Tuesday, January 16, 2018

What is being done about the opioid epidemic at a national, state, and local level

Elaine Zhang, BS
Research Associate 

The rise in pain killer prescriptions from doctors combined with aggressive marketing campaigns from large pharmaceutical companies in the 1990’s awakened a tsunami of addiction that has swept through the US resulting in significant increase in opioid drug overdose death rates. From 2000 to 2015 more than half a million people died from a drug overdose.1  Since 2011, the rate of drug overdose deaths due to opioid prescriptions started to level out while death rate due to heroin overdose experienced a sharp increase, see graph below. In 2016, roughly 64,000 people died due to drug overdoses making it the leading cause of death for Americans under 50 years old.2

Massachusetts is experiencing the opioid epidemic at a much higher rate than the rest of US. In 2014, Massachusetts’s age adjusted overdose death rate was 23.3 per 100,000 which is more than doubled the national rate of 9.6 per 100,0003. In 2017, there were 932 confirmed opioid related deaths in Massachusetts; 76% of deaths were male and 24% were female.4 The opioid epidemic also affects the white non-Hispanic population at a much higher rate than any other race. Of the 932 confirmed opioid-related deaths in 2017, 81% or 753 of those deaths were of people of white non-Hispanic race/ethnicity. This group has historically had higher death rates than any other race/ethnic group in the past three years4, see graph below. 

At a county level, certain counties are experiencing higher opioid overdose death rates than other ones. Barnstable, Berkshire, Bristol, Duke, Essex, Norfolk, Plymouth, and Worcester counties currently have the highest opioid overdose death rate,5 see map below. 

In October 2017, the president declared the opioid epidemic a national public health emergency. The Department of Health and Human Services has outlined a five-point strategy to combat the opioid epidemic:
1.       Improving access to treatment and recovery services
2.       Promoting use of overdose reversing drugs
3.       Strengthening our understanding of the epidemic through better public health surveillance
4.       Providing support for cutting edge research on pain and addiction
5.       Advancing better practices for pain management.
The Center for Disease Control and Prevention (CDC) awarded $28.6 million in funds to 44 states and the District of Columbia to help strengthen prevention efforts and better understand the epidemic through public health data6, which aligns with part of the HHS five point strategy.

In 2015, Massachusetts Governor Charlie Baker signed Chapter 55 into law in response to the opioid epidemic. The new law allowed different government data sets to be analyzed to help guide policy decisions and better understand the opioid epidemic.7 The Baker administration also allocated $34.5 million to combat the opioid epidemic through raising awareness, increasing prevention, and providing education. Recent data shows that in the first 9 months of 2017 there were 167 fewer opioid related overdose deaths when compared to the first 9 months of 2016, a 10% drop in deaths.8 Along with the decrease in deaths, there has also been a 30% decrease in the number of patients who were prescribed an opioid in the third quarter of 2017 when compared to the first quarter of 2015.8

At ICH, we work on several projects that focus on the opioid substance use disorders. SUSTAIN Communities Evaluation is an initiative funded by the GE Foundation with support from Partners HealthCare. SUSTAIN Communities provide grants and technical assistance to community health centers to build capacity for Medication Assisted Treatment (MAT) for patients with opioid use disorder.  ICH Assistant Director of Research, Leah Zallman, MD, MPH, works on a project funded by a small foundation (McManus) that uses electronic health record data to understand the relationship between opioid prescriptions and the development of opioid abuse disorder. ICH is looking into Cambridge Health Alliance data among patients who have ever been prescribed opioids and tracking how many developed opioid use disorders, how long it took, and what are the clinical predictors. Promoting Older Women’s Engagement in Recovery (POWER) is a collaborative project aimed at the prevention of opioid misuse in older women ages 55 or older in Cambridge and Somerville. The Institute for Health and Recovery received the grant and works alongside with Cambridge Health Alliance, Somerville Cambridge Elder Services, and the Cambridge Council on Aging to address the risk factors of opioid misuse among older women through technical assistance for partnership sites and direct support groups for women 55+. ICH is the evaluator on the project.

