybe I am very biased because I live in California with Silicon Valley and we do a lot of this stuff. But there is really a national movement of having people come in and actually take social service, health data, and public data and actually mash it up and make it very available. There is Code for America group, for example, that sends people into cities and they agree to work for a certain amount of time.

For example, in some cities like in San Francisco or LA, what you will see is – San Francisco is probably a better one where what they did was they went and combined with Yelp the actual report of all food poisonings. It cut down by – I think it was 30 or 33 percent food-borne illness. It is a rating. You can go online and the restaurant and see real quick when someone had something. The next thing you know it was really cleaning up. But that just gives you an example of ways in which when data mash ups occur that we can actually get some of this data we want. That is where the city begins to say what is important.

I think in some of the domain stuff we have, it is very traditional kind of orientation towards health. But when you have people coming in and doing mash ups like in Chicago. Their big deal is they wanted to know where the social services were in which they were in languages so that when they referred people, they could refer them to get services in the language that they needed. Each city I think has some unique things. But there is really a lot of work going on about this that I think – as Walter was saying, it may be that the work group really needs to put on something to work with you all and see if there is a better way to connect this with government.

MR. ROULIER: Thank you, Vickie, for thinking out of the box. Folks mostly agree I think it seemed like with what Bill was saying. The goal here in many ways is to provide multi-sector collaboratives at local, regional levels to actually assess, measure and really do improvement work. Is that a fair assumption still? That is one of the primary purposes or some other co-benefits to be able to do that. Again, if there is disagreement, feel free.

I am asking the question at least for myself. I am curious of your thoughts on it. What is really the purpose of the domains given that that is our primary purpose? Is it that we expect local communities will adopt these domains as their framework to drive their improvement work? Or is it that folks will be able to use these domains to actually navigate through and figure out what would be the most meaningful kind of community measures for either assessment or monitoring performance? I don’t know if it makes sense. What really do we expect the domains to do for us?

DR. REMINGTON: We found in the County Health Rankings that when a sector in a community has a measure in the matrix, they pay attention. I think one of the values of having multiple domains is you have potentially multiple investors, multiple vested, I should say, partners.

Again, I think that we talked about the difference between the problem of assessment cycle, the IOM performance monitoring cycle, that having multiple domains allows you to do problem assessment outside of health care and outside of public health and into education and poverty and housing. To me, multiple domains make a great deal of sense.

If you get into then the deep dive into process improvement or monitoring, I think it may leave these domains. You may not have to have cross-sector domains in a process improvement cycle. That depends on – we talked – if you are trying to improve emergency response and getting heart attacks into the hospital, those are very specific measures. There is a well-accepted process for doing that. I don’t know that you need measures of tobacco if you are really focusing on getting people who have had a heart attack into the hospital and saving their lives. To me, this is more at the problem assessment.

And I like the use of the categories because it assures that multiple partners are at the table or it increases the chance that they would come to the table.

MR. ROULIER: Particularly helping with problem assessment in allowing different sectors see their role within community improvement and well-being. Is that fair?

PARTICIPANT: I have been encouraged to add another comment. We talked a little bit along the same lines about different buckets that, as I was saying before, signal what it is we are after with this. We actually want to encourage action at the community level to improve to the extent they can the health system, the community system. I am responding to your don’t pretend you have it right because we certainly did not get it right. But we talked about re-bucketizing in ways that might include things that are community behaviors or community-level things that the community owes its citizenry, things around – this is where you might put housing and transportation, complete streets, other things that only the community can really do collectively went around personal behaviors, which is more the tobacco choices individuals have within that context.

Things around how the health care system writ large deals with its patients. Some of the things Bechara was talking about I think around support of individual patient’s care coordination and then another that might be around more the environmental contextual things that are more – you have to sort out whether a built environment goes in the things that a community can do for its citizenry or has to or not or whether it belongs in the air quality, water quality one.

But I think the intent of that was to try to draw more into this the things that the community itself can do to make for a vital population and a healthy population instead of going from the disease up and obesity and tobacco has in there things that a community could do, but it does not jump out at you and say hey community. If you want to be viewed as a vital community that is doing what it can for health, here is where you go.

MR. ROULIER: I see a couple of heads shaking. I wonder if we can just stay on this point for a minute around —

PARTICIPANT: Actually, I want to echo what was just said. If we are thinking about domains that reflect an overarching status or kind of an infrastructure or I don’t know what it is called. It is a good stew, the base, the stock. Then regardless of what the intervention is, in this case, diabetes or obesity, one already knows the implications of how much challenge you are going to have or not with trying to actually implement a change versus again the other way around, which is I have an issue with obesity. Now, what are all the factors involved, which then takes lots more measures, a lot more detail? If it is an overarching sort of set of domains, it will provide a broader value set regardless of what the focus du jour is on a disease health care perspective, but those are hard. Those are the ones that are what is the basis. It is like the infrastructure that you have to work with, but obviously in a domain name.

MR. ROULIER: We are probably are not going to figure that out today, but would love just again sprinkling of ideas, harvesting some thoughts around this.

PARTICIPANT: There was one other thing our group talked about was the unique opportunity especially with the folks that are here in this room. These goals can help communities too, as we were talking about, assess what their greatest needs are and then align multiple sectors, which is great. The issue often I think becomes from the community’s perspective is how do we align incentives to do the work. Let’s say a community was going to tackle obesity and they know that they need to create complete streets. They need to improve food access. They need to improve the mental health and social support in order to tackle obesity. But how do you do all of those things at once? They can apply for a grant to maybe get one thing done, but it does not address the other issues.

In this multi-sector group, potentially we have the opportunity to start actually aligning incentives for communities so they are not stuck after they find out what their biggest health issue is.

MR. ROULIER: What else? I want to open it up. That seemed to be significant in the conversations you have at our table that have not been aired, including – I heard a couple of dimensions whether they are a new domain or not around climate potentially or air quality, I think somebody said. What else either were significant or other domain considerations?

PARTICIPANT: I guess I what I just wanted to respond to considering federal representation, that piece of that first and second. And I am going to borrow from Ray for a minute from Baton Rouge, my colleague. There are a lot of communities like his. He does not even have a health department period. He is a one-man shop working for the mayor. He wants to help his community improve its health. What is the federal opportunity here? You guys collected a gazillion amounts of data on all kinds of stuff in all your different agencies.

The opportunity is, as Mr. Parrish and Dr. Cohen and other people have talked about already – if we could pull all of the data into a portal that is query-able, that somebody like Ray could sit down with his five hospital systems and they got to work on an ACA-mandated community health assessment and they can start pulling data on some domains together from all the data sources that exist even though they don’t have the resources to expand BRFSS or NHANES or whatever in their local level. That is what the opportunity is. It is the opportunity to help places like Baton Rouge.

DR. LEVINE: We did not actually talk about this at the table, but we heard this morning from Ohio about including cost metrics and value. In Virginia, we also looked at cost metrics. I think the opportunity that we are missing is that we are going broke paying for this incredible burden of chronic disease and not investing on the front end in prevention. We are at a time where we have to figure out how are we going to begin to re-allocate our resources and break the cycle.

I think one thing missing here is the whole issue of what should we measure around cost to help tell that story and to help the Baton Rouge’s of the country to realize that we do have limited resources and a lot of this is about where we are willing to invest them and more intentionally want them to go. Somehow in this discussion, cost has to be built in.

