Review the paper down below and write a reflection paper on this approach to community wellbeing. IGNORE FINANCIALS. Do you believe it would be successful? How would this approach comb

Review the paper down below and write a reflection paper on this approach to community wellbeing. IGNORE FINANCIALS. Do you believe it would be successful? How would this approach combat SDOH in our community? If you don’t believe this approach would be successful, what approach would you suggest communities take to overcome SDOH? public health exercise

review the paper down below and write a reflection paper on this approach to community wellbeing. IGNORE FINANCIALS. Do you believe it would be successful? How would this approach combat SDOH in our community? If you don’t believe this approach would be successful, what approach would you suggest communities take to overcome SDOH?
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A Sustainable Strategy to Reduce Health Disparities, Improve the Health of an Entire State, and Accelerate the Evolution of Health Promotion Michael P. O?Donnell, MBA, MPH, PhD
The three pillars critical to improving the health of the residents of a state or nation are enhancing the social determinants of health, providing universal access to medical care and providing universal access to health promotion. The missing element for most large-scale efforts is providing universal access to health promotion, even though that may be the most cost-effective method to improve the health of the people of a state and even a nation. To do this well, we need to deliver a therapeutic dose of scientifically valid health behavior change strategies (summarized here in the AMSO Framework). Funding this effort is likely to cost 10 or more times the amount available through foundations, public charities and public health departments. Therefore, these groups need to focus a portion of their resources on mobilizing funding from entities that have sufficient resources and that will also benefit from improved health status of their constituents. The most important contribution of this paper may be the financial analysis that illustrates how sufficient resources might be mobilized and how the overall effort can be maintained by capturing a small portion of these funds to maintain internal operations indefinitely, and in the process, stimulate investments several hundred times the initial investment.? Michael P. O?Donnell, MBA, MPH, PhD
}EXECUTIVE SUMMARY 4 }INTRODUCTION 5 }KEY ELEMENTS IMPORTANT TO SUCCESS 7 ??Adding Universal Access to Health Promotion to the Critical Pillars of Population Health ?Social determinants of health ?Access to medical care ?Universal access to health promotion ?Relative importance of the three pillars ??Awareness, Motivation, Skills, Opportunity (AMSO) Framework ??Therapeutic Dose ??Engaging Geographic Communities and Social Networks ??Mobilizing Other Resources ?Funding ?Social mobilization }CONCEPTUAL SCENARIO ON SOURCES AND USES OF FUNDS 18 ??Sources of Funding ??Applications of Funding ?Employer internal ?Community ?Buying coalition ?Health plan ?Clinical ??Allocation of Funds to Different Applications for Different Employers and People Types }ILLUSTRATION FOR THE STATE OF COLORADO 21 ??Sources And Applications Of Funds In Colorado ?Sources of data ??Implementation Timetable and Budget in Colorado ?Feasibility study ?Early development ?Rollout, refinement, early maturity and maturity ?State wide spending and internal operating budget ?Seed funding from foundations ??Financial Sensitivity Analysis ??Economic Impact on Colorado }SUMMARY 32 }NEXT STEPS: SEIZE THE OPPORTUNITY 34 }APPENDICES 35 ??A. Notes from the Author ??B. ColoradoÕs Commitment to be the Healthiest State ??C. Employer Business Case for Health Promotion ??D. Feasibility Study Questions ??E. State Level Policy Options ??F. About the Author and the Art & Science of Health Promotion Institute }REFERENCES 46 }ENDORSEMENTS Back cover
EXECUTIVE SUMMARY Despite successes in improving the health of individuals in organizations through workplace health promotion programs, clinical treatments that have prevented the onset of diabetes and reversed heart disease through lifestyle change, and even in nationwide reductions in tobacco use, life expectancy in the United States declined slightly in 2015. Equally important, spending on medical care has reached a level that is not sustainable for individuals, employers, state governments or the federal government. This may be a critical time to expand the geographic focus of health promotion efforts to reach entire states, with the goal of providing universal access to all residents. This paper describes an approach to provide universal access to health promotion to all of the residents of an entire state. It is based on reviews of the literature on successful workplace and large community programs and interviews with people involved in ColoradoÕs effort to be the healthiest state in the nation. The approach builds on five key elements: 1) Improving individual lifestyle, 2) Deploying all the components of the Awareness, Motivation, Skills and Opportunities (AMSO) Framework, 3) Delivering each of the AMSO elements with sufficient intensity that they represent a therapeutic dose likely to have an impact, 4) Engaging geographic and social communities to embrace the goal of good health and serve as conduits to reach the full population and 5) Mobilizing other resources (MORe) from nontraditional sources to provide the social and political will and sufficient funds necessary to be successful. Data from the State of Colorado are used to illustrate how this approach can be applied at the state level, with an annual budget of $1.385 billion, representing $250 for each of the 5.54 million residents. Funding would be provided by employers motivated to control their own medical costs, health plans agreeing to support the effort on a breakeven basis, increased tobacco taxes, and tapping into existing health promotion services covered by Medicare and Medicaid. Interventions would be delivered through worksites, hospitals and clinics, schools and other community settings, supported by a buyerÕs coalition and reinforced by local and state policy changes. Seed funding of approximately $32 million is required over seven years, most likely from local and national foundations. This effort is projected to become self-sustaining in year seven by capturing 1% of the $6.97 billion in new spending on health promotion it is projected to stimulate over 11 years; this represents a return of 219 times the $32 million in seed funding invested by foundations, in addition to improving the health of residents, creating more than 10,000 new jobs and generating more than $60 million in new annual state income tax revenues. The primary purpose of this paper is to provoke active discussion among scholars, policy planners and practitioners on how this innovative approach could be implemented at the state or major metropolitan area level. The best outcome would be for a state or large metropolis to step forward and work toward implementing it. 4
INTRODUCTION Despite successes in improving the health of individuals in organizations through workplace health promotion programs1 clinical treatments,2,3 and even in nationwide reductions in tobacco use,4 life expectancy in the United States declined slightly in 2015.5 Equally important, spending on medical care has reached a level that is not sustainable for individuals, employers, state governments or the federal government. Annual medical care expenses for a family of four are estimated to be $26,944 6 and median per capita medical spending for the nation are estimated to be $10,345 in 2017.7 Both amounts represent a huge portion of the estimated household income of $68,260 and the per capita income of $29,979 for 2015.8 (Note income numbers for 2017 will not be available until 2019, but costs are expected to increase by approximately 3.5 % -4.0% annually). Medicaid is the largest budget item for many states and continues to be difficult to fund, and future federal medical spending is projected to reach a level that could literally implode the federal government during the lifetime of millennials.9 It may be possible to reduce medical cost increases at the individual, state and national level, and improve the health of the population by providing universal access to health promotion to all residents of a state. Focusing on the state level adds challenges and opportunities relative to focusing on individual organizations. The challenges include reaching greater numbers of people who are part of different social groups, most of which do not have a financial incentive to improve their health. The opportunities include working at a governing level that allows passage of state and local laws that support healthy lifestyle through policies related to food supply, transportation, zoning, education, health insurance regulation, taxation and shaping the built environment, as well as crafting delivery mechanisms that allow people to access programs and opportunities not only in their preferred learning style, but also from their preferred learning source. A core element in this approach is replicating the most effective workplace and clinical health promotion programs in all workplaces and clinical settings, and identifying the most effective strategies implemented in schools, faith communities, recreation enterprises and other community settings and replicating them in all communities throughout a state or major metropolitan area. For the purposes of this effort, health promotion is defined as Òthe art and science of helping people discover the synergies between their core passions and optimal health, enhancing their motivation to strive for optimal health, and supporting them in changing their lifestyle to move toward a state of optimal health. Optimal health is a dynamic balance of physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be facilitated through a combination of learning experiences that enhance awareness, increase motivation, and build skills and, most important, through the creation of opportunities that open access to environments that make positive health practices the easiest choice.Ó10 The conclusions and hypotheses in this white paper are based on reflecting on successes the author has seen in workplace and clinical settings through his direct involvement as the leader of the program, or indirect exposure as a consultant or reviewer over the span of several decades, intensive study of the peer reviewed literature in those areas, and collaborating with colleagues to produce five editions of Health Promotion in the Workplace.11 They also involve more intensive reviews of ambitious efforts to improve health in large communities, including but not limited to recent efforts in New York City, so well documented in Saving Gotham,12 as 5