If you or someone you know is struggling with addition, there are some resources available to help. The Massachusetts SubstanceAbuse Information and Education Helpline provides free and confidential information and referrals for alcohol and other drug abuse problems. The Institute for Health and Recovery helps families and youth with substance abuse issues access publicly funded services. The Suboxone Hotline Office Based Opioid Treatment Program at Boston Medical Center provides referrals and information on opiate and heroin treatments available at doctor’s offices statewide. Cambridge Health Alliance offers an outpatient addiction service which helps adults to and maintain sobriety. The Fresh Start Alcohol and Drug Recovery Group is an anonymous peer support group that meets on Thursday evenings at CHA Revere Care Center. Smart Recovery is a scientifically tested program for adults who want to manage their addiction and is held every Tuesday evening at CHA Everett Care Center.

Below are the numbers for each helpline:
The Massachusetts Substance Abuse Information and Education Helpline:
Phone Toll Free: 1-800-327-5050
TTY: 1-888-448-8321

The Institute for Health and Recovery:
Phone: 1-866-705-2807
TTY: 1-617-661-9051

Suboxone Hotline Office Based Opioid Treatment Program at BMC:
Phone: 1-866-414-6926 or 1-617-414-6926


Wednesday, January 3, 2018

The Heart of ICH

Luisa Raleza 
Executive Assistant 

During this holiday season of giving and blessings, I am reflecting on how blessed I am.  I am fortunate to have good health, great family, friends, and colleagues.  The biggest blessing of all is that I am working for the Institute for Community Health (ICH).  ICH is a nonprofit consulting organization that provides participatory evaluation, applied research, and assessment and planning to help the helpers and, ultimately, assist local communities to create sustainable health.  Since the inception of ICH, it has contributed to communities, creating engagement and a chain of giving, which leads to a gratefulness for both the giver and the recipient alike.  The work ICH does leads to improved health, happier living, and better communities.

According to one of our founding fathers, Dr. David Bor, “ICH was created in response to the growing AIDS epidemic in the 1980's: David Bor, Marshall Forstein and Paul Epstein started the Cambridge AIDS Task Force. The task force considered health care to be the fourth priority after housing, work place anti-discrimination policies, and education about contagion -- a surprise to many health practitioners. That model of community engagement formed the basis for the ‘Cambridge-Harvard Health of the City Program (HoC)’, with funding from the Rockefeller Foundation and Pew Charitable Trusts. The co-directors of HoC included David Bor, representing the public hospital (CHA), Ron Arky, representing the private hospital (Mt. Auburn), and Frank Duehay, representing the city of Cambridge. The organization spawned the Men of Color Task Force, Healthy Children's Task force, and a "health information unit" whose purpose was to collect data to inform the public about local health and health needs. When funding ran out, the Cambridge Health Alliance, Mt. Auburn, and Mass General Hospital agreed to co-sponsor a new organization, The Institute for Community Health, based upon the same principles.”

The cosponsoring of ICH started this chain of partnership, involvement, caring, and giving to the communities.  My colleagues take this caring and giving to their partner organizations, who in turn pass it on to the communities they serve.  ICH assists our partners, for example, to help educate new parents on how to care for their children, and to improve the lives and health of folks that have health problems such as HIV, mental health, and/or substance use disorder.  ICH also assists our partners to prevent violence such as gang violence, domestic violence, and other relationship violence. And these are just a few of the areas in which we assist.  Overall, ICH creates better communities, especially for the underserved.  Best of all, ICH helps these foundations and programs work with the resources they do have and use them to the fullest. 

With great care, passion, and devotion, my colleagues assist ICH’s partners with creating safe and healthy environments.  Safe healthy environments then lead to greater prosperity and health equity, and in turn it gets passed on and given to others, who are able to make better lives for themselves.  I have always wished to work in an organization like this one and have been blessed.