MR. ROULIER: I think I am hearing you suggest it is not just an abstract notion of cost and prevention, but what is granular enough that allows Baton Rouge to really tell the story around what the opportunity costs of not investing in particular areas.

PARTICIPANT: Our group had some thoughts on some additional domains to potentially include. One was the impact of incarceration on communities. It could potentially be something that fell into that social and economic group. It is different from violent crime, but understanding the percentage of people with a history of incarceration in a community is very important if you are talking about issues related to communities’ enfranchisement. There are so many intersections with these different factors here, but it really is a bit distinct. It is something that we could consider.

We also thought that looking at some of the clinical care measures, thinking about quality of care, adding medical error in addition to preventable hospitalizations could be an example of a metric in particular.

We were in agreement that thinking about reproductive health and also unintended pregnancies could be another indicator of interest. And for environmental exposure, someone else had talked about this. There are several areas that we could consider including as for metrics, indoor air quality, outdoor air quality, drinking water, sighting, waste disposal and sanitation and pesticide. Understanding that we would – we are looking for a certain data set, maybe perhaps minimum data set, but those are just some things that we could consider.

We also talked about social cohesion and civic engagement if there are ways to consider that. For all of these measures and we are talking about data collection and accessing data and reporting on data, making sure that we are doing things in a culturally appropriate way and things that are done. And we are looking at services and making sure that they are being delivered in a culturally-relevant manner.

MR. ROULIER: Thank you. Some potential metrics and some implications for even some potential domains of rounding those out.

PARTICIPANT: Our table had similar comments on additional domains and metrics in the areas of environmental and also social cohesion and community. With environmental, related to what was just said, EPA has an index called the EJ, Environmental Justice Screening Tool. That has 12 environmental indicators as well as six demographic. Thinking about the domains for this proposed roadmap beyond air quality, there are six that are in the EPA EJSCREEN Tool relating to water and proximity to contaminated sites.

And the other one that we talked about specifically was a lead paint indicator. It has percent of housing units built pre-1960 from the American Community Survey. And our table talked about that one in particular because it cross cuts things like school performance and other metrics.

PARTICIPANT: A few others especially in social cohesion. We also talked about the broader collective efficacy, community resilience and social capital. And then within education as well, we had some concerns that especially if we just focused on high school graduation, it might be too late. It might be nice to some earlier indicators like third-grade reading readiness and absenteeism as well.

MR. ROULIER: While we are on this train of thought, any other —

DR. KING: Ray King. Just one more comment. In talking with the groups for our project with their potential collaborators, HUD, Department of Education, and CDC, one of the things that came up is they are all interested in walkability. Finding these indicators or domains or measures that cross the different agencies as well as – not only does it cross, but it is also a measure that takes into account physical activity, built environment. It is kind of these win-win type measures that – and I think EPA is currently developing an indicator for walkability with CDC as well. But they all are interested in it. I think sustainability use increases as we consider things like that.

PARTICIPANT: We had a similar discussion about social determinants or social cohesion, incarceration, et cetera. But one thing we talked about was collapsing access to care and quality of care and then renaming that to be access to health services. Get away from the clinics since we are supposed to avoiding hospitals. They are really going upstream.

MR. ROULIER: Thank you for that reminder. I hear that as I eavesdropped in all of your groups. I am glad that you named that. Any other thoughts for the moment before break?

DR. PHILLIPS: Bob Phillips with the American Board of Family Medicine. I just want to make a plea here. I have studied the UK’s index of deprivation, the New Zealand index and Virginia is I think very elegant too. What they all share is that they have taken these measures, these elements and empirically tested them against the outcomes. How much do these contribute to the outcomes of life expectancy and well-being? If you cannot measure one of them, what do you lose? If you want to load other factors in because you have them in certain communities, what do they contribute to understanding? That is really important because it does help you figure out what you actually need to measure and what are you missing if you lose a data element and how much should you work to improve the quality of your data collection?

The second thing it lets you do is take those outcomes and look across the communities and say now that we know how to assess risk against these outcomes, how are the communities actually doing? If we just look at the outcome measure, are they doing better or worse than expected? If they are doing better, what is it about the community that seems to be working to make them do better than expected? That actually helps you start to target what are the things we should be doing to overcome what we are measuring in terms of risk. What is this community doing that seems to be overcoming their expected outcomes? What is this community doing that is predicting their less than expected outcomes? How can we work at the community level to do the work we need to do to overcome what we are measuring as the expected risk? That is my plea. It is not just about measuring things, but how do we actually test to understand and then measure against what communities are actually experiencing.

MR. ROULIER: How we are using data, I hear a little bit of, and how do we learn from each other across communities.

MR. ALLEN: I just have a quick thing to add. I know that somewhere the mayor of Baton Rouge got a warm fuzzy feeling that we are all taking about Baton Rouge. If we are really trying to go through this exercise to be useful to multi-sectoral collaborations and coalitions across the country and what they can get out of it, maybe we ought to have more input from them as to what they need and what they want because we are a mid-sized city in the Deep South. This is a big country. And our needs and wants are not necessarily the same as everybody else’s.

I know from our work with the National League of Cities that there are some problems that other communities are facing that are not on our radar and vice versa because of the different makeup of the population and the situation there. I would hate for us to go down this road and have me be the only person who says I represent a multi-sectoral collaboration. Here is what we are trying to do without maybe necessarily understanding what other communities want out of this too so that it is at the end useful to that end user.

MS. TROCCHIO: One issue that occurs to me is that I don’t see any of these domains or metrics that are getting at the needs of the old-old and their caregivers. I have looked at a lot of community health needs assessment and the needs of the elderly and those taking care of them at home almost never come up as a need and yet we know it is out there. I don’t know if Denise’s ARP measures – I cannot remember if they captured that. But they are kind of hidden. You have to dig to get what their needs are, but they can be pretty significant.

MR. ROULIER: Thank you. And, again, from Catholic Health Association. I think a lot of folks know you, but your name again is?

MS. TROCCHIO: Julie Trocchio with Catholic Health Association.

DR. BRONSON: Jennifer Bronson, Department of Justice. One thing I have not heard mentioned and I realize that this could be controversial and that it is opening a whole can of worms. Access to firearms and gun violence is a huge problem in our communities and our nation.

To tell a little anecdote, I work collegially with a man whose daughter was killed in Sandy Hook. He said we moved to Connecticut because it was safe. We looked at all the metrics. It was walkable. It was this. It was that. We thought we had done the right thing and my daughter goes to school and gets shot. Again, I realize that this is a much bigger political issue, but if there is somewhere please that we could put this issue, I think it is absolutely vital and crucial to community health and well-being all the way across the board.

MR. ROULIER: Thank you for that. Let’s take a break. Give our brains a little bit of a rest and then we are going to come back with a fed perspective and continue to loop back to this. We have a little bit more time this afternoon to drill into the domains. Just take about ten minutes and be back at your seats please.