well as classic efforts,13 and more decentralized statewide efforts,14,15 as well as more limited applications in smaller communities by Blue Zone.16 Finally, they involve close examination of ColoradoÕs effort to be the Healthiest State in the Nation17 including reviewing published materials and speaking with many of the people leading this effort. (See Appendix A for Notes from the Author on this effort, and Appendix B on ColoradoÕs efforts) This working paper starts with a review of five key elements important to success in a statewide effort, provides a conceptual review of how this approach might be funded at a state level, uses data from the State of Colorado to make the approach more tangible, and closes with reflections on next steps to move this approach forward. The Appendices provide additional backup detail. This paper is not a systematic review of the literature, a critique of the programs cited and it does not provide details on specific intervention strategies, although references are provided to many of these. The primary purpose of this paper is to provoke active discussion among scholars, policy planners and practitioners on how this innovative approach could be implemented at the state or major metropolitan area level. The best outcome would be for a state or large metropolis to step forward and work toward implementing it. 6
KEY ELEMENTS IMPORTANT TO SUCCESS A central recommendation of this paper is that successful efforts will require five core elements. This conclusion is evidence and experience informed, not empirically derived. All five elements have not been present in any one effort described in the literature, and the relative importance of one over the other has not been empirically tested. In fact, one of the five (Mobilize Other Resources) has not been described in the literature. The other four build on concepts that have been well established in the scientific literature. The five elements are briefly described below. 1. Adding Universal Access to Health Promotion to the critical pillars of population health. 2. Improving awareness, enhancing motivation, building skills and creating opportunities for each of these behaviors. This approach is articulated in the Awareness, Motivation, Skills and Opportunities (AMSO) Framework. 3. Providing each of the AMSO elements with sufficient intensity that they represent a Therapeutic Dose likely to have an impact. 4. Engaging Geographic and Social Networks to embrace the goal of good health and serve as conduits to reach the full population. 5. Mobilizing Other Resources (MORe) from nontraditional sources to provide sufficient funds, and political will to be successful. Adding Universal Access to Health Promotion to the Critical Pillars of Population Health Improving the social determinants of health (SDH), providing universal access to medical care and providing universal access to health promotion are three critical pillars necessary to improve the health of a population. The approach advocated in this paper focuses primarily on providing universal access to health promotion, with the ultimate goal of improving lifestyle practices of the population and placing a strong emphasis on addressing the elements of SDH that impact lifestyle, especially in creating new opportunities that allow underserved populations to gain access to high quality programs that teach behavior change skills and to environments that make the healthy choice the easy choice. These three pillars and their relative importance are briefly reviewed below. Social determinants of health. The significant impact of SDH 18 and income inequality on health status19 have become well documented in the last two decades. SDH impacts health status directly through exposure to hazardous conditions including poor water and air quality, unsafe housing, violence, poor access to medical care, nutritious affordable food, safe places to be physically active, and indirectly through poor access to educational and career opportunities as well as the challenge of focusing on healthy lifestyle habits when basic necessities of life are at risk. People with low incomes are more likely to have lower perceived health status, higher rates of coronary heart disease, stroke, bronchitis, diabetes, ulcers, kidney disease, liver disease, arthritis, and hearing and vision problems and lower life expectancy.20 Inequality exacerbates the problems of absolute poverty by adding the emotional strain of discrimination and self-7
reflective social evaluative threat. There is growing evidence that income inequality, separate from absolute poverty, has a significant impact on disease and life expectancy.21 In fact health disparities are one of the primary reasons the United States ranks among the worst third in many areas of health (obesity 34th, life expectancy 22nd – 29th, cardiovascular disease 20th, insurance coverage 33rd, admissions for COPD 24th, diabetes 24th, cervical cancer 21st) among the 34 developed nations in the Organisation for Economic Co-operation and Development (OECD), despite spending more than twice as much as 30 of the nations.22 Recent research has shown that the county level health is directly associated with county level wealth, measured by the mean household income, mean home values and portion of children living in poverty, but that those differences are reduced based on the amount spent by the county on social services, including community