CDC Grand Rounds: Preventing A Million Heart Attacks and Strokes: A Turning Point for Impact

>>> GOOD AFTERNOON, AND WELCOME I’M JOHN ISKANDER WELCOME TO THE SEPTEMBER 2014 CDC PUBLIC HEALTH GRAND ROUNDS ON THIS FIFTH ANNIVERSARY OF THE FIRST GRAND ROUNDS, SPECIAL THANKS TO THE FOUNDING DIRECTOR OF PUBLIC HEALTH GRAND ROUNDS, DR. TONYA POPOVIC, AND THE CDC LEADERSHIP FOR THEIR CONTINUED SUPPORT OF AN ACTIVE PARTICIPATION IN GRAND ROUNDS I’D ALSO LIKE TO EXTEND A SPECIAL THANKS TO COLLEAGUES WHO ALLOW US TO BROADCAST GRAND ROUNDS FROM CDC, INCLUDING FROM OUR NEW LOCATION TODAY, AND THOSE IN THE STUDIO WHO WORK WITH US TO SUPPORT TAPING WE’LL CONTINUE TO STRIVE TO MAKE CDC PUBLIC HEALTH GRAND ROUNDS AN IMPORTANT PART OF THE SHARED SCIENTIFIC CULTURE OF PUBLIC HEALTH GRAND ROUNDS IS ALSO AVAILABLE ON ALL OF YOUR FAVORITE SOCIAL MEDIA SITES WE HAVE A FEATURED VIDEO SEGMENT ON YOUTUBE CALLED BEYOND THE DATA WHICH WE POST SHORTLY AFTER THE SESSION CONTINUING EDUCATION CREDIT FOR PUBLIC HEALTH GRAND ROUNDS ARE AVAILABLE FOR PHYSICIANS, NURSES, PHARMACISTS, HEALTH EDUCATORS, AND OTHERS ALL OF THIS INFORMATION IS AVAILABLE ON THE GRAND ROUNDS WEBSITE WE’VE PARTNERED WITH THE STEPHEN B. THACKER CDC LIBRARY FEATURES SCIENTIFIC ARTICLES RELEVANT TO THIS SESSION THE FULL LISTING IS AVAILABLE AT THE CDC LIBRARY WEBSITE IN ADDITION TO TODAY’S OUTSTANDING FEATURED SPEAKERS, WHOM I’D LIKE TO THANK FOR THEIR IMPORTANT AND ONGOING WORK I’D I’D ALSO LIKE TO ACKNOWLEDGE THE IMPORTANT CONTRIBUTIONS OF THE INDIVIDUALS LISTED HERE IN THE SPIRIT OF AMAZON, IF YOU LIKE THIS SESSION, HERE ARE SOME OTHER GRAND ROUNDS SESSIONS WORTH CHECKING OUT WITH RELATED TOPICS SO NOW, WITH ADDITIONAL THANKS TO THOSE HELPING US OUT IN OUR SPECIAL LOCATION FOR TODAY, IT’S MY PLEASURE TO INTRODUCE ADMIRAL ROBIN IKEDA WITH SOME INTRODUCTORY REMARKS >> THANK YOU AND GOOD AFTERNOON GOOD AFTERNOON WELCOME TO GRAND ROUNDS AND ESPECIALLY WANT TO WELCOME YOU TO THE CHAMBLEE CAMPUS THIS CAMPUS IS HOME TO THREE OF THE FOUR CENTERS HERE AT CDC I ALSO WANTED TO GIVE A SPECIAL SHOUT-OUT TO GEORGIA STATE UNIVERSITY SCHOOL OF NURSING I HEARD THERE ARE SEVERAL IN THE AUDIENCE [ APPLAUSE ] SO THANKS FOR JOINING US TODAY EACH YEAR MORE THAN 1.5 MILLION AMERICAN WILL HAVE A HEART ATTACK OR A STROKE THESE EVENTS CONTRIBUTE TO ALMOST 800,000 DEATHS EACH YEAR IN CARDIOVASCULAR DISEASE THAT’S ONE IN THREE DEATHS EACH YEAR IN THIS COUNTRY THE TRAUMAS TO FAMILIES AND COMMUNITIES IS DEVASTATING THE COST TO THE U.S. ECONOMY IS NEARLY $1 BILLION EACH DAY IN MEDICAL COSTS AND LOST PRODUCTIVITY MILLION HEARTS SEEKS TO PREVENT A MILLION HEART ATTACKS AND STROKES OVER A FIVE-YEAR PERIOD SHARING OUR GOALS AND OUR IRRATIONAL OPTIMISM ABOUT THE PREVENTABILITY OF HEART ATTACKS AND STROKES WITH OTHERS MILLION HEARTS IS CO-LED BY CDC AND CMS, BRINGING TOGETHER PUBLIC HEALTH AND CLINICAL MEDICINE IN UNPRECEDENTED WAYS MILLION HEARTS IS ABOUT DEFINING THE MOST IMPACTFUL STRATEGIES AND CLINICS AND COMMUNITIES, EMBEDDING MEASURES THAT MONITOR AND REWARD IMPROVED PERFORMANCE IN THOSE MEASURES INTO REIMBURSEMENT PROGRAMS, AND LEARNING FROM GRASSROOTS LEADERS WHAT IS WORKING TO CONTROL IMPORTANT RISK FACTORS FOR HEART DISEASE LIKE HYPERTENSION, TOBACCO USE, AND EXCESS SALT IN OUR FOOD SUPPLY THE MOST EXCITING AND PROMISING COLLABORATIONS IN MILLION HEARTS BRING TOGETHER THE COMPLEMENTARY ASPECTS OF THE PUBLIC HEALTH AND HEALTH CARE SECTOR MANY POWERFUL EXAMPLES EXIST AND TODAY’S PRESENTATIONS WILL HIGHLIGHT JUST A FEW MODELS OF THE WORK THAT PARTNERS FROM BOTH THE PUBLIC AND PRIVATE SECTOR ARE DOING TO ACHIEVE THE GOALS OF MILLION HEARTS SPECIFICALLY, WE’LL HEAR ABOUT HOW PUBLIC HEALTH AND CLINICAL CARE EXPERTS ARE COMING TOGETHER IN HEALTH SYSTEMS AND IN COMMUNITIES TO IMPROVE BLOOD PRESSURE CONTROL, HOW COMPREHENSIVE TOBACCO POLICY EFFORTS CAN BE SCALED TO HAVE STATE-WIDE IMPACT, AND HOW EFFORTS TO PROMOTE HEALTHY NUTRITION CAN OCCUR BY INCREASING THE AVAILABILITY OF LOWER SODIUM PRODUCTS THROUGH POLICY CHANGE WE’LL ALSO HEAR ABOUT THE DATA SHOWING THE PROGRESS THAT’S BEEN MADE THROUGH MILLION HEARTS, ALONG WITH THE WORK THAT IS STILL NEEDED TO ACHIEVE OUR GOAL OF PREVENTING 1 MILLION HEART ATTACKS AND STROKES BY 2017 AND WHILE WE APPLAUD THE SUCCESS TO DATE THERE’S MUCH MORE THAT

WE NEED TO DO WE’RE HALFWAY THROUGH THE INITIATIVE BUT WE’VE NOT YET PREVENTED 500,000 EVENTS SO NOW IS THE TIME TO GO ALL-IN FOR US TO REALLY PUSH ALL THOSE CHIPS TO THE CENTER OF THE TABLE WE’RE MORE CONVINCED THAN EVER THAT MILLION HEARTS IS THE RIGHT THING TO DO AND WE ARE FOCUSING ON THE RIGHT APPROACHES BUT WE KNOW THIS IS HARD WORK SO AS WE PASS THIS MIDPOINT MILESTONE WE LOOK FORWARD TO REALLY ENCOURAGE OUR PARTNERS ACROSS THE COUNTRY COULD COMMIT AND THEN RECOMMIT THE ABILITY TO ADDRESS THE NATION’S PUBLIC HEALTH CHALLENGES AND THE BIGGEST ONE BEING HEART ATTACKS AND STROKES, DEPENDS ON PUBLIC/PRIVATE PARTNERSHIPS AND GOAL ALIGNMENT WE KNOW THAT STRATEGIC COLLABORATIONS ARE KEY NOT ONLY TO THE SUCCESS OF MILLION HEARTS BUT REALLY ARE THE FUTURE OF PUBLIC HEALTH PARTNERSHIPS ALLOW US TO SPEAK WITH ONE VOICE, THAT IS BOTH EXPERT AND PASSIONATE AND AMPLIFY THE CALL FOR IMPROVED HEART HEALTH IN THIS COUNTRY BUT TOGETHER WE CAN SEND A CLEAR SIGNAL THAT LIFE THREATENING AND LIFE ENDING CARDIOVASCULAR EVENTS CAN BE PREVENTED IF EACH OF US TAKES A FEW SPECIFIC IMPACTFUL ACTIONS THANK YOU >> THANK YOU VERY MUCH, ADMIRAL OUR FIRST SPEAKER WILL BE DR. JANET WRIGHT [ APPLAUSE ] >> GOOD AFTERNOON, EVERYONE I’M JANET WRIGHT, EXECUTIVE DIRECTOR OF MILLION HEARTS AND ON BEHALF OF THE ENTIRE MILLION HEART TEAM BOTH HERE AND CMS AND OTHER PLACES, I WELCOME YOU TO CDC’S GRAND ROUNDS DESPITE THE DECLINE IN MORTALITY RATE OVER THE LAST 40 YEARS, CARDIOVASCULAR DISEASE DOES REMAIN THE NUMBER ONE KILLER FOR MEN AND WOMEN AND FOR ALL RACES AND ETHNICITIES AS ADMIRAL IKEDA SAID, MORE THAN 1.5 MILLION PEOPLE SUFFER A HEART ATTACK OR STROKE EACH YEAR, AND THESE ARE DEVASTATING EVENTS THAT CAUSE ONE IN THREE DEATHS AND THEY ROB FAMILIES AND COMMUNITIES OF LOVED ONES AND IT’S TIME THAT IT’S STOPPED IT’S TIME THAT WE STOP LOSING A BILLION DOLLARS A DAY IN LOST PRODUCTIVITY, AND MEDICAL COSTS, AS WELL AND IN 2010, LIFE EXPECTANCY FOR THE BLACK POPULATION WAS 3.8 YEARS SHORTER THAN THAT 6 THE WHITE POPULATION WITH CARDIOVASCULAR DISEASE MORTALITY ACCOUNTING FOR MORE THAN A YEAR OF THAT DIFFERENCE THIS MAP SHOWS THAT THE VARIANCE IN — SHOWS THE VARIANCE IN PREVENTABLE DEATHS BY COUNTY AS YOU SEE, THE HIGHEST PREVENTABLE DEATH RATES