MR. ROULIER: The one thing that we decided not to do is to say we are not leaving this room until we come up with consensus on the final domains. In all seriousness, I don’t think that was really the expectation. I just want to acknowledge and appreciate the spirit of us wrestling with and handling some ambiguity, which I think is to be expected when we are dealing with this much complexity. I won’t try to force consensus, but I think it is worth reminding. I would be curious that in many ways I think there is some clarity around some of the pieces that folks were saying that there is probably a number of different ways of lenses by which to look at the domains here, which includes a life continuum or life course perspective. Certainly an equity perspective is indispensable here that is maybe not as explicit, looking at what a community can do, how do we signal how a community can do this so that particular lens.

I heard a number of you wondering if ironically or maybe not ironically that actually having fewer and a broader set of measures night allow us to navigate into the complexity of this and actually might reach some of the community-level measures in different ways.

It seems like there is real clarity again on what is needed, which is really to support multi-sector collaboratives to certainly assess. I think this is where there are some differences in where people see priorities is beyond just assessment but actually provide measures and support for them to do improvement work. I don’t hear strong disagreements, but clearly to support multi-sector collaboratives in some ways. One of the big opportunities, the way this day is different than it has been before is because we have access to data that we have not had before and there is a need for it in a way that we have never needed it before. And whatever those domains are that provide pathways to helping multi-sector collaboratives and all the different things that they are doing because Baton Rouge is that just one community is really what is most important. It is providing those local, regional communities with access to these measures to do change work to better understand themselves.

Again, it seems like a lot of really – the other kind of feedback that I think I just noted is that this invariably with HHS and many of you started with a little bit more of a patina of health and that we need to make sure that this does not feel to health. There is probably a number of different ways that that could happen within these measures and some really good ideas obviously about some potential metrics we might add.

Before I get into the fed perspective, I don’t know if there is anything else you all want to name that is again sticking with you right now before we jump into some other exercises.

DR. REMINGTON: I just wanted to comment. Someone in our group brought up – I think it was Ed that when we showed the slide of the Institute of Medicine – I think it is the logic model for population health that you had resources and inputs, conditions and then health outcomes. There was a comment that this robust set of measures would not include those resources and inputs, policies and programs. But then when you read the examples in the handout, there are many places where it says, for example, it lists in the examples and policies that relate to and policies that relate to these other aspects. I think it is an important measure or I should say it is an important domain to think about measuring things that we do collectively as opposed to just the determinants and the health outcomes.

MR. ROULIER: What would you name that domain?

DR. REMINGTON: Besides things we do? I like community behaviors. I think the idea of – we have measures of personal behaviors or individual behaviors. These are community behaviors or community responsibility as oppose to individual responsibility. You could call it programs and policies. You could call it inputs. Things we do.

MR. ROULIER: This kind of ties together this idea of this being a little bit too individual focused, but what do we collectively do. What is this asset orientation to kind of how we start to create communities, et cetera?

DR. REMINGTON: I think the challenge is HHS tends to have individual level data that we build back up. This might have to be data that you would collect from communities de novo if it is not already in existing vital stats or census or other measures.

MR. ROULIER: So not readily available, but really important potentially.

DR. KING: One of the things that I promised the stakeholders that I would mention that every one of them brought up was the importance of mental health. Even if statistically it is not as important as vascular disease or diabetes that the citizens are actually more concerned with that than any other thing. How we wrestle with that I don’t know. But I just wanted to throw that out there.

MR. ROULIER: To make sure that that piece is not lost.

DR. LEVINE: To follow up to Bob Phillips’ comments about community and community action we were talking about. For those who are familiar with – if you look at communities that are actually doing well when they may not have all of the ingredients for opportunity, figure out how not only what it is – implement, utilize – I think gets a lot to the point —

DR. COHEN: I just want to add. There is going to be an interactive exercise later where we are going to record some answer to specific stuff, but if there is any take-a-way, bottom lines like you are providing now that you want to make sure that are incorporated as we pull all this together, write them on the flip charts and we will have a record of them. If there is anything that you said earlier that you have not had a chance to paste up or any other ideas that you want us to be aware of, please use the flip charts as a place to record these great ideas.

MR. ROULIER: We are going to have one more exercise here in a moment. We are going to hear some federal perspectives, but I just wanted to see if there is anything that was bubbling up over break.

PARTICIPANT: One other thing that came up was I guess also following up on a comment earlier about how we use the data and if we really can conceptualize community-level well-being as a multi-dimensional community-level measure or assessment and think about the impact of all these individual community behaviors and which of these has the greatest impact. Where do we get the most value as far as creating the greatest amount of well-being with specific behaviors or interventions?

MR. ROULIER: Building a little bit off of what I think Bob and Marissa are saying.

DR. MAYS: I want to really get us to seriously think about what Patrick was saying. This notion of what we do and think about it in terms of going from – there is a lot of data on individual level, but it is at the level of what the ways in which other people shape your behavior. We focus on telling an individual do something, but there is stigma on behavior change. There is peer pressure. There is all this stuff that probably can move the dial more if we think about it at the level of what others influence you to do and not just as individuals. This is why campaigns work. This is why taxes work. This is why certain kinds of policies work. I really think if – to me, that is one of the biggest take-a-ways is to say maybe we should not be focusing on what to do about all this individual level data, but we should be focusing on how to put group data around that individual level data.

MR. ROULIER: We are going to step back for a minute. We have invited a couple of our federal leaders to share their thoughts on what is strikingly significant about this conversation. Implications for how you think about your work or other things that you are doing that are related to this.

Do you want to kick us off, Jen?

Agenda Item: Reflections from the Federal Perspective

MS. DAY: Hi. I am Jennifer Day. I am with the Census Bureau. I have been at the Census Bureau for over 25 years. I have worked pretty much my entire career mostly on the individual level. In other words, population people, characteristics people. We have this other side of the Census Bureau that deals with the economic – where are the hospitals and that kind of thing. We try to at times put these things together because they make much more sense.

I think what I am hearing today is there is just a whole cadre of ideas here and even more than what is on the wall and how do we make sure we capture the important things and be able to still tell a story and be able to use what resources we have already in existence and really capitalize on that and then where are the gaps. Where would we need the federal perspective to be able to say we are going to collect this kind of stuff or maybe there is administrative data that we have that we could use to answer some of these questions or maybe go down to the community level where we put some kind of framework out there where communities can look within their own assets and try to figure out what they should be measuring in there.

We have all kinds of great ideas going on here, but it is going to take quite a bit to get to what is it really we are trying to – what is the whole meaning of this. Maybe it is more flexible than that. Maybe it is something that we start with this framework and then as time goes on, things change. We know things change quickly, but be able to really capitalize on what we have already in existence I think would be very helpful.

I think people have mentioned this. We have a lot of things already at the Census Bureau and CDC and CHS, et cetera. And sometimes it is really difficult to get to them or to even know you put this with this and you could up with a really interesting group.

MR. ROULIER: Thanks. Again, I just hear a couple of voices and invite others to join in or even ask questions.

MR. HOMER: My name is Charlie Homer. I work at in HHS in the Office of the Assistant Secretary for Planning and Evaluation and particularly I lead the office focused on human services policy. I have had a number of people come up to me and say what are human services anyhow. And basically those are those services which are directly intended to affect the conditions of the most vulnerable populations and reduce the harm associated with poverty. Those programs still exist within Health and Human Services. To some extent, that is why I am so excited about this opportunity. That same comment about the Willie Sutton theory.