health care and public health, parks and recreation, public welfare, housing and community development, police protection, solid waste management, natural resources and fire protection.23 Similarly, there is persuasive evidence the reason the United States has such poor health outcomes among developed nations despite spending almost twice as much as any of them is because it spends less than most of them on social services.24 This growing body of evidence on the link between health status and SDH, and between increased social services and improved health status motivated the National Academy of Medicine to form a committee in 2009 to consider data and measurement, law and policy related to population health. Their findings were released in a seminal report titled For the Public’s Health: Investing in a Healthier Future 25 and summarized here: ÒIn this final report, the Institute of Medicine (IOM) assesses both the sources and adequacy of current government public health funding and identifies approaches to building a sustainable and sufficient public health presence going forward, while recognizing the importance of the other actors in the health system, including clinical care, governmental public health, and others. For health outcomes to improve in the U.S., we will need to transform the way the nation invests in health to pay more attention to population-based prevention efforts; remedy the dysfunctional manner in which public health funding is allocated, structured and used; and ensure stable funding for public health departments.Ó That report stimulated Resnick and colleagues to suggest a Foundational Public Health Services framework to help describe the level of funding public health departments need to provide the foundational services necessary to improve the health of the nation. 26 It is understandable that a growing number of health advocates and non-profit health foundations are focusing on eliminating health disparities, and doing so needs to be a central component of enhancing the health of a state population, but doing so is a daunting task. Effective techniques to provide high quality education to all children, provide high paying jobs to all adults, and eliminate racial and other forms of discrimination have not been well studied or documented. For example, a recent systematic review of the literature of interventions to address patients social and economic needs found weak study methodology but encouraging mixed outcome success.27 Sixty-seven studies were found reporting the results of 37 programs; 19 were randomized controlled trials, 7 were quasi-experimental designs and 40 were non-experimental designs. Most studies focused on process issues. Of the 20 studies that measured 26 different health outcomes, 16 showed favorable outcomes and 4 did not. Of the 18 that measured 11 financial outcomes, 14 showed positive outcomes. In addition to lack of consensus on best practice strategies, the societal and political will to make this a priority has not been established. Access to medical care. One of the core strategies to reduce health disparities is to provide access to medical care for all people, something every other developed nation besides the 8
United States has achieved. Getting close to this goal was a central tenet of the Affordable Care Act (ACA). Having affordable access to high quality medical care makes it possible for people to avoid many diseases through vaccines, detect and treat others before they become serious through regular preventive screenings, as well as reduce pain and disabling consequences of serious or chronic diseases. In fact, lack of medical coverage was estimated to cause an estimated 44,789 annual deaths 28 among the estimated 44 million people uninsured prior to passage of the ACA.29 It is difficult to argue that the richest nation in the history of civilization should not provide medical care to each of its residents as a basic human right, or that doing so should not be a central component of any effort to improve the health of a population. However, achieving such a goal will be remarkably expensive, perhaps costing approximately $10,345 anually per capita, as cited earlier in addition to the challenge of developing the political will to make this a priority. Universal access to health promotion. The critical element missing from most efforts to improve the health of large populations by reducing health disparities is providing universal access to health promotion, with the goal of improving the health habits of individuals, including getting regular physical activity, eating a nutritious diet, and avoiding tobacco, excess alcohol and other toxic substances. This is despite the fact that lifestyle factors are the primary cause of 7 of the top ten causes of death,30 and 40% of all premature deaths.31 Tobacco use alone causes an estimated 450,000 premature deaths annually, in addition to 16 million chronic diseases.32 In addition to reducing lifespan an estimated 10 – 15 years, poor lifestyle habits are estimated to increase disability at the end of life by 10 years.33 A growing body of literature is demonstrating that lifestyle can turn on or off the genetic propensity of genes for 80% of diseases.34 From a financial perspective, more than two decades of research findings from large studies has shown that about one of every four dollars of medical care spending by employers can be explained by lifestyle related factors.35 