Happy New Year to all!

Monday, December 18, 2017

Employee Spotlight Interview: Leah Zallman, MD, MPH

How would you describe your role at ICH? 
I have been at ICH since 2012 and I am currently the Assistant Director of Research. My responsibilities include advising and directing the research portfolio at ICH. I also serve as a team lead on many evaluation components. Because I am a physician, I have an advisory role on health system work which means I also help co-lead ICH’s health system focus area with Ranjani Paradise.

I am also a primary care physician for adults at one of the community health centers in East Cambridge. I serve in two administrative capacities at Cambridge Health Alliance. One is provider lead for provider engagement. This is a role in which I co-chair the Provider Engagement Steering Committee, an interdisciplinary group that is tasked with advising the organization on how to improve provider engagement. I also am the provider lead for social determinants of health. I help develop a strategy and process around systematically screening for and appropriately following up on social determinants of health.

What is your educational background?
I went to Swarthmore College for undergrad. Interestingly I was a bio major with a concentration in public policy, which I think actually has turned out to serve me well. I am more closely aligned with that then I had anticipated.

Then I went to medical school at New York University and then I did my internal medicine internship and residency at Boston Medical Center. My general internal medicine fellowship, which is essentially a research fellowship, was at Harvard Medical School and that was what brought me to Cambridge Health Alliance. CHA was my clinical site and so through the general internal fellowship, I got my masters in public health through the Harvard School of Public Health.

What was your career path before coming to ICH?
After college, I spent some time as a research coordinator at Montefiore Medical Center in the Bronx. There I really wanted to expose myself to physicians that were doing public health work and to see if that was a path I wanted to take. I found that I was really excited by the possibility of being involved in a really meaningful way in individual patient’s lives but also thinking about health policy and how we deliver care. I spent a couple of years there before I went to medical school.

What made you decide to come to ICH? 
I was really excited by the concept of a group that was dedicated to helping people improve health in a meaningful way. I have always found data to be really powerful and walked out of my general internal medicine fellowship with research training but really wanted to apply that training with people in a meaningful way to help them understand how to deliver care or programs better.

What has kept me at ICH is the incredible talent and passion within the organization. I feel blessed to be in a position where I derive joy from working with our partners

What are some projects that you are working on right now?
Community Catalyst: Community Catalyst is a national non-profit health care advocacy organization. They have an initiative called the Center for Consumer Engagement in Health Innovation that helps consumers and families, particularly vulnerable populations, have a voice in the healthcare delivery system. The Center runs a grant program called Consumer Voices for Innovation, which provides funding and technical assistance to state consumer health advocacy organizations to build consumer engagement in health system transformation. We are evaluating Consumer Voices for Innovation, which spans multiple states and organizations. It is really fun to think about how to do cross state evaluation of a program that aims to get consumers engaged in advocacy.

California Healthcare Foundation: The goal of this project is to understand to what degree are immigrants contributing and utilizing private health insurance dollars. This is a follow up to some papers that I had written demonstrating that immigrants subsidize Medicare and so now we are investigating if immigrants contribute more to private health insurance than they expend. We are using national data sets as well as data specific to California.

Click here to read more on Leah's paper about how immigrant are subsidizing Medicare. 

McManus: This is a grant we got from a small foundation to leverage electronic health record data to understand a little more of the relationship between opioid prescribing and the development of opioid abuse disorder. We are looking within CHA data among patients who have ever been prescribed opioid in our system to see how many developed opioid use disorders, how long it took, and what are clinical predictors of that. The goal is to help guide our understanding of how to prevent opioid use disorders.

What are you most excited about for the future of ICH?
I am really excited for ICH to continue to grow and really take on some of the challenges in healthcare happening right now. I think there are really great opportunities to lend our expertise and our understanding of health systems to help community based organizations and health systems to build capacity for improvement and sustainable community health.