OCCUR PRIMARILY IN THE SOUTH CENSUS REGION THE GOOD NEWS IS THAT WITH GOOD HABITS, AND GOOD CARE, HEART DISEASE CAN GO AWAY FROM THIS COUNTRY THAT WE CAN HAVE A HEART HEALTHY NATION MILLION HEARTS IS DESIGNED TO ACTUALLY REALIZE THAT VISION AS ADMIRAL IKEDA SAID IT IS A NATIONAL INITIATIVE LAUNCHED IN JANUARY OF 2012 BY THE U.S DEPARTMENT OF HEALTH AND HUMAN SERVICES IT’S CO-LED BY CDC AND CMS AND THE CONSULTS ARE TO BRING TOGETHER COMPLEMENTARY STRENGTHS OF PUBLIC HEALTH AND HEALTH CARE THE CO-LEADS ARE ASSOCIATED IN DEEP AND MEANINGFUL PARTNERSHIPS WITH FEDERAL AND STATE AGENCIES IN THE PRIVATE SECTOR WE KNOW THAT IT WILL TAKE SPECIFIC FOCUSED ACTION BY ALL TO ACHIEVE THIS GOAL, AND YOU’RE GOING TO HEAR ABOUT PROGRESS TODAY, AS WELL AS WHAT YOU CAN DO TO ACCELERATE THAT PROGRESS TO PREVENT A MILLION HEART ATTACKS AND STROKES WE NEED TO DO TWO THINGS WE NEED TO CHANGE THE ENVIRONMENT IN WHICH WE LIVE AND WORK AND PLAY AND WE NEED TO ACHIEVE EXCELLENCE IN HEALTH CARE BOTH ARE DAUNTING, BUT ABSOLUTELY POSSIBLE THROUGH THE RIGHT PARTNERSHIPS, AND THE RIGHT ACTIONS COMMUNITIES CAN HELP THEIR CITIZENS STAY HEALTHY BY INCREASING ACCESS TO SMOKE-FREE SPACES, LOWER SODIUM CHOICES, AND BY ELIMINATING TRANS FAT IN THE FOOD SUPPLY HEALTH CARE PROFESSIONALS, AND THE PEOPLE THAT THEY SERVE, CAN AVOID AND PREVENT HEART ATTACKS AND STROKES BY PRIORITIZING WHAT WE CALL THE ABCS SO THAT’S ASPIRIN WHEN APPROPRIATE BLOOD PRESSURE CONTROL CHOLESTEROL MANAGEMENT AND SMOKING CESSATION AND BY DEPLOYING HEALTH INFORMATION TECHNOLOGY AND NEW MODELS OF CARE, AS WELL AS QUICKLY SCALING AND SPREADING THOSE MODELS THAT PROVE EFFECTIVE AND FINALLY, BY FOCUSING ON THE POPULATIONS WITH THE GREATEST BURDEN OF DISEASE AND THE GREATEST RISK, WE CAN GUARANTEE FOR OUR NATION CONTINUING RETURNS ON THIS FIVE-YEAR INVESTMENT FOR MANY YEARS BEYOND 2017 SO THAT’S THE FRAMEWORK

LET’S TAKE A LOOK AT THE TARGETS FOR THE ENVIRONMENT, WHAT WE NEED TO DO IS WE NEED TO REDUCE THE USE OF COMBUSTIBLE TOBACCO PRODUCTS REDUCE DAILY SODIUM INTAKE BY 20% AND ELIMINATE THE CONSUMPTION OF ARTIFICIAL TRANS FATS ON THE CLINICAL SIDE, WE ARE AIMING FOR 70% PERFORMANCE ACROSS ALL OF THE ABCS AN AMBITIOUS BUT ACHIEVABLE TARGET, AND A HEALTHY DOWN PAYMENT ON THE MILLION PREVENTED EVENTS ACHIEVING 70% FOR THOSE PATIENTS THAT ARE IN CLINICAL CARE SETTINGS WILL HELP PULL THE POPULATION WIDE TARGET UP TO 65% BECAUSE THAT INCLUDES INDIVIDUALS WHO ARE NOT IN USUAL CARE NOT CONNECTED TO A USUAL HEALTH CARE SETTING SO LET’S TALK ABOUT A FEW OF THE CHALLENGES AND SOME SOLUTIONS THAT ARE ALREADY BEING BROUGHT TO THE TABLE IN MILLION HEARTS WE’LL START WITH THE CHALLENGES FIRST OF ALL, MANY PEOPLE BELIEVE THAT THE FAMILY HISTORY DICTATES THE FAMILY FUTURE THEIR FATE NOT EVERY PERSON OR AGENCY OR ORGANIZATION CAN PUT CARDIOVASCULAR HEALTH AT THE TOP OF ITS PRIORITY LIST WE KNOW WHAT WORKS FOR CARDIOVASCULAR PREVENTION BUT WE DO NOT ALWAYS IMPLEMENT SYSTEMATICALLY AND THEN FINALLY WE OFTEN WORK ALONE OVER ON THE SOLUTION SIDE WE KNOW THAT CLEAR ACTIONS, AND EXAMPLES OF THOSE WHO HAVE ACHIEVED RESULTS, LIKE THE SPEAKERS YOU’RE GOING TO HEAR FROM TODAY, WILL SHOW THAT THE FAMILY FUTURE IS ACTUALLY YOURS TO WRITE UNTIL CARDIOVASCULAR DISEASE IS NO LONGER THE LEADING CAUSE OF DEATH IN THIS COUNTRY, IT’S A PRIORITY FOR ALL AMERICANS SPECIFICS ABOUT THE HOW, AND REWARDS FOR RESULTS WILL HELP US ACCELERATE PROGRESS AND FINALLY, BIG JOBS LIKE PREVENTING A MILLION EVENTS REQUIRES A TEAM, AND IN FACT MANY TEAMS SO WE WANT TO SHOW YOU A FEW EXAMPLES OF HOW THIS IS WORKING IN MILLION HEARTS FIRST OF ALL, THE MISSION OF MILLION HEARTS HAS MEANING LITERALLY FOR MILLIONS OF PEOPLE TOUCHED BY THIS DISEASE WE’VE SEEN A DEEP AND GENUINE TEAMWORK ACROSS THE DEPARTMENT OF HEALTH AND HUMAN SERVICES, AND WELL BEYOND PRODUCING RESULT S AND ALSO VERY VALUABLE RESOURCES HIGH PERFORMERS LIKE YOU’LL SEE TODAY ARE HONING AND SPREADING THE STRATEGIES THAT WORK AND PROGRAMS IN THE FIELD ARE BREAKING DOWN TRADITIONAL SILOS AND AMPLIFYING THEIR REACH AND IMPACT IN 50 STATES, FEDERAL PROGRAMS ARE WORKING TO THE TO DRIVE SUCCESS AMONG THESE ARE MANY HHS REGIONAL LEADERS, OMB’S REGIONAL EXTENSION CENTERS, STATE DEPARTMENTS OF HEALTH, QUALITY IMPROVEMENT ORGANIZATIONS AND WE HAVE REPRESENTATIVES HERE FROM THE NEW QIO, QIN IN GEORGIA AND NORTH CAROLINA BIG INNOVATION MODELS AND CARE PRACTICES AS WELL AS STATE MEDICAID AGENCIES AND IN THE PRIVATE SECTOR WE’VE SEEN STATE CHAPTERS OF MEDICAL AND NURSING AND PHARMACIST ORGANIZATIONS NUMEROUS COMMUNITY-BASED AND FAITH-BASED ORGANIZATIONS, MEDICAL GROUPS, LARGE AND SMALL, AND BUSINESSES AND BUSINESS ALLIANCES BUT THE MOST EXCITING THING IS THE DYNAMIC AND ORGANIC COLLABORATION BETWEEN AND AMONG THESE STAKE HOLDERS SOME OF THESE NEW COLLABORATORS ARE LISTENING IN TO TODAY, AND ALL ARE CONTRIBUTING TIME AND TALENT TO PREVENTING HEART ATTACKS AND STROKES THIS TABLE SHOWS A SUB SET OF THE INDICATORS THAT WE ARE TRACKING ADOPTION OF ELECTRONIC HEALTH RECORDS, REPORTING ON QUALITY MEASURES, AND WIDESPREAD ADOPTION OF SODIUM PROCUREMENT AND SMOKE FREE SPACE POLICIES CAN HELP SET THE FOUNDATION FOR THE RESULTS AND THE SUCCESS THAT WE’RE AFTER OUR INTERMEDIATE OUTCOMES ARE IMPROVED PERFORMANCE ON THE ABCS AND SODIUM WE’RE MONITORING THE RESULTS FROM THE ROBUST SURVEILLANCE SURVEYS THAT YOU SEE HERE, AVAILABLE EVERY TWO YEARS AND ALSO WE’RE MONITORING CLINICAL QUALITY MEASURE REPORTING SYSTEMS THAT CAN PROVIDE ANNUAL SNAPSHOTS OF PARTICIPANTS, A SUB SETH OF THE NATION NATIONAL PARTICIPANT — >> AND HERE YOU SEE A LONG-TERM OUTCOME CMS PROVIDES QUARTERLY CLAIMS DATA TO MONITOR LONG-TERM OUTCOME AMONG MEDICARE FEE FOR SERVICE BENEFICIARIES CURRENT DATA SHOW THAT EIGHT HEART ATTACKS AND .5 STROKES PER THOUSAND BENEFICIARIES OR OVER 50,000 HEART ATTACKS AND 55,000 STROKES OCCUR EACH QUARTER AS PERFORMANCE ON THE ABCS IMPROVES WE WILL BE LOOKING AT THESE DATA FOR AN IMPACT ON THAT ULTIMATE LONG-TERM OUTCOME WITH THE MONITORING PLAN IN MIND LET’S TAKE A LOOK AT SOME EX