Furthermore, a systematic review of the literature on the financial return on investment of workplace health promotion programs found that 46 of 47 programs reduced medical costs or absenteeism, and savings were greater than program costs for 41 of 47 of them. The return on investment for all the 25 programs in which medical costs were measured directly averaged $3.74 in savings for every dollar invested.36 However, nationwide, only 5% of all healthcare spending is devoted to ÒpreventionÓ in all forms, including medical screening.37 Fortunately, these efforts have been growing in some sectors, especially among employers, in the form of workplace health promotion programs, with an estimated 83% of employers with 200 or more employees offering some type of program, but only 46.6% of working adults report having access to a program.38 Unfortunately, most of these programs are too superficial to have much impact, offering a level of intensity lower than a therapeutic dose. In fact, only 13% of programs are judged to be comprehensive.39 Furthermore, the size of the provider community supporting these programs is tiny. The entire workplace health promotion industry is estimated to have revenues of only $6 billion. If the entire industry were one company, it would rank 435th in the Fortune 500 list, just behind St. Jude Medical ($6.004 billions) and just ahead of Harley-Davidson ($5.997 billion).40 A discussion of the employer business case for health promotion is in Appendix C. Cost effectiveness and cost benefit analysis research is more limited for state and federal spending on health promotion efforts, but the Centers for Medicare and Medicaid Services (CMS) has concluded that heart disease reversal 41 and diabetes prevention and treatment 42 produce positive health outcomes and are at least cost neutral, meaning they save at least as much as they cost. This positive financial 9
outcome is not surprising given that 83% of all Medicaid and 96% of all Medicare spending is tied to chronic diseases,43 and lifestyle factors are the primary cause of chronic diseases. At a cost of several hundred dollars per resident, universal access to high quality health promotion may prevent or at least delay most chronic diseases, reduce disease related disability at the end of life, reduce the need for medical care and improve wellbeing and quality of life. Achieving universal access to health promotion could probably be achieved in one generation or less and may be the most cost effective means of reducing health disparities. Moreover, universal access to health promotion could be achieved at a fraction of the cost of eliminating disparities for the other social determinants of health, such as education, income access to medical care. Furthermore, the disease prevention and chronic condition management benefits of universal access to health promotion may pay for itself in medical cost reduction. States need to focus on all three pillars, but states that want to have the fastest and greatest impact on the health of their residents need to increase their focus on providing universal access to health promotion now. Relative importance of the three pillars. The relative importance of these three pillars on health outcomes has not been well documented through rigorous analysis, however, McGinnis and Foege estimated that hazardous environments account for 5% of premature death, poor access to medical care for 10%, poverty for 15% and individual lifestyle for 40%, making the SDH, collectively associated with 60% of premature deaths, thus a slightly more powerful predictor than individual lifestyle at 40%.44 It is important to stress that these three approaches, increasing access to medical care, enhancing health equities and improving individual health behavior are complementary, not competing. Improving health behaviors like eating nutritious foods or being physically active in structured exercise programs will be far more challenging for someone living in poverty than a middle class person, and more feasible for someone already in good health than someone suffering from a chronic or acute medical condition. However, a person in any income class or health condition will lose an estimated 15 years of life and add years of disabling illness by using tobacco, drinking excessively, being sedentary and not eating nutritious foods. Awareness, Motivation, Skills, Opportunity (AMSO) Framework The AMSO Framework recognizes that efforts will be successful in stimulating health behavior change for population groups only when they do more than educate people on the benefits of healthy lifestyle (Awareness). Efforts also need to 1) tap into each personÕs core priorities in life and clarify how improving health will help achieve those priorities (Motivation), 2) train people in the skills required to learn each new health behaviors (Skills), and most importantly, 3) provide abundant opportunities to practice newly learned healthy behaviors (Opportunities). The AMSO framework was developed based on several systematic reviews of the literature,45,46 a large benchmarking study,47 and validation against programs that have won national awards.48 It incorporates many of the most highly validated health behavior change theories and provides the conceptual framework for the 700+ page Health Promotion in the Workplace, 5th edition text,49 which can be downloaded at no charge from the website listed in the reference below. Providing a complete review of the AMSO Framework is beyond the scope of this paper, but 10