What are your hobbies or things you like to do for fun?
My biggest hobby right now is hanging out with my 3 and 6 year boys. They are delightful but also challenging in every way.

What are your plans for the holidays? 
We always go to D.C to spend time with my mom, sister, and niece. We are Jewish but love celebrating Christmas. Then for New Year's Eve, I will be heading over to Cape Cod with some family friends. Our kids love running around outside there- especially at night with glow sticks on the beach!

Monday, November 6, 2017

Community Health Centers: Centers of Innovation and Best Practices in a Changing Healthcare Landscape

Leslie Chatelain, MPH, Research Associate

PCH – Partnership for Community Health
CHC – Community Health Center
ICH – Institute for Community Health

The landscape of healthcare in the U.S. has rapidly changed in the last several years. These changes have compelled community health centers (CHCs) to innovate to keep up. One mechanism enabling CHCs to implement innovative projects is grant programs. Some of these grants are funded by foundations which, in 2014 alone, gave away $60 billion (http://data.foundationcenter.org, most current data).  An example of this is the Partnership for Community Health Excellence and Innovation Grant Program (PCH), which has awarded over $17 million to CHCs in Massachusetts since 2014.  This money has helped grantees to develop and implement innovative projects to transform their operations and patient communications. The PCH grant program contracted with ICH to lead the foundation and grantee-level evaluations.  By using a participatory, utilization focused approach to this evaluation (http://instituteforcommunityhealth.blogspot.com/2017/10/the-foundation-to-effective-reporting.html), grantee CHCs have been able to collect meaningful data on the successes and challenges they have encountered while implementing their projects.  To magnify the impact of the foundation’s grant-making activities, ICH helps to strategically disseminate lessons learned so others can replicate and expand upon the grant-supported work.  One way this is done is by convening best practices forums or learning collaboratives.    

A learning collaborative or best practices forum offers an opportunity to grantees to pool and share knowledge with other CHCs who may benefit from such an exchange. PCH held such a forum most recently in September 2017 with 3 panels consisting of some of the current grantees. The panel topics included: addressing social determinants of health through adding new roles to the care team, improving care through telehealth technology, and taking a population health approach to chronic opioid dependence.
Insights from the forum’s panel on telehealth technology include the following:
·         With their small profit margins, community health centers generally cannot implement the kinds of projects presented at the forum without additional resources committed to innovation. Consequently, the investment provided by the funders was critical.
·         For technological projects, there is a need to assess the technology that is currently in place to determine what software or program would fit best with the existing infrastructure.
·         For all of the potential benefits that telehealth projects can have, it is essential that the right staff is in place to manage and harness the potential of the technology.

·         Telehealth projects have advanced thinking about what is possible to achieve with technology. Patient access to specialists is difficult across all health centers in the state and telehealth projects may be able to address that.
o   Example:  One project utilizing telehealth technology to triage dermatological conditions has determined that 75% of referrals to dermatology specialists are unnecessary.  Cutting down on unnecessary referrals frees up the services of dermatologists for patients who really need them.
At the conclusion of the discussion, one forum attendee reported that they “couldn’t wait to head back to their community health center and implement some of the ideas discussed at the forum.” Other attendees spoke similarly. This open sharing of knowledge, best practices, and lessons learned will serve to inform future innovative projects at community health centers and help to improve quality of care, increase patient/staff satisfaction, and reduce costs/increase operational efficiency at CHCs.
If interested, please see the following video to view the presentations and discussions from the forum

Thursday, October 5, 2017

The Foundation to Effective Reporting: A Utilization-focused, Participatory Approach