CITING EXAMPLES SINCE MILLION HEARTS LAUNCHED 127 ADDITIONAL COMMUNITIES HAVE GONE SMOKE FREE A DECISION THAT LEADS TO AN ALMOST IMMEDIATE DROP IN HEART ATTACK RATES WITHIN THAT COMMUNITY TIPS FROM FORMER SMOKERS HAS BROUGHT 150,000 PEOPLE TO QUIT PHARMACIES CAN BE SOURCES OF EXPERT ADVICE AND SUPPORT THE HEALTH NEW POLICY IS ONE TO BE CELEBRATED AND EMULATED AND HOSPITALS, SCHOOL SYSTEMS AND OTHER FOOD PURCHASERS ARE USING THE POWER OF PROCUREMENT TO INCREASE ACCESS AND AVAILABILITY TO LOWER SODIUM FOODS YOU’LL HEAR ABOUT ONE OF THESE EFFORTS TODAY OPERATING IN LOS ANGELES ONE REQUIREMENT FOR RAPID PERFORMANCE IMPROVEMENT IS TIMELY DATA SHARED WITH TEAMS, WITH PATIENTS AND OTHERS WHILE WE AWAIT THE BIENNIAL RESULTS REPORTED EVERY TWO YEARS WE’RE ACTIVELY MONITORING OTHER DATA SETS ON THIS, THE MILLION HEARTS CLINICAL QUALITY MEASUREMENT DASH BOARD AVAILABLE NOW ON THE WEBSITE THIS DASHBOARD SHOWS HOW YOUR STATE, REGION AND THE NATION ARE PERFORMING ON THE ABCS WE ALSO HAVE DATA SETS FROM CMS’ PHYSICIAN QUALITY REPORTING SYSTEM THIS SNAPSHOT SHOWS THE FEDERAL QUALIFIED HEALTH CENTERS MAKING SUBSTANTIAL PROGRESS IN SMOKING ASSESSMENT AND TREATMENT AS RE-TREATED BY THE CHANGE FROM RED TO YELLOW AND EVEN TO GREEN WE’RE EXCITED TO SHARE THESE STATE LEVEL DATA SETS AND LOOK FORWARD TO WORKING WITH PARTNERS TO HELP THEM SHOW THEIR PROGRESS AT THE HEART OF MILLION HEARTS IS PROGRESS IN REDUCING DISPARATE OUTCOMES IN CARDIOVASCULAR DISEASE WE’RE ENCOURAGED BY THE WORK UNDER WAY IN THE POPULATION’S HARDEST HIT ONLY A FEW EXAMPLES ARE NOTED HERE IN ADDITION TO THE CDC ASTHO PROJECT IN NINE STATES, AND THE QIO WORK WE’RE DELIGHTED TO WORK WITH PARTNERS SUCH AS THE NAACP, AND OVER 70 FAITH BASED ORGANIZATIONS WHO ARE COMMITTED TO IMPROVING CARDIOVASCULAR HEALTH TO PREVENT A MILLION, 6.3 SMOKERS MUST QUIT, 10 MILLION MORE PEOPLE WITH HYPERTENSION NEED TO BRING IT UNDER CONTROL AND ALL OF US NEED TO REDUCE OUR SODIUM INTAKE BY 20% WE SEEK THESE OUTCOMES FOR ALL AMERICANS BUT WE’LL FOCUS IN POPULATIONS WITH THE GREATEST BURDEN AND AT THE GREATEST RISK TODAY YOU’LL HEAR EXPERTS DESCRIBING THEIR FIELD TESTED EXAMPLES OF SUCCESS AND IMPLEMENTING WHAT WORKS TO PREVENT HEART ATTACK AND STROKE THROUGH HYPERTENSION CONTROL, SMOKING CESSATION, AND SODIUM REDUCTION AS YOU LISTEN, DECIDE HOW YOU WILL DISSEMINATE AND DEPLOY THE LESSONS LEARNED HOW YOU WILL SCALE AND SPREAD THEIR INNOVATIONS, AND UNLEASH THIS POWERFUL COLLABORATION OF PUBLIC HEALTH AND HEALTH CARE IN YOUR COMMUNITY I LOOK FORWARD TO HEARING YOUR QUESTIONS FOR THE PANEL AND AS ALWAYS WE LOOK FORWARD TO YOUR ADVICE TO ALL OF US IN MILLION HEARTS OUR FIRST SPEAKER TODAY IS ANDREW TREMBLAY [ APPLAUSE ] >> FIRST OF ALL, THANK YOU FOR HAVING ME HERE TODAY MY NAME IS ANDY TREMBLAY, I’M THE CHAIR OF THE DEPARTMENT OF PRIMARY CARE AT THE CHESHIRE MEDICAL CENTER DARTHMOUTH-HITCHCOCK IN KEEN AND I AM A SORRY STAND-IN FOR THE PRESIDENT BUT I FIGURE, HEY, WE’LL START THERE SO, WHAT I’M GOING TO DO IS TAKE YOU ON A WHIRLWIND TOUR THROUGH AN 18-MONTH PROJECT THAT WE STARTED ON IN OUR INSTITUTION AND WHEN I SAY WHIRLWIND I DO MEAN THAT BEAR WITH ME AS WE MOVE SO I’M GOING TO SET THE STAGE HERE FOR MANY OF YOU YOU’VE HEARD ABOUT THE THREE-PART AIM OR THE TRIPLE AIM BEFORE AND THIS IS OUR TAKE ON IT WE WISH TO CREATE A CULTURE OF HEALTH NOT ONLY IN OUR INSTITUTION BUT OUTSIDE OF THAT MOST OF THE RESIDENTS IN OUR AREA DO SEEK THEIR HEALTH CARE WITH US AS THE NEAREST HEALTH CARE FACILITIES OUTSIDE OF OUR INSTITUTION ARE BETWEEN 30 AND 35 MILES AWAY BUT NOT EVERYBODY SEEKS THEIR CARE WITH US HOWEVER WE FEEL A RESPONSIBILITY TO OUR COMMUNITY TO MAKE SURE THAT WE A RESOURCE FOR THEM IN WHATEVER CAPACITY THAT MAY BE AND SO OUR GOAL IS TO IMPROVE THE HEALTH OF ALL OF THE RESIDENTS IN OUR COMMUNITY, NOT JUST THOSE THAT NEEDED HEALTH CARE AND OVERALL OF COURSE BECAUSE THEY DO UTILIZE OUR E.R AND HOSPITAL SERVICES THE END GOAL IS TO DECREASE COSTS AND ALLOW INVESTMENT AND PREVENTION IN PRIMARY CARE AS A RESULT OF THAT WE CAME UP WITH A RATHER ELABORATE MODEL WHICH I KIND OF LIKE AND THIS IS AN INTEGRATION OF THE PUBLIC HEALTH SYSTEM AND THE MEDICAL CARE SYSTEM YOU CAN SEE ON THE FAR RIGHT HERE IT TALKS ABOUT COMPLEX MEDICAL CARE THOSE ARE THINGS THAT PRIMARILY LIVE IN THE MEDICAL ENVIRONMENT, YOUR HOSPITAL, AND YOUR CLINICS AS WE MOVE INTO THIS SORT OF

OVERLAP AREA WE TALK ABOUT PATIENT CENTERED PRIMARY CARE MEDICAL HOME FACILITIES THAT ARE INTERESTED IN PROVIDING WELLNESS CARE AND DEALING WITH CHRONIC DISEASE MANAGEMENT ON THE EXTREME LEFT YOU SEE THOSE THINGS THAT ARE REALLY OUT THERE IN THE COMMUNITY THAT EQUALLY IMPACT STATION’S HEALTH BUT AREN’T NECESSARILY THINGS THAT ARE HAPPENING WITHIN THE CONFINES OF YOUR FACILITY AND THEN IN THE INTERSECTION HERE IS HOW DO WE WORK ON THE PROTECTION OF OUR VULNERABLE PEOPLE THOSE PEOPLE WHO BEAR THE HIGHEST RISK AND BURDEN OF RISK THIS IS WHAT WE CALL INTEGRATION AND WHAT WE’RE STRIVING FOR IN OUR RATHER SMALL COMMUNITY THIS IS WHAT WE HOPE WILL TRANSFORM HEALTH CARE GOING FORWARD AND WE’VE HAD FAIR SUCCESS FOR THIS IN A NUMBER OF PROGRAMS THAT WE’VE INSTITUTED THUS FAR BY CREATING COLLABORATIVE EFFORTS WITH OUR COMMUNITY PARTNERS BOTH ORGANIZATIONALLY AND AS INDIVIDUALS SOME BACKGROUND ON CMCDHK WE HAVE ABOUT 30,000 ACTIVE ADULT APPLICATIONS WE HAVE OVER 12 PROVIDERS, WE HAVE 32% OF OUR PATIENTS WHO HAVE HYPERTENSION THAT’S IN THE AGE RANGE OF 18 TO 85 YEARS SO THAT’S ABOUT 12,580 SOME ODD PATIENTS I KNOW THOSE NUMBERS BECAUSE I SLEEP WITH THEM AND LIVE THEM EVERY DAY ABOUT 8.5% ARE MEDICAID ELIGIBLE 3.7 REPRESENT A RACIAL OR ETHNIC MINORITY WE ARE A VERY, VERY HEAVY MEDICARE DEPENDENT ENVIRONMENT AS IS MOST OF NORTHEASTERN UNITED STATES AS WE BEGAN TO LOOK AT THIS THE THING THAT REALLY SET US UP FOR HYPERTENSION WAS UNDERSTANDING WHAT’S HAPPENING IN OUR COMMUNITY, UNLIKE OTHER PLACES IN NEW HAMPSHIRE, WE TEND TO DEAL MOSTLY AS HIGH CAUSES OF MORTALITY AND MORBIDITY WITH CORONARY ARTERY DISEASE AND STROKE FOR OBVIOUS REASONS THAT WERE PREVIOUSLY MENTIONED AS WE WORK ON THIS WE DECIDED THAT HYPERTENSION SHOULD BE OUR FIRST TASK TO LOOK FORWARD TO AND WE BEGAN TO LOOK THE INCONSISTENCIES ABOUT WHY WE’RE NOT DOING BETTER WITH OUR BLOOD PRESSURE CONTROL OR AS WELL AS WE WOULD LIKE TO DO WE FOUND A NUMBER OF INCONSISTENCIES INCLUDING WORK FLOW BETWEEN PRIMARY CARE TEAMS, THE ENGAGEMENT OF SPECIALTY CARE DEPARTMENTS THAT’S AN ISSUE WHEN YOU WORK IN A MULTISPECIALTY CLINIC THE DOCUMENTATION ESPECIALLY OF SECOND BLOOD PRESSURE READINGS, INCONSISTENT BLOOD PRESSURE TECHNIQUE WHICH HONESTLY AT THE OUTSET OF THIS PROJECT WAS A SIGNIFICANT SORT OF HIDDEN THING THAT WE FOUND BUT WAS INCREDIBLY IMPORTANT AND LACK OF TIMELY MAINTENANCE AND CALIBRATION OF EQUIPMENT ALSO OTHER BARRIERS THAT WE OBSERVE WERE THE COST BARRIER OF BLOOD PRESSURE REJECT PATIENTS HAVE HIGH DEDUCTIBLE INSURANCES THEY CAN’T AFFORD TO ALWAYS COME BACK IN A TIMELY MANNER LACK OF RESOURCES TO EFFECTIVELY MANAGE REGISTRIES WHICH ARE AN IMPORTANT CONCEPT AND TOOL IN HEALTH POPULATION NO AGREEMENT ON A UNIVERSAL