I am a pediatrician and I am relatively new government service and working with my dedicated colleagues in the human services field. They are acutely aware of the extent to which there are grossly inadequate federal resources or resources at any level allocated to addressing the conditions of poverty. For example, we are talking about assessing housing stability. We are talking about access to food. We are talking about having inadequate income. You may well know that, for example, only 15 percent of those people who are eligible for childcare vouchers, for example, actually receive them. Similarly, you may know that less than 25 percent of TANF, Temporary Assistance for Needy Families, dollars actually goes to provide cash benefits and fewer than 25 percent of women who are eligible for those services receive them.

The excitement here is that we are identifying and pointing a bright light finally on in fact these are the social determinants that influence outcomes. And I think the hope on the human services side is since health, public health and health care don’t seem to be stigmatized in quite the same way as services for poor people are, perhaps this will be a vehicle by creating metrics that will actually finally enable us to get the public will to actually address these underlying conditions. That is why I am personally extremely excited to see these kinds of measurements and I think several of my colleagues as they begin to understand the levers that this could unleash, it could really result in substantial improvement. I just wanted to give that framework as to why now and why this may be different.

If I could just then segue onto another. There is an incredible amount of activity happening at the community level. I have not heard mention in any of the conversations the very substantial amount of federal attention played to the White House driven place-based initiatives, modeled initially on the Harlem Children’s Zone. Those include promised neighborhoods. They include promised zones. They include many other programs. All of those programs have been required to establish measures. They have all been grappling with this. Very few of them have identified health measures as part of them.

Through that process, we have learned that there are actually local data intermediaries that are very savvy about aggregating administrative data at the community level. It would be critically important for us to connect to them. There are groups like actionable intelligence for social policy is a group at the University of Pennsylvania. There is the National Neighborhood Indicators Project that the Urban Institute runs. I think we should be connecting to those entities.

I would say that ASPE – my office has contracted a project that Urban Institute is finishing up, which has already published a data inventory for measures that can be used at a community level and that report will also include a series of recommendations for what needs to happen at both federal and local policy.

Some of that includes building capacity as was mentioned at the local level to be able to use these data, building relationships with these skilled intermediaries, many of whom are at local universities that can do that as well as things that we the federal government need to do to make our data more available and available across sectors. More to follow that document is soon to enter clearance. It is not quite available for the public. Although the inventory is readily available.

DR. WHELAN: Ellen-Marie Whelan and I am from CMS. I have been at the Innovation Center now for four and a half years and for the past six months or so I am the chief population health officer over at Medicaid. So excited about the work that we are doing here and I guess just to start to continue to pay homage to the work that has been done before.

I started a clinic in the crack capital of Philadelphia back in the late ‘90s. At that point, the kind of care we were delivering was called community oriented primary care, which I am sure if very familiar to lots of folks.

At the Innovation Center, we often say that what we are looking at now is not necessarily the idea is new. What is new is that we are paying differently for it. We know that a lot of these ideas have been out here for a long time.

I always when I have the opportunity, I did a post-doc with Barbara Starfield, who was one of the first folks that tied primary care with social determinants. She is not with us anymore. I like to tip my hat to her and the work that folks like her have done.

Coming from CMS, we think a lot – what is different now? This kind of work has been going on for a long time. What is different now? What is different is we are paying for it differently. As we move from fee for service to value-based care, obviously to pay for value, we have to measure what worked and what did not work. I think that is the critical importance of better understanding what are the metrics that we are using and how we are going to pay for it. Because we know that people will play to the test. We pick certain metrics. We will probably see them improve so how important it is to make sure that in the mix there are some of these things that we are measuring that we might be able to look to improvement.

I think examples have been – we have heard from clinicians. We have heard from states that are willing and interested in looking at measuring some of these things. Pediatric provides. I have been coordinating the pediatric portfolio at CMS for the past four years. We have heard providers say I would love to measure school readiness, but I don’t know what metric to use and there is no single metric. They go okay, fine. I am not going to do it. We are hearing it from states as well.

We have seen now with the change in payment movement towards housing, for example. Medicaid is a flexible payment. There are lots of opportunities there. We would like to see states take better advantage of that.

We have seen states that have – New York, for example, is looking at housing. And Medicaid for a long time have paid for supportive services and housing. In fact, for our long-term services and supports, we are just now in the first year of having more of those services being delivered at home than they are in the institution, which is the direction we want it to go. We don’t really know how to measure success there though. I think better understanding what possibly a core data set could be. And I think that is important for us because we want to be able to compare across different sites. What might be a single core set?

I think about what the role of the federal government is and I think about when the train tracks – the federal government’s role when the trains first got started was to say the train tracks need to be 14 inches apart. Put whatever train you want on there, but we have to set the guidelines for the 14 inches apart. And then we allow folks to pick their – identify for their community. And what role do we have especially as payers to say what might be a core set where we can compare what is working in one state or one community and then allow some extra variation, but let’s try to get to some that we can actually put into place.

I think along the lines of paying for it – we had a discussion at our table is really understanding why a measure was developed and then what we are using it for. Not every measure should be used for payment. Some are for quality improvement. Some are for research. Helping us understand and make sure that we are acknowledging that a certain metric may have been designed for this, does not mean it should be used then for payment.

I think there have been instances where we did not have a measure. We used one as a proxy and we never moved from it. It became the thing that we kept using there. We want to make sure that once we finally set that and what it is for payment, that is in fact something that a provider can make a change and look to measure success.

Just last. When we have been working with these providers and states, they have said over and over again that if you can tell us which measures to use, we would be really happy to do that. Clinicians on the ground do a great job providing care. They should not have to know what measures are. They really want someone to help them say here is the class. Here is what you can do and move forward.

PARTICIPANT: Great to meet you as a fellow fed. I have always thought the Innovation Center at CMS is one of the greatest things and the concepts of testing new payment models, et cetera. It is so exciting to see CMS starting to focus more on population health, et cetera.

I am curious. Based on a lot of the discussion we have had today, do you foresee or is there any room that the Innovation Center could maybe partner with Department of Education or Housing? You said that Medicaid already covers some housing things. But with let’s say just education on the issue of school readiness. Does Education have some community-based grants and could we somehow do an innovation project that involves health and school readiness?

DR. WHELAN: I think there are lots of opportunities there. Again, I have been doing mostly pediatrics. We work closely with HRSA and the Department of Maternal Child Health. There was an instance there where we funding something to look at reduce prematurity and they were doing home visits. We then helped to fund and enhance their evaluation so that they could evaluate looking for that prematurity aspect. I think yes is the short answer. We are trying to do it. We work closely with AHRQ so where there is measure development and they found a good measure, can we take that and hand it to some other providers and say here is something that at least have been through the ringer at some point.

We are also working with ACF, the Agency for Children and Families, to see where there are opportunities for having Medicaid data be linked to social services data. I think yes – and not just at the Innovation Center. I think this is CMS generally. HRSA, ASPE. We are looking wherever – Charlie and I actually talk. These silos are not as high sometimes.

And the other thing is ideas. We have not thought of it all. We would love to hear from folks. If you think that there are other opportunities that we might be able to bring forces together to look at this.

PARTICIPANT: Specifically, I was asking about going outside of HHS.