several of the most important elements within the AMSO Framework can be summarized: 1. Best results are achieved when efforts are integrated within existing social settings including workplaces, families, schools, faith communities, and social clubs and existing transactional entities including health plans, hospitals, and local governments. 2. Different people have different preferred learning styles, be they cognitive, experiential, or emotion driven; different preference for communication mediums; different preferences in sources from which they receive education, training and support; and different sizes and composition of social groups to which they feel connected. 3. Strategies, including messaging, and skills training, need to be tailored to each geographic, cultural and age group. 4. Low income populations are likely to need several times the investment of other populations to achieve the same results. 5. State and local laws need to reinforce healthy lifestyle practices. 6. Conflicting forces need to be acknowledged and incorporated into solutions. 7. Changing health behavior may take years and support needs to be maintained indefinitely after those changes have occurred. 8. Intensive grass roots outreach efforts will be necessary to engage active participation among a critical mass of organizations and entities in each target sector as well as individual community members. Of all the social settings, workplaces may have the greatest potential to influence health behavior for several reasons. First, it is possible to create physical and cultural norm environments in which the healthy choice is indeed the easiest choice, and to teach employees the skills they need to learn and adopt healthy lifestyle habits. Second, most employees remain in the same work setting for several years, the amount of time often necessary to transform newly adopted health practices into long term habits. Thousands of studies have demonstrated that health promotion programs can be successful in improving health habits and related conditions cost effectively, and best practice methods have been well documented.50 Perhaps most importantly, employers are willing to fund these programs because healthy employees have lower medical costs and are more productive, and the most talented employees are attracted to work settings that offer comprehensive health promotion programs. For children, schools provide an outstanding setting to help them learn and also practice healthy lifestyle habits. Furthermore, a growing body of literature is demonstrating that well-nourished and physically active students are better behaved, more able to focus on learning, and often perform better on tests.51,52 However, schools do not have the same financial incentives for having healthy students as employers do for having heathy employees and the level of rigor used to test best practice standards for schools are not as rigorous as those for workplaces, despite the emergence of growing documentation of encouraging case studies.53 Therapeutic Dose In medical care, achieving the desired outcome is dependent upon a patient receiving a sufficient amount (or dose) of care to produce the desired outcome. This concept is most tangible for medications. For example, to overcome an acute condition, like an infection, a patient needs to take the prescribed number of pills over the prescribed number of days in the prescribed concentration. To manage a chronic condition, like high blood pressure, the patient needs to 11
follow the prescription guidelines over a long period of time. The concept of therapeutic dose also applies to health promotion on the individual, organization and community level.54 Therapeutic dose levels have been set for some areas of lifestyle improvement. For example, the highest success rate will be achieved in quitting smoking through a combination of brief motivational counseling from a physician and referral to a clinic that includes a combination of ÒtalkÓ (or cognitive) therapy and medication. Meta-analyses have shown that the optimal amount of talk therapy may be 300 minutes presented in 8 sessions; success rates do not seem to improve above those amounts. Meta-analyses have also shown the likely quit rates achieved by different types of talk therapy and different medications.55 Improving the health of a state size population will require reaching each person with a therapeutic dose of each of the AMSO elements relevant the each of the health behaviors that drive health conditions, including regular physical activity, eating a nutritious diet, and avoiding tobacco, excess alcohol and other toxic substances. The therapeutic dose of funding required to support an effective comprehensive health promotion program has not been established through rigorous methods. Therefore, it must be estimated based on practical experience. For this proposal, a per capita annual value of $250 is used. This figure is derived from a bench marking study of the best workplace health promotion programs, adjusted for inflation, and confirmed by budgets of current programs.56 This represents the investment made by institutions, and does not include money individuals spend on fitness and sports clubs, recreation, home equipment, sports attire, food and other discretionary purchases. Engaging Geograp

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