TRIAGE OF TREATMENT ALGORITHM WITHIN OUR GROUP VARIED PROCESS FOR SLOW STAFF IN OTHER WORDS THOSE OF PROVIDERS OF CARE PUT PATIENTS IN ROOMS TO NOTIFY US OF ELEVATED BLOOD PRESSURE LACK OF ENGAGEMENT OF THE PATIENT IN THE COMMUNITY ONCE THEY LEFT OUR OFFICE WHAT WAS THEIR INCENTIVE TO CONTINUE THE PROTOCOL I THINK IT’S IMPORTANT TO KNOW THAT WE DID NOT START WHERE THE NATIONAL AVERAGE IS WHICH IS GENERALLY SOMEWHERE BETWEEN 35% AND 45% HYPERTENSION CONTROL WE ACTUALLY STARTED REALLY WELL WE WERE AT 74% WE SET A GOAL OF 81% AND WE USED AN INTERNAL BENCH MARK WITHIN THE DARTMOUTH SYSTEM THAT IS THAT A PROVIDER HAD BEEN ABLE TO ACHIEVE WITH A SUBSTANTIAL NUMBER OF PATIENTS 81% HYPERTENSIVE CONTROL WE FELT IF THIS INDIVIDUAL COULD DO IT WE COULD DO IT AS A GROUP THEN WE WERE USING A MULTIDISCIPLINARY QUALITY IMPROVEMENT TEAM WHICH WE ENLISTED THE ROLE OF HYPERTENSION CHAMPION IMAGINE AN ORTHOPEDIST ON THIS GROUP WE CREATED FREE NURSE CLINICS WE WROTE POLICY INTO HOW WE PROVIDE CARE TO ELIMINATE THAT COST BARRIER WE IMPLEMENTED PROTOCOL BASED MODIFICATION SO THE NURSES KNEW WHAT TO DO, ESPECIALLY KNEW WHAT TO DO WITH AN ELEVATED BLOOD PRESSURE AND NEW TO THIS CONCEPT WAS WHAT OUR COMMUNITY PARTNERS LIKE THE YMCA VISITING NURSES SO THAT THEY KNEW WHAT TO DO WE USED OUR ELECTRIC HEALTH RECORD OR EMR TO PROVIDE PROVIDER SPECIFIC REGISTRY COORDINATION SO THAT YOU AS A PROVIDER HAD A PREDOMINANT HAND IN HOW YOU MANAGED YOUR POPULATION AND WE BEGAN ROLLING OUT BEHAVIORAL HEALTH STRATEGIES TO ENGAGE PATIENTS NOT WITHIN THE CONFINE OF OUR INSTITUTION, WORK, HOME, NURSING HOME, OTHER ASPECTS OF THE COMMUNITY EVEN LIKE FIRE DEPARTMENT AND THE LOCAL YMCA WE HAD TEN STRATEGIES FOR SUCCESS AFTER WE WENT THROUGH THIS PROCESS AND THEY’RE VERY WELL OUTLINED HERE WE CONVENED A MULTIDISCIPLINARY TEAM I DO MEAN WE DID HAVE ORTHOPEDICS AT THE TABLE WE DID HAVE EMTs WE HAD NURSING WE HAD MEDICAL SECRETARIES WE HAD COMMUNITY PARTNERS WE HAD EXERCISE FITNESS GURUS COMING IN FROM OUTSIDE TO WORK WITH US WE DID WIN THROUGH A QUALITY IMPROVEMENT PROCESS THAT WE HAVE OUR CHAIRMAN’S AWARD IN 2014 WE SURVEYED PRIMARY CARE PROVIDERS AND OUR NURSING STAFF AND PATIENTS, ABOUT THEIR BARRIERS TO ADEQUATE BLOOD PRESSURE CONTROL AND USED ALL OF THAT INFORMATION TO HELP FORWARD OUR PROCESS THE ONE THAT WAS A SHOCK TO ALL OF US IS CALIBRATING COSTS AND I’LL PAUSE A MOMENT ON THIS WHEN WE GOT TO A 75% OF THE BLOOD

PRESSURE COSTS ON OUR CAMPUS WERE NOT CALIBRATED CORRECTLY OR WERE BROKEN WE HAD SEVEN DIFFERENT TYPES OF BLOOD PRESSURE CUFFS AND SO THROUGH THIS PROCESS WE ELIMINATED THAT AREA TO ADEQUATE BLOOD PRESSURE MANAGEMENT WE THEN TOOK THAT TO OUR COMMUNITIES WE CREATED A CORE COMPETENCY FOR ALL NURSING STAFF CERTAINLY WITHIN OUR ORGANIZATION BUT SPREAD THAT TO OUR COMMUNITIES, AS WELL, WE WENT TO OUR NURSING HOMES, OUR VISITING NURSES, OUR YMCA, FIRE DEPARTMENT, ANY PLACE WHERE WE KNEW OUR PATIENTS WOULD GO TO GET A BLOOD PRESSURE WITH THE EXCEPTION OF AUTOMATED KIOSKS, AND MADE THEM TAKE OUR CORE COMPETENCY EXAMS WE DISTRIBUTED A SINGLE BLOOD PRESSURE BROCHURE THROUGHOUT THE COMMUNITY SO EVERY ORGANIZATION IN OUR COMMUNITY USES OUR BLOOD PRESSURE BROCHURE THAT WE DEVELOPED AS PART OF THIS COMMUNITY THERE ARE NO OTHERS THE INFORMATION IS CURRENT, IT’S STANDARDIZED, IT’S REVIEWED EVERY SIX MONTHS WE CREATED A NURSE CLINIC WHICH ALLOWED FOR NO COST BLOOD PRESSURE AND CENTRALIZATION OF RESOURCES CREATED A CENTRALIZED TRIAGE ALGORITHM IT ALLOWED A NEW TOOL FOR US TO UTILIZE IN DIRECTOR CARE FOR THE PATIENTS WE PROVIDED INDIVIDUAL PROVIDER REGISTRIES THAT GAVE MONTHLY DATA FEEDBACK WHICH WE STILL DO WITH A NUMBER OF QUALITY METRICS FOR PROVIDERS TO SEE AND THIS IS A LIVE INPERSON DEAL THAT WE DO IN OUR OFFICE WE WILL SUBSTITUTE A PATIENT VISIT TO ALLOW THIS WORK TO OCCUR BECAUSE WE THINK IT’S THAT IMPORTANT SO WE HAVE ADDED REGISTRY MANAGERS TO HELP US WITH THIS AND THEY BECOME INTEGRAL PARTS OF OUR TEAM WE HAVE INCENTIVIZED PROVIDERS WE USE A QUALITY INCENTIVE IN OUR COMPENSATION, 5% OF COMPENSATION IS BASED ON HOW YOU’RE DOING WITH YOUR HIP HYPERTENSION CONTROL WE DISTRIBUTED SOMETHING CALLED KNOW YOUR NUMBERS LAST YEAR THEY DEMONSTRATED THE KNOW YOUR NUMBERS WALLET CARD WE’VE ISSUED OVER 12,000 WE’VE GOT ABOUT 50 PEOPLE YET TO SUCH SO I THINK WE’RE DOING PRETTY WELL THIS IS AN EXAMPLE OF HOW YOUR EMR DOWNLOADS INFORMATION TO AN EXCEL SPREAD SHEET FORM THIS HAPPENS TO BE MY REGISTRY FROM A COUPLE YEARS AGO YOU CAN SEE THE NAME OF THE PROVIDER, THE PATIENT IDENTIFIER HAS BEEN REMOVED YOU CAN SEE THEIR BLOOD PRESSURE, WHEN IT WAS TAKEN AND THOSE THINGS I’VE SHARED WITH MY REGISTRY COORDINATOR ABOUT HOW I WOULD LIKE THIS PATIENT ATTENDED TO THIS IS A DIFFERENT TYPE OF DATA THAT OUR PROVIDERS ARE ABLE TO SEE EVERY VISIT WHAT I LIKED ABOUT THIS SLIDE WE WERE PUTTING THIS FORWARD FOR OUR BOARD TO SEE THE BLUE GRAPH REPRESENTS ALL THE PATIENTS WE HAVE WITH ELEVATED BLOOD PRESSURE THE RED IS THOSE PATIENTS THAT ARE MEDICARE BECAUSE WE ARE PART OF A PIONEER ATO BUT WE WANTED TO MAKE SURE THAT OUR PROCESS WAS NOT REALLY JUST LIMITED TO THOSE PATIENTS IN A CERTAIN PYRAMID SO THE GREEN IS ALL PATIENTS THAT ARE NONMEDICARE AND THE PROCESS WORKS FOR EVERYBODY REGARDLESS OF PAY OR MIX BECAUSE WE SET IT UP THAT WAY WE DID NOT DESIGN IT TO BE SPECIFIC FOR THAT AS WE GOT INTO THIS REALIZED OUR MISSION INTEGRATED WITH THE MILLION HEARTS PROGRAM WE DECIDED TO APPLY FOR MILLION HEARTS CHAMPION STATUS THIS IS AN EXAMPLE OF HOW THIS DRAFT THAT I SHOWED YOU EARLIER, THIS PICTO GRAM WORKS IN REGARD TO BLOOD PRESSURE YOU CAN SEE HOW THE MEDICAL CARE SYSTEM IS WAY INVOLVED AT THIS END, 25% OF THAT GRAPH BUT THE OTHER THREE QUARTERS OF THIS REPRESENT THINGS THAT COULD OCCUR EITHER OUTSIDE THE COMMUNITY ON INTEGRATED FASHION BUT WE WERE VERY EXCITED TO RECEIVE OUR CHAMPIONSHIP STATUS AND THEY CAME AND VISIT US EARLIER THIS YEAR SO HERE’S THE ACTUAL SUCCESS STORY YOU CAN SEE WHERE WE STARTED AROUND 74%, 73.8% AND BY THE END OF JUST A VERY SHORT PERIOD OF TIME, WITH A VERY STEEP INCLINE IN THIS GRAPH WE’VE ACHIEVED 85% I’M HAPPY TO SAY THE DATA THAT CAME OUT IN SEPTEMBER AND THERE IS A TWO-MONTH LAG IN THAT DATA FOR US THAT WE GET, DOES HAVE SEVERAL PROVIDERS IN OUR DEPARTMENT THAT ARE IN SUCCESS OF 90% CONTROL OF OVER 500 PATIENTS INCLUDING MYSELF I HAVE 850 HYPERTENSIVE PATIENTS I’M AT 96% CONTROL I’M NOT SURE I’M GOING TO DO MUCH BETTER THAN THAT MAYBE AS A RESULT YOU HEARD ABOUT ASTHO WE WORKED WITH SOME THE FEDERAL FEDERALLY QUALIFIED IN MANCHESTER WHAT WE HAVE SEEN IN THOSE TWO PARTICULAR HEALTH CENTERS IS 6% AND 8% IMPROVEMENT IN THE BLOOD PRESSURE CONTROL RESPECTIVELY OVER SIX MONTH PERIOD OF TIME PRETTY IMPRESSIVE FOR SUCH A SHORT ORDER AND A RELATIVELY CHAOTIC ENVIRONMENT THAT GENERALLY DOES NOT HAVE CONTINUITY AS THERE’S A LOT OF TRANSIENT CARE THAT OCCURS WE’RE REALLY TRYING TO MOVE THESE STRATEGIES WE HAVE STRENGTHENED OUR RELATIONSHIPS WITH OUR MANCHESTER DEPARTMENT OF HEALTH AS PART OF THIS PROCESS AS MENTIONED EARLIER WE’VE DONE A LOT OF WORK AND WE’VE BEEN WORKING WITH A LOT OF THE OTHER COMMUNITY HEALTH CENTERS TO DISSEMINATE THIS INFORMATION