DR. WHELAN: We have our long-term services and support. They have biweekly meetings with HUD to see where there are opportunities there. With the school, there was a rule that just got reversed. The Free Care Act that showed that Medicaid could reimburse for services that they hadn’t officially been funded to do and that had implications in the school-based settings so Medicaid could pay for some school-based settings. We work with the Department of Education there too. Again, we would look for opportunities where they could be.

DR. ZARTARIAN: Hi. Valerie Zartarian with the Environmental Protection Agency. I am in the Office of Research and Development and specially our Sustainable and Healthy Communities Research Program. I had a couple of comments on are there other domains to consider, how can domains be used and then I will turn it over to my EPA colleague, Intak(?), who had a few other things to add.

Earlier I mentioned the EJSCREEN, Environmental Justice Screening Index and some other environmental and demographic indicators that might be considered. Our Office of Research and Development has been developing different indicators and indices related to health and well-being. In addition to that, one that I mentioned before, Office of Environmental Justice. Those include the Environmental Quality Index. There is a Human Wellbeing Index, a Tribal Wellbeing Index, a Climate Resilience Index, and the EPA’s report on the environment that has some other metrics and indicators that might be helpful.

Specifically, I will mention the Human Wellbeing Index has considered eight domains of well-being described by 27 indicators. You can just do an Internet search to look up EPA HWBI if you want information on that.

In terms of the question of how can these domains be used, I missed some of the earlier conversations so forgive me if Health Impact Assessment already came up. We had some conversation at our table about there are so many variables. Can we focus it by keeping focus on specific community decisions and then figuring out what are the key indicators and indices and data needs for those specific decisions? That got me thinking about the work that EPA has been doing and I know CDC and many others working in the area of HIA, Health Impact Assessment. I really think that these domains and the data that we are talking about here today can help better quantify the assessment step of HIAs and also the monitoring and evaluation step of HIAs, which oftentimes are qualitative because of the lack of local scale data.

With that, I will turn it over to my colleague Intak who wanted to mention a few other things.

MR. HAN: Thank you, Valerie. Hi. I am Intak Han(phonetic). I work at EPA. Both Valerie and I represent the Office of Research and Development.

Recently, our assistant administrator Tom Burke said that ORD EPA research becomes meaningful when it translates to actionable items to solve communities and public health.

As Valerie mentioned, under our Sustainable and Healthy Communities National Research Program, Valerie mentioned a lot of in-house efforts relevant to what we are talking about here today. I work for Center for Environmental Research where we actually fund extramural research grants to universities and small businesses. I am in charge of EJ Science, Environmental Justice and Health Disparities Research Science.

I really thank you for inviting EPA to be part of it. I really appreciate this discussion. I don’t feel the need to add one more domain to already robust domains. I feel like I would like to share with you. Recently, when we funded our academy researchers, we specifically asked them, the professors, to involve local communities, the universities and involve community leaders and the citizens in the communities in the EJ and Environmental Health Service. That includes of course the obvious vulnerable populations like tribal communities and children – communities and all that.

But every community is so interested in health and the environment. You cannot imagine how eager they are to participate in the air monitoring for their community or diabetes studies or healthy school buildings studies. The citizens are so eager. What often we refer to as a citizen science, we are realizing that the communities and individuals that make up the communities is they really feel for the first time they do have a stake in their community, their well-being, their health. They can do something about it. That is extremely important. I know a gentleman from Louisiana already mentioned. Some of you mentioned the social cohesion. That is extremely valuable to all communities.

The last thing is that when they feel that they can – not do something, but they can actually participate in monitoring air quality, indoor air quality, their home environment, their healthy school building projects. They already feel the sense of their health and well-being improved. It is psychological. It is more than physical, physiological, more than chemical exposure. We all know this in this room. But I would just like to emphasize that. Thank you so much.

MR. ROULIER: Thank you. Again, a reminder of the process is a product in some ways. We are in a whole different world of where we are seeing the role of residents, community members in new ways. I know working a little bit on the KP CHNA, which is all the CHNA.org where actually this week working on collecting data around tree canopy and really looking at climate change measures within that kind of default CHNA. There is enormous interest around this intersection of natural environment and health. Really glad that you are here.

MS. MARUSCHAK: Hi. I am Laura Maruschak with the Bureau of Justice Statistics, part of the Department of Justice. Just a big thank you for inviting us to come. A colleague received the invitation and passed it along to Jennifer and myself.

I was really excited when I looked over the materials for this meeting. It brought me back about five years and actually in this same exact room when BJ partnered with the National Center for Health Statistics to bring together a group of correctional heath care experts to talk about data gaps in our field and talk about emerging issues and what do we need to be measuring in our correctional population to assess and track change and level of the health in our correctional settings. I would say incarcerated population. But we even went broader and thought about the whole criminal justice spectrum. When we said health, we did not just think physical thought, behavioral thought, substance abuse, mental illness like everything and took on a big project.

We started thinking about what are the domains. What do we need to measure? What are the indicators? From that came a project where we have been working with a visiting fellow, Ingrid Binwswanger, who has been helping us to develop a framework for data collections on correctional health and health care, identifying key statistics as a statistical agency. We like to measures these key statistics. What do we need to be measuring?

This is all very familiar and I thought this would be very helpful to what we are doing. If you think about your communities, maybe you could think of incarcerated population as a community. They are a group of people who are together. And what do we need to be measuring in this group to assess their health and health care?

I just thought it would be really interesting to come, to listen, and to hear. It is also important for us as a statistical agency to comport with some of the general population statistics. If we learn if this work is going on and that a set of medical indicators have been identified and then BJS can replicate those in some of our surveys then we can make some comparisons with the general population. That is all how you guys can be helpful to us, but I am thinking how could we be helpful to you. I would encourage at hearing what could the Department of Justice do.

We have people who are confined, in prisons for a longer period of time and jails for shorter periods of time. They are coming back into your communities. Those in prison. Someone mentioned the impact of incarceration on health. It could maybe have a positive impact on health if they come into the prison systems, get tested, get treated or maybe come back healthier. For those who come in and out of jail, maybe don’t have as much time to get the treatment, to get diagnosed, but they are coming back into your community. There are sick folks. There are people who have problems and there are people who maybe aren’t being captured in the traditional household surveys. They might be living in a house, but if they are not a resident of that household, they are not being captured. You have that population, that group of people. Just ideas on how that population might be unique in your community and how you might capture data on thinking about how you might capture data on those folks.

I guess back to how it helps us too is if this has developed communities become healthier, a lot of the determinants of health are determinants that are linked to crime and arrest and incarceration. If they become healthier, we maybe reduce the crime or reduce our incarcerated populations or community corrections populations. I would encourage anyone to come to talk with us.

Just one last thing. Thinking about a mission or goal of our federal statistical agency of collecting and analyzing and disseminating data where federal is focused entirely on national level statistics. We do some state with our – we do think about local level as well, but it obviously becomes a cost issue. We don’t always whittle down to that level. But I hope that at that national or even state level that our data could be helpful.

MR. ROULIER: Thank you for putting that out there. It would be interesting to do that with all the agencies. That maybe something that we think about. What does that more systematically look like? But it is great that you see value and some relevance in this. I think you started to answer your question in some ways where there might be some real value added to you all and vice versa.

Did we have another federal perspective or other kind of thoughts or questions that someone wants to put out there before we do one last dip into the roadmap?