THERE’S STILL PLENTY TO DO, THOUGH WE’RE EXPANDING OUR REGISTRY COORDINATION TO IMPROVE COMPREHENSIVE CHRONIC DISEASE MANAGEMENT, DIABETES, CORONARY ARTERY DISEASE, EXPLORE THE USE OF BLOOD PRESSURE KIOSKS IN OUR OWN FACILITY, WHICH WILL SAVE TIME FOR PATIENTS ACTIVITY IS A GOOD MEDICINE WHERE INDEPENDENT OF OUTSIDE FINANCING HAS SUBSIDIZED FOR OUR PATIENTS TO JOIN THE YMCA AND WE COLLECT THEIR BIOMETRIC FACTS THEY GET FREE DIETETIC CARE, IT’S A WONDERFUL PROGRAM INTEGRATE NUTRITION COUNSELING AND THERAPY WHICH IS AN ONGOING EFFORT FOR US IN ALL OF OUR CHRONIC DISEASE WE ARE LOOKING AT PHARMACY INTEGRATION I HEARD THAT MIGHT BE NEXT GRAND ROUNDS TOPIC IT’S A GREAT RESOURCE THAT WE FEEL ON HEALTH CARE HAS NOT BEEN TAPPED ADEQUATELY IN A TRADITIONAL CLINICAL ENVIRONMENT SPREADING OUR IMPROVEMENT WHICH WE’RE ALREADY WORKING ON AND PLAN FOR MAINTAINING OUR GAINS TO MAKE SURE WE DO NOT SLIP BACK SO IT HAS BECOME PART OF OUR CULTURE NOW AND WE WANT IT TO STAY THAT WAY OUR NEXT SPEAKER THIS MORNING IS PATRICIA HENLEY GOOD AFTERNOON I’M HERE TO PRESENT TO YOU THE WORK OF THE TOBACCO CESSATION PROGRAM AND HOW POLICY EFFORTS CAN BE SCALED TO HAVE A STATEWIDE IMPACT MASSACHUSETTS IS 44th IN THE NATION OR LAND AREA BUT IT’S 13th IN THE NATION FOR POPULATION AT ABOUT 6.3 MILLION AND WE’RE FIRST IN THE NATION FOR THE NUMBER OF LOCAL PUBLIC HEALTH DEPARTMENTS THE MASSACHUSETTS CONSTITUTION GRANTS BROAD AUTHORITIES TO CITIES AND TOWNS TO MAKE THEIR OWN LAWS AND REGULATIONS, AND THERE ARE 351 MUNICIPALITIES WITH A LIMITED FORM OF LIMITED COUNTY GOVERNMENT EACH MUNICIPALITY HAS A BOARD OF HEALTH THAT CAN PASS LOCAL REGULATIONS, AND SO BECAUSE OF THIS, MASSACHUSETTS HAS BEEN ABLE TO DEVELOP MANY TOBACCO CONTROL REGULATIONS AT THE LOCAL LEVEL THE SMOKING POPULATION IN MASSACHUSETTS IS 16.6% BUT THERE’S STILL A LONG WAY TO GO TO BRING SMOKING RATES DOWN FOR ALL MASSACHUSETTS RESIDENTS 77% OF MASSACHUSETTS SMOKERS FALL IN ONE OF THE CATEGORIES UNDER MORE LIKELY TO SMOKE, SUCH AS POOR MENTAL HEALTH IN 1993, A REFERENDUM WAS APPROVED FOR 25 CENT CIGARETTE TAX DEDICATED TO THE HEALTH PROTECTION FUND AND THAT FUNDED THE MASSACHUSETTS TOBACCO CONTROL PROGRAM IN 1994 MTCP HAD A $52 MILLION BUDGET WE FUNDED 95% OF THOSE 351 MUNICIPALITIES SO WE FUNDED AN AWARD WINNING, HARD-HITTING MEDIA CAMPAIGN ESTABLISHED IN MASSACHUSETTS SMOKERS HELPLINE FUNDED LOCAL TOBACCO TREATMENT IN MANY COMMUNITY HEALTH CENTERS AND HOSPITALS, AND ALSO PROVIDED FUNDING FOR LOCAL SCHOOL DEPARTMENTS, POLICE AND FIRE DEPARTMENTS AND ALL OF THAT CHANGED DRAMATICALLY IN 2003 WHEN WE HAD A STATE FISCAL CRISIS AND A NEW ADMINISTRATION THE CONSEQUENCES OF A LIMITED BUDGET WHICH DECREASED TO $2.5 MILLION WAS THAT IT FORCED US TO CHANGE OUR STRATEGIES TO A MORE POPULATION BASED APPROACH AND ALSO FORCED US TO FOCUS ON PRIORITY POLICIES BUT THERE WAS SOME VERY WISE PEOPLE AT MTCP AT THE TIME AND THEY WORKED VERY HARD TO MAINTAIN A CORE INFRASTRUCTURE AND THAT INCLUDED LOCAL PROGRAMS, COMMUNITY PARTNERSHIPS, AND USED A VERY STRONG SURVEILLANCE AND EVALUATION TEAM, LEGAL AND POLICY TECHNICAL ASSISTANCE TEAMS, IT KEPT OUR QUIT LINE AND THAT INCLUDES OUR QUIT WORKS PROGRAM, AND COMMUNICATIONS THAT INCLUDED STAKEHOLDER EDUCATION, EARNED MEDIA, WHICH WAS CRITICAL BECAUSE THAT’S THE MEDIA THAT YOU CAN’T BUY, AND THEN ALSO SOME PAID MEDIA AND ALL OF THESE CONTRIBUTE TO PROMOTING SUSTAINABLE POLICY SO THE LOCAL PROGRAMS ARE REALLY ESSENTIAL TO THE CORE INFRASTRUCTURE OUR LOCAL BOARDS OF HEALTH PROGRAMS ARE THE CENTER OF REGULATION AND POLICY SETTINGS FOR THE MUNICIPALITIES THEY EDUCATE THEIR DECISION MAKERS AND THEN THEY ENFORCE ALL MUNICIPAL REGULATIONS THE COMMUNITY PARTNERSHIP PROGRAM PROVIDES COMMUNITY EDUCATION, CONNECTS PEOPLE TO RESOURCES, AND THEY GET THE MESSAGES OUT THEY ARE THE PRIMARY CONTACT WITH LOCAL MEDIA OUTLETS, AND THEY GENERATE EARNED MEDIA, AND THEY BUILD LOCAL PARTNERSHIPS AND THE 84 YOUTH PREVENTION PROGRAM, WHICH IS NAMED AFTER THE 84% OF YOUTHS WHO CHOOSE NOT TO SMOKE IN MASSACHUSETTS, IT’S A LOCAL CHAPTER STRUCTURE, AND IT’S FOCUSED ON YOUTH ENGAGEMENT YOUNG PEOPLE WORK TO EDUCATE THEIR PEERS AND THEIR DECISION MAKERS ABOUT THE NEED FOR STRONG ANTI-TOBACCO POLICIES AND THAT’S ALSO ABOUT THE IMPACT TOBACCO HAS ON THEIR LIVES AND THE LIVES OF THEIR PEERS SO ALL THREE PROGRAMS, LOCAL BOARDS OF HEALTH, REGIONAL COMMUNITY PARTNERSHIP PROGRAMS, AND THE 84 YOUTH PROGRAM WORK TOGETHER TO AMPLIFY THE KEY MESSAGES TO BRING TOBACCO ISSUES TO THE FOREFRONT IN THEIR

COMMUNITIES MTCP PROVIDES THE GUIDANCE AND THE DIRECTION FOR ALL STRATEGIES FOR THE LOCAL PROGRAM OF THE CORE INFRASTRUCTURE TECHNICAL ASSISTANCE IS PROVIDED IN THE FORM OF MODEL REGULATION LANGUAGE, AND STATEWIDE SUPPORT FOR COMMUNICATIONS, YOUTH ENGAGEMENT, AND POLICY AND IT PROVIDES ASSISTANCE TO PASSING LOCAL REGULATIONS MTCP HAS DEVELOPED STANDARDIZED COMMUNICATIONS MESSAGES AND TOOLS THAT PROMOTE POLICY INITIATIVES AND WE ENCOURAGE COLLABORATION, AND UNIFIED MESSAGING AMONG THE FIELD, SO REGIONAL COMMUNITY PARTNERSHIP PROGRAMS AND YOUTH PROGRAMS PROVIDE PUBLIC SUPPORT FOR POLICY INITIATIVES THEN THE LOCAL BOARDS OF HEALTH PROGRAM ENFORCE THE POLICY AFTER IT’S PASSED INTEGRATION OF THE FIELD, AND THE FEED MESSAGES IS KEY MTCP IS FOCUSED ON THE FIVE PRIORITY AREAS AND THEY’RE SUPPORTED BY OUR INFRASTRUCTURE SO PROVIDING ACCESS TO COMPREHENSIVE CESSATION BENEFITS WILL INCREASE THE PERCENTAGE OF SMOKERS WHO MAKE A QUIT ATTEMPT PROTECTING YOUTH FROM TOBACCO INDUSTRY REDUCES USE BY YOUTH INCREASING THE PRICE OF TOBACCO WILL REDUCE TOBACCO USE OVERALL AND ASSURING ALL SMOKERS RECEIVE INTERVENTION BY THEIR HEALTH CARE PROVIDER WILL MOTIVATE SMOKERS TO QUIT PROTECTING EVERYONE FROM SECONDHAND SMOKE WILL HELP ELIMINATE THE HEALTH PROBLEMS CAUSED BY SECONDHAND SMOKE AND SUPPORT THE SOCIAL NORM THAT MOST PEOPLE DON’T SMOKE SO PRIORITY ONE, ACCESS THE COMPREHENSIVE CESSATION BENEFITS IN 2006 THE MASSACHUSETTS MEDICAID PROGRAM ESTABLISHED A BENEFIT THAT PROVIDED COMPREHENSIVE SMOKING CESSATION COVERAGE TO ALL MEDICAID ENROLLEES OUR INFRASTRUCTURE SUPPORTS THE PROMOTION OF THIS BENEFIT TO INCREASE ITS UTILIZATION THE QUIT LINE DISCUSSES HEALTH BENEFITS WITH ITS CALLERS, THE QUITWORKS PROGRAM EDUCATES HEALTH CARE PROVIDERS OF THE BENEFITS SO IT INCREASES PATIENT INTERVENTION AND THE LOCAL COMMUNITY PROGRAMS PROMOTE THE BENEFITS AND CESSATION RESOURCES 44% OF CALLERS TO THE QUIT LINES HAVE MEDICAID INSURANCE SO WE’RE REACHING THIS POPULATION PRIORITY TWO, PROTECTING YOUNG PEOPLE FROM TOBACCO INDUSTRY TACTICS LOCAL RETAIL REGULATIONS ARE PRIMARY TO OUR EFFORTS TO REDUCE THE INITIATION OF TOBACCO USE AMONG YOUTH AND RETAIL POLICIES PROTECT YOUTH FROM TOBACCO INDUSTRY TACTICS THESE POLICIES CREATE THE ENVIRONMENT TO ONE THAT CREATES A SOCIAL NORM THAT DOESN’T SUPPORT SMOKING AS TOBACCO USE IT MOTIVATES SMOKERS TO QUIT AND SUPPORT QUITTING NIECE POLICIES ALSO MAKE STAYING QUIT EASIER LOCAL POLICIES, WHEN IMPLEMENTED IN A STRATEGIC WAY CAN RESULT IN STATEWIDE POLICY CHANGE SO THEY CAN PROMPT INDUSTRY CHANGE AS WE’VE SEEN WITH THE RECENT MOVE BY CVS TO STOP SELLING TOBACCO PRODUCTS BECAUSE MORE THAN 50% OF THE POPULATION IN MASSACHUSETTS IS COVERED BY A LOCAL REGULATION THAT BANS THE SEAM OF TOBACCO PRODUCTS IN PHARMACIES WE APPLAUD CVS ANOTHER REGULATION A YOUTH PREVENTION STRATEGY AND IT’S ALSO A PRICING STRATEGY LOCAL MUPTDS HAVE BEEN ADOPTING REGULATIONS THAT PROHIBIT THE SALE OF — PROHIBIT THE SALE OF TOBACCO USE OF CHEAP SINGLE CIGARS, AND WHEN SINGLE CIGARS THEY MAY STILL BE SOLD BUT THEY CAN’T BE SOLD FOR UNDER $2.50 0 IN MASSACHUSETTS WE’RE PROUD CIGARETTE SMOKING IS DECLINING AMONG OUR YOUTH AND THE 84 YOUTH WILL TELL YOU THEY GOT THEIR NAME BECAUSE IT STANDS FOR THE 84% OF MASSACHUSETTS YOUTH WHO CHOOSE NOT TO SMOKE BUT THEY ARE LOOKING TO CHANGE THE NAME AND WE’VE ALREADY WE ALREADY HAVE THE RIGHTS FOR THE 90.ORG SO, WHEN THE FUNDING CUT BROUGHT OUR BUDGET $2.5 MILLION THE YOUTH SMOKING RATE PLATEAUED AND THEN AS THE FUNDING INCREASED, YOUTH PROGRAMS WERE RESTORED, AND THE MODEL REGULATION WAS INTRODUCED MORE REGULATIONS WERE BEING PASSED, AND MORE YOUTH WERE INVOLVED AND THEN THERE WERE ALSO TAX INCREASES AT BOTH THE STATE AND FEDERAL LEVELS PRIORITY THREE INCREASING THE PRICE OF TOBACCO ONE WAY TO INCREASE THE PRICE OF CIGARETTES IS BY RAISING TAXES AND MASSACHUSETTS HAS ONE OF THE HIGHEST CIGARETTE TAXES IN THE COUNTRY WE ALSO HAVE A MINIMUM PRICE LAW THAT HELPS US TO KEEP THE PRICE OF CIGARETTES REASONABLY HIGH THE MINIMUM PRICE FOR A PACK OF MARLBOROS IN MASSACHUSETTS IS $9.54 AND THIS FORMULA, IT ATTEMPTS TO DETERMINE THE COST TO THE RETAILER OF SELLING CIGARETTES, AND THEN IT PROTECTS SMALL BUSINESSES FROM UNFAIR PRICING PRACTICES OF LARGER RETAILERS SO THIS ASK NOT A PUBLIC HEALTH CARE BUT IT CERTAINLY HAS PUBLIC HEALTH BENEFITS AND THEN AS THE PRICE OF CIGARETTES GOES UP, CONSUMPTION GOES DOWN PRIORITY FOUR IS TO ENSURE THAT ALL SMOKERS RECEIVE AN INTERVENTION BY THEIR HEALTH CARE PROVIDER THE QUITWORKS PROGRAM HAS BEEN INSTRUMENTAL IN ESTABLISHING A SYSTEM OF REFERRAL FOR HEALTH CARE PROVIDERS THE PROVIDERS SEND THE REFERRAL TO THE QUIT LINE AND THEY

CONTACT THE SMOKER AND THEN THE QUIT LINE SENDS A REPORT BACK TO THE PROVIDER THIS HAS INCREASED OUR CALLS TO THE QUILT LINE, IT’S INCREASED THE NUMBER OF SMOKERS WHO RECEIVE AN INTERVENTION BY THEIR HEALTH CARE PROVIDER AND TECHNICAL ASSISTANCE IS ALSO PROVIDED TO THESE HEALTH CARE PROFESSIONALS IN TOBACCO TREATMENT INTERVENTIONS, AND ALSO IN THE QUITWORKS REFERRAL PROCESS SO THERE’S BEEN A STEADY INCREASE OF PROVIDERS WHO RECOMMEND SOME FORM OF TOBACCO TREATMENT IN MASSACHUSETTS SO PROTECTING ALL MASSACHUSETTS RESIDENTS FROM SECONDHAND SMOKE MASSACHUSETTS HAS A VERY STRONG SMOKE FREE WORKPLACE LAW AND WE HAVE A VERY STRONG SMOKE FREE WORKPLACE LAW AND COMPLIANCE WITH THAT LAW IS REALLY VERY HIGH SO THEN WHEN THE COMMUNITY TRANSFORMATION GRANTS CAME ABOUT, MASSACHUSETTS GOT A TRANSFORMATION GRANT AND WHAT WE WERE ABLE TO DO IS MOVE IN TO SMOKE-FREE PUBLIC HOUSING BECAUSE OF OUR STRONG INFRASTRUCTURE WE WERE ABLE TO REALLY ACT QUICKLY, AND REACH OUT TO LOCAL PUBLIC HOUSING AUTHORITIES AND RESIDENTS OF THOSE HOUSING AUTHORITIES TO TEACH THEM MORE ABOUT THE DANGERS OF SECONDHAND SMOKE, AND SECONDHAND SMOKE IN SMOKE-FREE HOUSING POLICIES BECAUSE OF THAT, AND BECAUSE OF THAT STRONG INFRASTRUCTURE, OUR LOCAL PROGRAMS DID ALL OF THAT OUTREACH, THEY WORKED WITH STATEWIDE TECHNICAL ASSISTANCE PROVIDERS, AND NOW — YOU CAN SEE THAT THE NUMBER OF SMOKE FREE PUBLIC HOUSING AUTHORITIES HAS DRAMATICALLY INCREASED OVER THE PAST THREE YEARS AND THE NUMBER OF SMOKE FREE UNITS OF PUBLIC HOUSING HAS ALSO INCREASED THE COMPUTER JUST REALLY WANTS ME TO GET TO THIS SLIDE IS IT TIME? OKAY SO, WE’VE LEARNED AND ADAPTED TO CHANGING CONDITIONS OVER THE PAST TWO DECADES AND WE’VE SEEN AN INCREASED IMPACT WITH STANDARDIZED LANGUAGE IN OUR SAMPLE REGULATION, AND A PRIORITY SET OF POLICIES WE’VE ALSO SEEN THAT YOUTH GROUPS ARE REALLY VALUABLE IN EDUCATING STAKEHOLDERS BECAUSE THEY BRING REAL LIFE EXAMPLES AND THAT COMPREHENSIVE PROGRAMS IS JUST ESSENTIAL IT’S CRITICAL THAT WE’RE ABLE TO REFER SMOKERS TO FREE CESSATION SERVICES WHEN ENVIRONMENTAL POLICIES MOTIVATE THEM TO QUIT SOME LAWS AND REGULATIONS MUST BE ADOPTED ON THE STATEWIDE LEVEL SUCH AS TAXES OR THE MINIMUM PRICING BUT LOCAL POLICY, LOCAL PUBLIC HEALTH REGULATIONS CAN PROVE — CAN REALLY PAVE THE WAY FOR STATE LEVEL LEADERSHIP AND AS YOU CAN SEE, LOCAL INVOLVEMENT IN TOBACCO CONTROL PROGRAMS IS REALLY IMPORTANT MTPC WORKS TO SUPPORT THE MILLION HEARTS INITIATIVE BY CREATING ENVIRONMENTS THAT ENCOURAGE SMOKERS TO QUIT, SUPPORT SUSTAINED QUIT ATTEMPTS AND REDUCES EXPOSURE TO SECONDHAND SMOKE THEREBY REDUCING THE RISK FOR HEART DISEASE AND STROKE THANK YOU AND OUR NEXT SPEAKER IS PATRICIA CUMMINGS [ APPLAUSE ] >> HI, GOOD AFTERNOON, EVERYONE TODAY I’M GOING TO DISCUSS OUR EFFORTS TO IMPROVE CARDIOVASCULAR HEALTH THROUGH SODIUM REDUCTION EFFORTS IN LOS ANGELES COUNTY ALTHOUGH THERE ARE NUMEROUS MILLION HEARTS RELATED PROGRAMS IN L.A. COUNTY, TODAY I WOULD LIKE TO FOCUS OUR ATTENTION ON SODIUM REDUCTION INCLUDING SOME SPECIFIC AND MEASURABLE SUCCESSES WE HAVE HAD, WHAT WE HAVE LEARNED, AND WHAT WE’RE PLANNING FOR THE FUTURE JUST LIKE IN TOO MANY PARTS OF THE COUNTRY, ALMOST A QUARTER OR ONE IN FOUR ADULTS IN L.A COUNTY HAVE BEEN DIAGNOSED WITH HYPERTENSION THIS IS A KEY RISK FACTOR FOR HEART DISEASE AND STROKE WHICH ARE LEADING CAUSES