MS. HUNTER: Good afternoon. My name is Mildred Hunter. I am the regional coordinator for the Office of Minority Health, Office of the Assistant Secretary for Health, but also located in the Office of the Assistant Secretary for Health in the regional office in Region 5, which includes Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. There are ten of us around the country. We are resources in that there are state offices of minority health in many of the states that are willing and can be a resource and can help connect you to community groups.

I would like to add and I think Rashita earlier mentioned in terms of cultural considerations, I would also ask that you also include in that consideration of language as well that that be added.

MR. ROULIER: Things like linguistically isolated and some other specific questions around language.

MS. HUNTER: Exactly. Working with various communities groups. As I have mentioned as Dr. Mays mentioned earlier in terms of what we call statistically insignificant populations, why the science – they may be statistically insignificant. As we look at their health status then we need to look at it from a public health approach.

MR. ROTHWELL: First of all, thank you all for coming. I am Charlie Rothwell. I work at the National Center for Health Statistics. I have worked in health data now for well over four decades. I have seen these types of gatherings before and I hope we make something of this frankly.

Several things to consider. One is again what can the federal government do and when should we get out of the way. I think in the past there was a program that NCHS did that supported activities at the state and local level. That died out basically because there wasn’t anything in it for us directly. That is what we have to think about as sustainability.

But I do think that one of the things where we could help is to provide community guidance as far as how to use indicators. If we cannot provide you that information from a national perspective, at least we can help you provide that type of – how to use these indicators.

Number two is I think you have to decide whether you want to be able to measure yourself against other communities or whether you want actionable items in your community that you can work on. And maybe that you do two things. Maybe you have a set of indicators that you want to be measured across communities in your state or beyond that. And then you have some that are really politically things that you can do within your own community that can make a difference. That is a reason why I think these various domains make sense.

Tomorrow I am going to be going to a meeting that is going to be with all the federal statistical directors. You all should be giving us a challenge. What is it that we can do for you? It was mentioned earlier I think by Gib about the American Community Survey, not that I have any direct control over that. That is the Census. But I am one of three or four reviewers of what the content is in that survey. It would be nice to know what is needed overall in that survey that we could perhaps use. It takes a long time to make changes in that type of activity.

Just recently, I was asked if NCHS should be involved in geocoding vital records. Initially, I said no because we had no use for that at NCHS. I am being frank with you. And folks came back. Robert Wood Johnson Foundation, Trish and several other people and said would you please reconsider. They made their very strong case. Hopefully, we are going to be doing that and we will see how it works. But you have to make the case to us or we are not going to take the next step.

My recommendation is that you have some actionable items that at least at the federal end that we can work on. I am not making a plea to expand my surveys or anything of that nature because frankly the money is not there.

But what is it that we can do? How can we maybe add on to our surveys from an Internet perspective that maybe cost justifiable that we could do that might be helpful to you? How could we provide a framework for local surveys that would be helpful to you? Those are the types of things that I think that maybe the federal government could be helpful with.

Finally, don’t feel bad about not having a whole lot of data. Healthy People have 1200 indicators. Now if you think we know how to direct health care services because of 1200 indicators, give me a break. We have too many of them. What we ought to be doing is saying what is it that we believe at the department level. What is the responsibility of NIH? What is the responsibility of FDA? What is the responsibility of CDC within that? We need to get there. Whatever you do, don’t develop too many of these things. Thank you very much.

Agenda Item: Working Session: Drilling Down

MR. ROULIER: Thank you. Good advice and an interesting invitation. Did we miss anybody else that was planning on speaking?

Remember how we said we are going to make this up as we were going towards the end of our time here? I am going to suggest that we use the remaining amount of our mental energy just to name where we are, which is still obviously wrestling with what those domains are, but also recognizing that there is increasing clarity on at least what the opportunity is, what we are trying to provide and support multi-sector collaboratives in. That may be doing a little bit, but there is not enough of it.

At the beginning of the day, Bill put out this roadmap. I think this roadmap had some assumptions about where we might be in this process, but we were also very open to that. This roadmap could go in a number of different directions. I think we used the term strategic advisors. You could use the term consultant. Gib was calling himself a consultant earlier. I am wondering if you could kind of recognizing where we are right now in the next 6 months to 12 months. What is our roadmap? It may be building off some of these elements and defining those maybe. Maybe there are some other pieces. You talked about ACS, kind of an inventory of what is out there, connecting with some of the other kind of local efforts. There are a number of things that you started to name. But I wonder if you could just spend 20 minutes just saying strategic advisor consultant hat on. What would you advise the smaller team to make sure that this is a conversation that actually materializes into something significant that starts to realize some of the aspirations that have been surfaced here?

I know it is a really broad question. But I am just going to allow you to take this where you will in the next to 6 to 12 months. If it is helpful to look at this roadmap, great, but it is really the notion of the roadmap. What would help the group to really move forward in some meaningful ways?

DR. COHEN: A couple minor additions. One, if you did not check in before and have a badge, but just showed up, please make sure you sign in at the back of the room so we can keep you involved in the conversation.

Second, this has been a phenomenal day. It is not exactly the roach motel, but now that you are in the community, it might be difficult for you to get out. We might be calling on you in the future to help as we move down this road. The bus is really big. Hopefully, we have interested you enough today so you will want to get back on the bus with us. We do need your help.

MR. ROULIER: We put the flip charts back. Muscle whatever energy. We will leave here earlier than planned. But if you could do your best thinking around whether those are questions, tasks, things that you think would really help us move the next 6 to 12 months. Make sense? We will check back in with you. Remaining ideas if you have them. Continue to put these flip charts up. Check back in with you between 15 and 20 minutes.

(Pause for Discussion)

Agenda Item: Report Outs: Filling in Roadmap Ideas

MR. ROULIER: This is going to be as close to a report out as I typically do. You don’t have to read every word that you have on there. There are a couple of things that just to remind you is that Susan – I don’t know if folks have met Susan. She is extraordinary at both capturing and synthesizing ideas. She is going to continue to help capture ideas. We are not going to capture everything on a large group. We will also take your flip charts.

I think we will just go around. In a couple of minutes, give us a high-level sense of what you think rea the potential next steps to help move us forward. If you have heard something already being mentioned then you can just click on it, but you don’t have to explain in detail. Let’s try to build off of what you have heard. I know some of you taken somewhat different approaches of this, which is great because I think we will capture a lot of good ideas.

I will go ahead and start in this corner if you all could model two or three minutes’ worth.

DR. STEAD: What we decided to do was – which is where we are today, we think it would be a good step – and do an environmental scan of the core domain that other sectors have such as transportation – the easiest way to create the multi-sector grid would actually be to adopt the main framework of another sector if it turned out to be applicable at this level. That was one idea.

In that process, we could do an inventory of the data that the other sectors already have at the neighborhood level that could be made accessible. It is possible that some of that data does not have the privacy constraints of some of the health data. That could maybe give us a jump forward.

We also think that whatever framework of core domains we come out with it should have a separate infographic for each of the views of life course determinant and equity so that everybody could see that it actually works for all three perspectives.

PARTICIPANT: One more, which is communication is ensuring early communication so that we have better continued feedback from the domains both for feedback input, but then also use.

MR. ROULIER: Virtuous cycle of what are we getting feedback and not just reporting back. That is great. Just out of curiosity, how many of you had some variation of an environmental scan of sorts like that?