OF DEATH IN THE COUNTY, AND THE U.S ONE SOLUTION TO LOWERING YOUR BLOOD PRESSURE IS TO REDUCE YOUR SODIUM INTAKE HOWEVER, CURRENT LEVELS OF SODIUM IN THE FOOD SUPPLY ARE HIGH, AND NOT SAFE AND IT CAN BE DIFFICULT FOR EVEN THE MOST MOTIVATED CONSUMER TO REDUCE THEIR SODIUM INTAKE TO ADDRESS THIS ISSUE THE LOS ANGELES COUNTY DEPARTMENT OF PUBLIC HEALTH LAUNCHED A NUMBER OF FIELD POLL SURVEYS TO GAUGE THE OPINIONS ON SODIUM AND THE RESULTS REVEALED A MAJORITY OF ADULTS IN L.A COUNTY BELIEVE THERE SHOULD BE RESTRICTIONS, AND REDUCTIONS IN PACKAGED AND RESTAURANT FOODS SO TO ADDRESS THESE CONCERNS THE LOS ANGELES COUNTY DEPARTMENT OF PUBLIC HEALTH LAUNCHED ITS SODIUM REDUCTION INITIATIVE IN 2010 AND THIS WAS DONE THROUGH FUNDING FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION SODIUM REDUCTION IN COMMUNITIES PROGRAM SINCE THE LAUNCH, WE HAVE WORKED WITH COUNTY, AND CITY OF L.A., GOVERNMENT DEPARTMENTS, SCHOOL DISTRICTS, SUCH AS THE LOS ANGELES UNIFIED SCHOOL DISTRICT, AND HOSPITALS, TO IMPLEMENT STRATEGIES TO IMPROVE FOOD SERVICE VENUES AND REDUCE SODIUM INTAKE THE LOS ANGELES COUNTY DEPARTMENT OF PUBLIC HEALTH ALSO SIMULTANEOUSLY LAUNCHED ITS HEALTHY FOOD PROCUREMENT INITIATIVE IN 2010 SHORTLY THEREAFTER, OUR LOCAL

GOVERNING BODY FOR THE LOS ANGELES COUNTY REGION PASSED A MOTION REQUIRING THE DEPARTMENT OF PUBLIC HEALTH TO REVIEW AND MAKE NUTRITION RECOMMENDATIONS FOR ALL NEW AND RENEWING FOOD SERVICE CONTRACTS IN THE COUNTY SINCE PASSAGE OF THIS MOTION WE HAVE WORKED WITH SIX OUT OF OUR TWELVE COUNTY DEPARTMENTS THAT SERVE, PROCURE AND/OR DISTRIBUTE FOOD AND I WILL BE PRESENTING EVALUATION DATA SHORTLY ABOUT ONE OF THESE DEPARTMENTS, OUR CEO DEPARTMENT AS A CASE STUDY BUT FIRST OUR COUNTY GOVERNMENT STRUCTURE IS COMPROMISED OF 37 DEPARTMENTS WITH OVER 100,000 STAFF THESE 37 DEPARTMENTS ARE SPREAD ACROSS 88 CITIES, AND PROVIDE SERVICES FOR OVER 10 MILLION RESIDENTS WHICH IS MORE POPULOUS THAN 42 INDIVIDUAL U.S. STATES OUT OF THE 37 DEPARTMENTS, 12 OF THEM PURCHASE, SELL AND/OR DISTRIBUTE FOOD AND THEY FALL INTO ONE OF TWO CATEGORIES THE FIRST IS OUR NONRETAIL OR MEALS SERVED TO DEPENDENT COMMUNITY MEMBERS AND THE SECOND IS RETAIL OR FOOD SOLD ON OUR GOVERNMENT PROPERTY, SUCH AS OUR CAFES OR SNACK SHOPS FROM THESE 12 DEPARTMENTS WE SERVE A CONSERVATIVE ESTIMATE OF 37 MILLION MEALS AND SNACKS EACH YEAR SO TO OPERATIONALIZE OUR HEALTHY NUTRITION STANDARDS OUR DEPARTMENT UTILIZES A FIVE-PHASE PROCESS FRAMEWORK AND THE FIRST PHASE IS WHERE WE INVESTIGATE FACTORS THAT MAY IMPEDE HEALTHY EATING BY CONDUCTING A NEEDS ASSESSMENT THE SECOND PHASE IS WHERE WE IDENTIFY AND EDUCATE OUR KEY STAKEHOLDERS THAT ARE CHAMPIONS IN THIS WORK AND THE LAST THREE PHASES OF ADOPTION, IMPLEMENTATION AND EVALUATION I WILL GO THROUGH IN A BIT MORE DETAIL NOW SO THE CONTRACTING PROCESS, WHICH INCLUDES THE REQUEST FOR PROPOSAL OR INVITATION FOR BID PROCESS IS VERY SIMILAR TO LIKE APPLYING FOR A GRANT THE PROSPECTIVE VENDOR NEEDS TO PROVIDE A LETTER OF INTENT, AND THEN SUBMIT A PROPOSAL DPH, OUR DEPARTMENT OF PUBLIC HEALTH, THEN PRESENTS OUR NUTRITION STANDARDS AT THE BIDDER’S CONFERENCE TO ANSWER ANY QUESTIONS ABOUT THE CONTRACT REQUIREMENTS OR NUTRITION STANDARDS ONCE THE VENDOR IS CHOSEN, AND EXECUTES THE CONTRACT, OUR DEPARTMENT RECOMMENDATIONS IN THE RFP OR REQUEST FOR PROPOSAL NOW BECOME CONTRACT REQUIREMENTS FOR EXAMPLE, IN ONE OF OUR VENDING CONTRACTS, THE RECOMMENDATIONS FOR PLACEMENT AND PROMOTION STRATEGIES SUCH AS ADVERTISING HEALTHY BEVERAGES, AND PLACING WATER AT EYE LEVEL, ARE NOW CONSIDERED CONTRACT REQUIREMENTS SINCE THE VENDOR HAS OFFICIALLY EXECUTED THIS CONTRACT IN ADDITION TO THESE CONTRACTS REQUIREMENTS, IF THE CONTRACT IS FOR VENDING MACHINES, OUR GOVERNING BOARD ALSO MANDATES THAT ALL COUNTY CONTRACTED VENDING MACHINES MUST ADHERE TO THESE SPECIFIC NUTRITION STANDARDS FOR EXAMPLE, SNACKS IN OUR VENDING CAN HAVE NO MORE THAN 360 MILLIGRAMS OF SODIUM PER INDIVIDUAL ITEM OR PACKAGE TO ASSESS ADHERENCE OF THESE GUIDELINES WE CONDUCTED AN IN-DEPTH EVALUATION OF OUR LARGEST VENDING CONTRACT, WHICH COVERED OVER 500-PLUS VENDING MACHINES ACROSS 200 LOCATIONS IN OUR COUNTY AND WE COLLECTED DATA BEFORE AND AFTER IMPLEMENTATION, AND AS YOU CAN SEE, WE SAW AN IMPROVEMENT IN ADHERENCE IN BOTH OUR SNACKS AND BEVERAGES LEADING TO 1 2% IMPROVEMENT IN ADHERENCE FOR SNACKS AND 35% IMPROVEMENT IN ADHERENCE FOR OUR BEVERAGES FOR OUR SODIUM AVERAGES WE ANALYZED MULTIPLE DATA SOURCES INCLUDING SALES DATA, PRODUCT LIST INFORMATION AND ENVIRONMENTAL SCAN DATA USING THE VALIDATED NUTRITION ENVIRONMENT MEASURES SURVEY FROM THESE DATA WE WERE ABLE TO IDENTIFY ON AVERAGE A 57% REDUCTION OF SODIUM IN PACKAGED SNACKS BEFORE AND AFTER IMPLEMENTATION OF OUR NUTRITION GUIDELINES SO THE QUESTION THAT WE ALL WANT THE ANSWER TO IS WHAT IS THE IMPACT OF OUR SODIUM REDUCTION EFFORTS IN THE COUNTY? WE PROGRAMATICALLY THE PROGRAM ADHERES TO OUR VENDING MACHINE POLICY NUTRITION STANDARDS WHICH IN TURN IMPROVES THE HEALTH OF OUR EMPLOYEES, OUR VISITORS AND OUR CLIENTS AND TO TRANSLATE THIS INTO A MEASURABLE OUTCOMES WE USE THE FUTURE ELDERLY MODEL WHICH IS AN ECONOMIC DEMOGRAPHIC MICROSTIMULATION AND WE APPLIED IT HERE TO CALCULATE PRELIMINARY ESTIMATES OF A MODEST REDUCTION AMONG 51 YEARS OF AGE AND OLDER POPULATION IN LOS ANGELES COUNTY AND WE EXAM DIFFERENT SCENARIOS IN WHICH SALT CONSUMPTION IS REDUCED BY ONE GRAM PER DAY IN OTHER WORDS 400 MILLIGRAMS OF SODIUM PER DAY THIS TRANSLATES TO ABOUT TWO LIVES SAVED EVERY WEEK AND A SUBSTANTIAL AMOUNT OF SAVINGS IN TOTAL MEDICAL SPENDING BETWEEN TWO TO THREE BILLION IN LOS