DR. COHEN: Before I mentioned our couple, the issue — Bill just mentioned privacy and that issue came up earlier today. One of the things I forgot to mention is one of our most recent products of the national committee has been a toolkit for stewardship and privacy that focuses on strengthening community’s ability to deal with issues as more data are generated. It is available on our website. It is an incredible, valuable resource that has recently become available. As you do your community work or you talk with communities, I really recommend you go to the NCVHS website and locate this toolkit for stewardship and privacy.

Four things. One, create ongoing collaboration across federal statistical agencies around multi-sectorial measures and domains.

Two, task the Census and NCHS to develop technical support for communities around data collection and implementing community surveys.

Three, identify and develop a use case, which could be a domain or set of metrics to play out data definitions, collections and use. We suggest perhaps education and the variety of measures that we mentioned today that links to a variety of issues and domains.

The fourth is standardized domains for CHNAs, HIAs, and PHAB accreditation processes.

MR. ROULIER: If you hear something that you want to actually double click on, drill into, aren’t clear on, then I am going to leave it up to you to pause. Standardized domains though. Just around those templates around those particular functions. HIAs, CHNAs.

MS. HILL: Good afternoon. My name is Jessica Hill. I am from the Public Health Informatics Institute. It is my honor and responsibility to reflect the thoughts of the yellow table.

Our comments were really around just revisiting and clarifying where we are going on the road trip and then also some action items that we would recommend the group consider. The first was communicate why the value proposition to communities. It was brought up that we are at the end of an administration. Communities whom we have really identified as our partners in this, they need to know that this will continue.

Also, along those lines, be more clear about what we are going to do. I think that is kind of enumerated in the other points we said. We need to engage our other stakeholders and to be clear on what data already exists, similar to the environmental scan.

Also, a conscious decision could be made about if the domains are going to be health focused, more traditional clinical care related to health indicators or if they are going to focus on root causes of health outcomes. The current domain seemed to be a mix. There might be an opportunity to clarify the role this group could play.

Parsimony. Are these measures to help at the local level for local-level decision measures? If so, what already exists again around the environmental scan?

We would like some more clarity around the goal for is this around data collection. We heard there are needs around data collection or is it around metric development. What can our federal partners do?

Again, environmental scan and what data can be tapped into. We know that communities are already working so maybe use the examples of data they are already using and have those be examples to the rest of us.

And make more continuous measures and data available as much as possible so others can step in and make the data more useful. So guidance. We don’t need to over-engineer the data before we make it available to the public.

Focus on outcome data that are available on a timely basis.

MR. ROULIER: Thank you. Let’s keep going around the horn.

MS. POLIS: Hello. I am Rene Polis(phonetic) from NCHS. I am not going to read through all of ours. One of our main things was about creating an inventory.

But the other thing that I thought was really important that our group came up with was about methodologic developments to be clear about a methodology that is used for possibly for improved linkages, for appropriate waiting that might need to be done, developing composite variables, looking at data quality of reliability and validity. I think that is the main thing. Everything else kind of was already mentioned.

DR. SUAREZ: Our group, the green group – the first thing that we talked about was refinements to be done to the domains. We have heard a lot of input from a lot of people about the various domains that have been described, a lot of experiences with other domains. I think one of the first things in terms of next steps in the roadmap is to come to some refinement of this domain. Some of the domains that we see and people have expressed are more granular. Others are more high level. It seems like there are some hierarchical structuring of the domains in which there is some higher level domains, maybe some sub-domains within the large domains and then some metrics down the road.

Second, we need to have more health measures that are actionable. We talk a lot about the measures that are related to end of life, for example, death and life expectancy and things like that. We want to see more measures related to health conditions that can be acted upon while the person is alive ultimately and improve their health. That is one.

Another one is ask agencies to provide a mapping of the data that they have and the domains that they cover in those data structures. I know in Vickie’s work group of data access and use, it can provide some of the templates and some people at the table mentioned that there are some templates and some expectation in the content, for example, a data dictionary, meta-data about the data elements and all that. That is another action I think that we came up with.

Two more. One is examining community health assessment tools and frameworks such as the NACCHO framework that is being promoted and moved to 3000 state and local or county and local health departments to ensure that those align with ultimately the recommended domains that we come up with.

And then the fifth one is identify and prioritize work into short, medium, and long-term steps.

PARTICIPANT: Make more efficient use of what we have. We wanted to take up the charge or the opportunity that Charlie gave about geocoding birth and death records. We think a lot more could be done with those vital records data if they were geocoded.

And the second is we thought that the ACS. I am sorry that the Census person is not here any long. We think that if you could make access to the American Community Survey better, you actually cover probably at least half if not more than half of these domains here with that data down to the Census track or even below level.

The second thing was we wanted to suggest a new either category or domain related to something we termed community behavior or community responsibility or community action. Pick whatever you want to call it. That would actually be policies, programs and services that are available at the community level through city government, through city programs, through town programs, whatever.

Then the second thing we wanted to do was suggest the use of ratios to combine various measures. We have given some examples here of measures that might be useful just derived from, for example, the American Community Survey. For example, the health care costs – actually, those are not from the American Community Survey, but if you get health care cost divided by median income, it would give a sense of health care affordability or health care cost as a percent of income.

Secondly, percent of people eligible for support who actually receive it. This is along the lines of what was suggested here by the ASPE fellow. For example, percent of people in poverty who receive divided by the ratio of those who receive food stamps – the other way around. SNAP, for example. Or housing affordability is another, which are essentially median housing costs over median income or something like that.

Anything else from our group?

MR. ROULIER: Interesting stuff. Thank you.

DR. LINDE: Sarah Linde from HRSA and the red team. Our ideas are very much aligned with what has been said. Revisit and revise the domains based on today’s meeting.

One of our big recommendations is seeking additional stakeholder input and in particular from more local communities. Invite Andy again and then ten of his closest city buddies – from Baton Rouge. The other additional stakeholder input. The other federal departments maybe that we did not hear from today, specifically, housing, interior, education, transportation. Do they have anything comparable to the EPA Environmental Justice Index? All of those things I thought were great.

Get data at a more micro-level no matter what the topic or metric is. Encourage more transparent, innovative, and collaborative work among federal granting agencies that fund programs and projects in the communities and actually having tried to do something like this between HRSA and CDC. I am not sure that it is going to happen in any of our lifetimes to do it like HHS and Education and Transportation, but I would be delighted to be proved wrong on that. Can you strike that all from the record? That was my personal opinion. I was not speaking in an official capacity.

Explore opportunities to add local data to federal surveys and then making existing data tools like the Census more accessible. That is all.

MR. ROULIER: Wonderful. Everything struck that was supposed to be struck.

DR. BENJAMIN: We will jump on the bandwagon about identifying data and what level granularity. I think our issue I think was that you may not necessarily have to have a coherence around all the various levels of data you collect. In other words, you might have non-health data at zip code level or community level, lowest level you can get. Health data may only be available at a much higher level. It is okay to do that and put those data sets together and try to look at how you can improve health that way.

Secondly, I am not quite sure who is in charge for community health improvement at the federal level. We probably do need to identify at the federal level that is in charge. It does not necessarily have to be someone at HHS by the way.

Strengthening the agenda of the National Prevention Council. I think that is a nice place to begin thinking about creating healthy communities. Right now, their agenda is very much disease focused and kind of a collection of all the nice things that they are doing, but not really with a real agenda.

Convening the users of the data. We are all data folks, but people that actually get in the field and do this for a living each and every day an idea of trying to convene or at least trying to get around to all their meetings to try to convene them in place. And then doing some more pilot testing and figuring out how to take that information from people that are actually doing this right now. There are lots of places that are experimenting right now in trying to find more effective ways to disseminate it so that people can utilize and emulate that data over time and the programs over time.

MS. CHANG: I am Stella Chang from Truven Health Analytics. At our table, we talked about a number of concepts. The first one is having a core set of measures that all communities could report. The reason for that is that – we thought that having a core set and having a standard set would be a starting point. It would help bring some focus into what a community could do, what a community should do.

We also thought that in developing this core set, we need to take a pragmatic approach. We need to understand what data are commonly available. And from there I think the theme there is really around having some early success. Having some early success will encourage more use of data and from there even with the core data, you can start superimposing additional data. If we were starting with health data, for example, then you can bring on housing, et cetera. You take a stepwise approach.

Another concept that we discussed. We kind of skipped past into creating tools on this roadmap, assuming that the rest of you guys have solved all the problems in terms of data availability and quality so thank you very much. It is the idea of a portal, a data portal, an analytical portal. This is a place where there would be federal support down to the community level. And the idea there is that this portal could already have available all of these national-level data sets that we are talking about where there might not be enough awareness or even access at the community level, but then you also allow through this portal locally that communities could upload their own data. It is really up to them as the data owners in terms of how they want to report and to whom they want to report. It could be used locally or it could be shared with other communities. Those were two ideas that we had. I do have to confess that I was so busy —

MR. ROULIER: Thank you. Last and certainly not least.

MS. HERRING: Hi. I am Donna Herring from the National Quality Forum. Everyone already said all of our good ideas. We are going to jump on the data bandwagon. We talked a lot about having data available in one place and having the sources and inventories listed, not only national data, but county and local-level data. Also, the environmental scan we touched on and who is doing what. We really liked when Trinity presented, but a lot of people had never heard of that idea before. We thought just having a collection of stories or case studies such as Trinity to link community experiences would be really beneficial. Also, an exploration or a pilot of using EHRs to collect BRFSS’ type data and linking determinants of health to EHR data.

We also thought there should be an increased focus on social determinants. We thought that we should identify indicators that can move through multiple sectors so relevance beyond health such as HUD, EPA, DOJ, DOE, DOT, all the DO’s. There should be more of a federal focus on prevention and shift focus from solely outcomes more to prevention.

Agenda Item: Final Reflection and Next Steps

MR. ROULIER: Great. Anything you hear that disturbed you? Somewhat aligned in terms of the nature of some of the next steps. It seems like some of them were more process oriented and some of them were some ideas that we could maybe take advantage of right away or take advantage in some different ways. Obviously, we won’t name all the things and thankfully Susan captured them, but obviously this idea an environmental scan in some ways. I think closely related to that is how do we start to engage some of the stakeholders that are actually doing this work. There are a number of initiatives that are doing some of the things that we are talking about. A kind of a number of different things around collaboration and how this group or configuration of this group could support collaboration across some of the federal agencies including communication and a conduit for helping to have two-way communication there. A lot of methodological kind of pieces and some ratios that could be taken advantage of around existing data collection.

This idea of really pointing to the purpose of CHNAs, CHPs, things that communities are already doing in making that work better and more effective that adds considerable more value. I think just this notion of piloting, experimenting, kind of getting in the river a little bit on a number of fronts and kind of a common data portal that provides access to data at multiple levels.

It feels like there is definitely a confluence of what would be helpful despite the fact that we still need to consider how to conceptualize the framework. Is that fair?

Any questions or other kind of thoughts that come to mind as you have heard everybody name some? Have you hit your saturation point?

I was kind of curious. I joined the planning group I guess a couple of months ago and kind of where we would land on a day like this and knowing that this is really heady stuff and it is pretty complex. There is a lot of different ways of thinking about it. I feel like the charge, as we talked about earlier on, is to start to hone in on both some of the domains and how we might conceptualize that, but to provide obviously some direction on the roadmap and hopefully to tap into some collective wisdom. I feel like in many ways maybe despite even how we design some pieces of it, you all have tapped into some collective wisdom and just from me eavesdropping a little bit on your small group conversations. I know working with Community Commons and a lot of communities and working with some of you in this room, what you all are up to is extraordinarily important. What difference are we making at this particular time that we rest in? I think communities really desperately need some of the things that we are talking about.

I am encouraged to the fact that we can stay in this room and wrestle with a lot of ambiguity. I feel hopeful that there could be something that really comes to this conversation. I am thankful for the subcommittee for convening this and this committee not just convening, but to figure out how we start to really move this roadmap forward. Bill, Bruce, Denise and I guess – who else was part of the planning group here? Some of the planners are now here. Bill and Bruce, you were clearly part of the planning group and Denise obviously. Thank you for setting the table for I think a really important conversation.

Did you have any final thoughts, Bill or Bruce?

DR. STEAD: First, thank you for your effort, unbelievable job driving the ship today. It was a real privilege to be in the room with the intelligence and experience that each of you represent. I have not seen that kind of focus in this space. It is a privilege to be with you. Thanks to Rebecca and the staff team. Awesome job. I will give it to Bruce.

DR. COHEN: Again, thank you all for coming. It was a remarkable learning experience and very humbling for me. I thought we were a lot further along than we really are. But hopefully some clarity will emerge out of this chaos. Having everyone share their wisdom and perspectives is just an incredible beginning for this. Thank you all.

MR. ROULIER: Be careful of what you ask for. I think that wisdom is going to help direct the path in some productive ways.

MS. LOVE: You have heard them say — Bruce says you got on the bus or it is like the roach motel. You can come but you can never go. We will definitely be following up with you. I have heard people make requests for slides. There is now an NCVHS email box where if you have any follow up, you can just send it to that or if you don’t have that address, most of you should have gotten an email from that. You can just send it to me. But we will definitely do our best to keep this group connected. Who knows? We may have another one of these kinds of events or something virtual. Who knows? We would like to stay connected with you. We will do our best to do that. If there is anything that you think of tomorrow at 9 a.m. before your day starts, shoot us a note and we will include it in all of our deliberations.

DR. LINDE: Can we get a workshop participant contact list?

MS. LOVE: Yes.

DR. MAYS: I think one of the most exciting parts of being here today for us is that we had people who were outside our usual suspects like EPA and DOJ and others. I am going to actually put a real pitch out to say don’t leave us yet. I know when you go back, you have a big workload. But if you can stick with us to get us through this, we are hoping that what we develop will benefit both you and us. We really need our partners that are in other agencies outside of HHS in order to make this work. And the people.

MR. ROULIER: A great day. Thank you so much.

PARTICIPANT: On the agenda, it talked about upcoming meetings in February and June. Is that this group or is that another group?

DR. COHEN: That is the entire National Committee. We have not planned our next get together.

MR. ROULIER: Bruce, is it fair to say obviously drinking in a lot of this information synthesizing that people will get back – thanks for being here. Thanks for showing up. We will be in touch.

(Whereupon, at 4:30 p.m., the meeting adjourned.)