ANGELES COUNTY OVER A PERIOD THESE TWO LIVES SAVED PER WEEK IS EQUIVALENT TO ABOUT 100 LIVES SAVED PER YEAR AND THIS TRANSLATES TO UPWARDS OF 500 LIVES SAVED AND UP TO 700 MILLION IN MEDICAL COSTS AVERTED IN LOS ANGELES COUNTY OVER THE FIVE-YEAR PERIOD COVERED BY MILLION HEARTS SO WHAT ARE THE LIMITATIONS AND LESSONS LEARNED? WELL, ONE, VENDOR PRODUCT LIST INFORMATION CANNOT BE ASSUMED TO BE WHAT IS IN THE MACHINE AS WE FOUND FROM DOING IN-PERSON ENVIRONMENTAL SCANS AND COMPARING IT TO THE PRODUCT LIST INFORMATION PROVIDED BY THE VENDOR THERE COULD BE DIFFERENCES IN THE TWO SECOND PARTNERSHIP WITH THE DEPARTMENT AND THE VENDOR IS VALUABLE FOR ADHERENCE AND EVALUATION IS ABSOLUTELY ESSENTIAL LASTLY IN TERMS OF NEXT STEPS WE WILL CONTINUE TO COLLECT SODIUM INTAKE DATA AND MORE TON OUR END RESULT IN CLOSING I WOULD LIKE TO THANK MY COLLEAGUES AT L.A. COUNTY FOR THEIR CONTRIBUTIONS AND ONGOING WORK ON THIS VERY IMPORTANT ISSUE AND I WOULD LIKE TO NOW BRING JANET WRIGHT BACK UP TO THE PODIUM THANK YOU [ APPLAUSE ] WELL, TODAY’S SPEAKERS HAVE OFFERED US ALL POWERFUL EXAMPLES OF THE CLEAR SIGNAL THAT SMALL, SMALL, SUSTAINED ACTIONS CAN PROTECT OUR FAMILY OUR FRIENDS OUR COWORKERS FROM HEART ATTACK AND STROKE WE ASK YOU TODAY TO MAKE PREVENTION OF CARDIOVASCULAR DISEASE A PRIORITY FOR YOURSELF, FOR YOUR HOMES AND YOUR FAMILIES, FOR YOUR PRACTICE, AND FOR YOUR COMMUNITY WE ASK THAT YOU MEASURE YOUR WAY TO BETTER HEALTH AND LET US KNOW YOUR PROGRESS AND FINALLY, HELP FIND THOSE AT RISK FOR THIS PREVENTABLE DISEASE CONNECT THEM TO HEALTH CARE AND TO COMMUNITY RESOURCES AND DO NOT REST UNTIL THAT RISK IS CONTROLLED THE CLOCK IS TICKING WE WILL BE COUNTING, AND THE NATION IS COUNTING ON YOU THANK YOU [ APPLAUSE ] I THINK WE’LL BE TAKING QUESTIONS WE HAVE MICROPHONES AT BOTH SIDES — OH, WE’VE GOT MICROPHONES AND RUNNERS AND WE’LL ALSO BE TAKING A FEW QUESTIONS I 24I FROM SOCIAL MEDIA PLEASE >> THIS WAS A PHENOMENAL PANEL THANK YOU VERY MUCH IT’S ALWAYS GOOD TO SEE HOW YOU TAKE THE GUIDELINES AND THEN YOU IMPLEMENT THEM USING YOUR LOCAL FLAIR AND I HEARD COLLABORATION, COLLABORATION, DISSEMINATION SO THANK YOU VERY MUCH FOR THAT SO MY COMMENT ACTUALLY IS FOR JANET, BECAUSE THIS IS A REQUEST WHEN WE TRY TO COLLABORATE IT’S REALLY HELPFUL WITHIN A STATE TO KNOW WHO HAS SIGNED THAT PLEDGE WITHIN A STATE SO THAT THE PEOPLE WHO ARE WITHIN A COMMUNITY CAN KNOW WHO WE CAN WORK TOGETHER WITH, SO MY REQUEST TO YOU IS A WAY TO MAKE PUBLIC, OR AVAILABLE, THOSE OF US WHO ARE WORKING IN MILLION HEARTS TO BE ABLE TO COLLABORATE WITH ONE ANOTHER THANK YOU GOOD ADVICE WE’LL GET BACK TO YOU ABOUT THAT HI NUTRITION PHYSICAL ACTIVITY AND OBESITY HERE AT CDC I HAD A QUESTION FOR PATRICIA REGARDING SALES FOR THE VENDING CAN YOU MAYBE COMMENT ON THE TREND IN SALES THAT YOU OBSERVED? THERE’S TWO PATRICIAS I’M LAUGHING WE ARE IN THE PROCESS OF EXAMINING SALES DATA IN TERMS OF REVENUE CURRENTLY WE HAVE USED IT, IT WAS ON THE SLIDE WE’VE USED IT TO WEIGHT OUR DATA BECAUSE AS YOU KNOW YOU CAN CALCULATE AVERAGES OF SODIUM, YOU KNOW, FROM YOUR PRODUCT LIST INFORMATION AND NUTRITION ANALYSIS DATA BUT YOU CAN ALSO USE SALES DATA TO WEIGHT IT TO ACTUALLY GET AT A MORE ACCURATE PICTURE OF WELL WHAT WE USE AS A PROXY FOR CONSUMPTION NOT REALLY CONSUMPTION BUT WE’RE GETTING AT MORE OF WHAT PEOPLE ARE PURCHASING, AND SEEING IF WHAT THEY’RE PURCHASING IS HIGHER SODIUM THAN WHAT’S AVAILABLE SO WE ARE IN THE PROCESS, HOWEVER, OF MOVING THIS ANALYSIS FORWARD THESE ARE THE NEWEST RESULTS SO ALL OF YOU ARE HEARING FIRSTHAND THIS DATA THAT’S JUST BEEN RELEASED WE ARE IN THE PROCESS OF CONTINUING THAT TO LOOK AT REVENUE >> ONLINE AND SOCIAL MEDIA AUDIENCES IS THERE RESEARCH ON THE RELATIONSHIP BETWEEN HEART HEALTH AND REMAINING CONNECTED TO FAMILY AND IN COMMUNITIES? TO ANYONE

THERE IS I’M NOT AN EXPERT IN THAT AREA, BUT WE KNOW THAT CONNECTIONS THAT WE HAVE CONTRIBUTE TO OUR MENTAL AND PHYSICAL HEALTH I COULDN’T QUOTE YOU A SOURCE FOR THAT >> NOT SURE IF THIS IS WHAT THEY’RE GETTING AT BUT CERTAINLY WE KNOW THAT FROM SOME STUDIES AROUND FIT WHICH IS CALLED FAMILIES IN TRAINING WHERE WE HAVE FAMILIES THAT STAY HEALTHY TOGETHER, WORK TOGETHER, ANOTHER PROGRAM THAT I THINK IS WORKING AT THE YMCA RIGHT NOW WHERE WE’LL HAVE FAMILIES SORT OF WORKING TO THE, WORKING OUT TOGETHER, GETTING DIETARY AND NUTRITION INFORMATION TOGETHER SO THAT IT REALLY FEELS LIKE A MORE COLLECTIVE APPROACH TO HOW A FAMILY FEELS BETTER I THINK CERTAINLY THERE’S RESEARCH OUT THERE THAT COULD PROBABLY SUPPORT THAT MY QUESTION IS TO DR. TREMBLAY YOU WERE ABLE TO DEVELOP A PROTOCOL FOR MANAGING THE IMPROVEMENT OF THE MEDICATION WERE YOU ABLE TO INCORPORATE SOME OF THE DISCOUNT MEDICATIONS, THOSE $4 FORMULARIES THAT ARE MORE ACCESSIBLE TO ALL? ABSOLUTELY YEAH, I THINK THAT’S ONE OF THOSE THINGS THAT REALLY DEPENDS ON YOUR COMMUNITY, BECAUSE EACH COMMUNITY HAS DIFFERENT STORES AND DIFFERENT PHARMACIES THAT HAVE THESE DEALS FOR US AS PROVIDERS, AT LEAST IN OUR ORGANIZATION, THERE’S VERY FEW TIMES THAT WE’RE EVER USING ANY BRAND NAME, I HATE TO SAY THAT BUT IT’S TRUE BECAUSE ALMOST EVERYTHING IS $4, OR $9 FOR THREE MONTH SUPPLY AND WE’RE VERY SENSITIVE TO THAT ISSUE WITH OUR PATIENTS IN GENERAL AND SO AS PART OF THE MEDICATION LISTS THAT WE PROVIDE AS PART OF OUR EMR ONLINE TOOL THE LIST OF ALL OF THE LOCAL PHARMACIES THAT DO OFFER THOSE PLANS SO IF THERE’S ANY QUESTION FOR A PROVIDER THAT INFORMATION IS AVAILABLE MOST OF THE STUDIES THAT ARE OUT THERE ALSO USUALLY ARE FOCUSED PRIMARILY ON GENERIC-TYPE MEDICATIONS AND AS A RESULT OF THAT, THAT’S THE EVIDENCE THAT WE USE TO SUPPORT OUR ALGORITHMS AND SO WE FILL THOSE IN TO OUR PRACTICE ANOTHER QUESTION FROM OUR ONLINE AUDIENCES ON YOUR DATA OR BREAKDOWNS ON WHICH ETHNIC GROUPS — AND WHICH ETHNIC GROUPS ARE MOST AFFECTED BY HEART DISEASE, AND DO WE HAVE A RESOURCE FOR THAT INFORMATION? >> WE ACTUALLY HAVE SOME INFORMATION ON OUR WEBSITE ABOUT THAT THAT’S MILLION HEARTS, AS WELL AS THE CDC HAS DATA THAT THEY COULD OFFER >> I HAVE A QUESTION, AND I THINK THIS MIGHT BE FOR PATRICIA HENLEY AND MAYBE ANDREW PATRICIA I’LL START WITH YOU IN MASSACHUSETTS YOU MENTIONED THAT QUITWORKS WHICH AS I UNDERSTAND IT HELPS PROVIDERS DO A GOOD JOB OF OFFERING THE INTERVENTIONS COULD YOU SPEAK TO THE OBSTACLES THAT PROVIDERS MENTION WHEN — WHAT PROBLEMS IS QUITWORKS HELPING THEM SOLVE? QUITWORKS HAS REALLY HELPED THEM SOLVE THE ISSUE OF WHAT TO DO WHEN THEY FIND SOMEBODY, YOU KNOW, THEY WORK WITH SOMEBODY WHO SMOKES THEY HAVE FELT IN THE PAST THAT THERE WERE LIMITED RESOURCES — QUITLINE WOULD CALL THE SMOKER, IT WOULD — IT MADE THAT CONNECTION — AND THEN ACTUALLY FOUND OUT WHAT — THE ONLINE STAFF WOULD GO BACK TO THE HEALTH CARE PROVIDER BUT THEY KNEW THAT THAT CONNECTION WAS MADE AND THAT QUESTION COMES AGAIN I THINK THAT THAT JUST KEEPS — >> SIMILARLY I THINK ONE OF THE BIG THINGS WE FOUND WITH THE BARRIERS IS ONE OF THE CLASSIC EXAMPLES THAT WAS BROUGHT UP WAS I WOULD SEE A PECCENT IN MY OFFICE IN JANUARY WHO HAD HIGH BLOOD PRESSURE, AND THE BLOOD PRESSURE WAS FANTASTIC, THERE WAS NO NEED — SOMEWHERE IN A FOUR-MONTH PERIOD WAS AGE TO GO — AND SUDDENLY THERE WAS NO CONNECTION BACK TO PRIMARY CARE AND THAT WAS ONE OF THE BARRIERS THAT WE ENCOUNTERED SO PROVIDING TOOLS THAT DIDN’T JUST GET ALONG TRYING TO MONITOR ALL THESE DIFFERENT THINGS, AND ENGAGE WITH THE PRIMARY CARE PROVIDERS SO THAT’S WHY WE CREATED THIS PROCESS SO IF SOMEONE WERE TO HAVE AN ELEVATED BLOOD PRESSURE OUR EXPECTATION–