Eileen Dryden, PhD and Ranjani Paradise, PhD

Foundations gave away over $60 billion in 2014[1].  According to Social Solutions, reporting expectations for these financial distributions have increased over the last five years and are expected to increase even more over the next five years [2]. Driven largely by limited resources, these expectations increasingly focus on impact – evidence that shows what they are funding ‘works.’  However, many deserving grantee agencies that are stellar at providing services don’t necessarily have the experience or skills to know how to evaluate the impact of their work.  Additionally, the foundations themselves may not know quite what to ask.  Foundations often fund an array of agencies and programs whose goals have an implicit, if not explicit, alignment with their own mission. In an attempt to speak to that mission and make it easier to aggregate data in the end, many foundations create one generic reporting template for all grantees to complete.  Unfortunately, this approach is not likely to truly capture the unique contributions and impacts of each grantee.  Grantees get frustrated at trying to shoehorn their data into a report that doesn’t quite fit, and foundations end up with data that is less than compelling.  Technical assistance from experienced evaluators at ICH can help to address this problem. 

ICH works with foundations to clarify and focus their grant-making goals and effectively document their own, as well as their grantees’, impact. Our approach includes a number of activities that can be utilized as a comprehensive package or individually, as needed. 

Multi-level Logic Modeling and Evaluation Planning
Collaborating with foundation staff, we develop an overarching, foundation-level logic model, a visual that depicts the underlying theory of how their grant-making activities will accomplish their goals.

Example of foundation level logic model from
the Partnership for Community Health (PCH)  Excellence and Innovation Grant Program. 
 This granting program has distributed over $17 million since 2014.

We also work closely with each grantee to develop a project-specific logic model. Through this process we guide grant recipients to think about what their project can really accomplish and to ensure that their activities link to their anticipated outcomes.

Examples of grantee level logic models from
the Partnership for Community Health Excellence and Innovation Grant Program.

Working in partnership with each grantee, we develop evaluation plans that are meaningful and relevant to them, while simultaneously measuring outcomes that align with the foundation’s overarching goals. Using the grantee- and foundation-level logic models as a guide, we facilitate discussions to prioritize outcomes to measure and create evaluation plans that are focused, feasible, and useful. This process fosters buy-in to evaluation on the part of the grantee.

Layered, Strategic Reporting
We craft a tailored set of evaluation measures for each grantee’s project that is derived directly from their evaluation plan and flows naturally from the work they are doing. This ensures that the reports submitted by grantees capture project-specific outcomes that are connected to the foundation's key goals, making reporting a useful and relevant activity for both the grantee and the foundation. We provide technical assistance to grantees, as needed, to develop data collection tools, and collect and analyze their evaluation data.

We create summary reports at multiple levels of detail to meet the needs of different audiences, ranging from short, visual reports highlighting impact stories to in-depth data summaries for tracking individual grantees’ progress against goals. Comprehensive final reporting at the end of the grant period highlights program impact by rolling up individual grantee accomplishments into the foundations’ overarching goals. 

Collecting and Sharing Lessons Learned
To help document the collective learning that occurs throughout the implementation of each grantee’s project, we conduct qualitative interviews that allow us to gain a deeper understanding of grantees’ experiences. We summarize and share back the qualitative findings to ensure that future grantees can build upon the collective best practices and lessons learned to optimize their work.

Finally, we facilitate learning collaboratives among current and potential future grantees.  At these forums, grantees have an opportunity to share what they have learned and participants can informally network and discuss projects.  In this way, we ensure that lessons learned are disseminated to those who can benefit most.

“I just shaved months off of my project talking to someone I met here today.”

 - Best Practices Forum participant


This individualized, participatory approach generates a number of benefits including helping to:

Ensure grant-making success
    Foundations can monitor grantee progress and jump in when needed to help ensure grantee success
    Foundations continually improve their own grant-making process by learning from grantees’ experiences 

Promote sustainability
    Provides grantees with data that they have prioritized as useful.  This data can be leveraged for funding to sustain their work beyond the grant period.
    Builds grantee capacity to ‘think evaluatively’ and participate more effectively in evaluation activities in the future

Demonstrate and expand impact
    Foundations can readily demonstrate to their board and other stakeholders how their grant-making activities support their mission
    Because successes and lessons learned are disseminated strategically, others can replicate and expand upon the grant-supported work, magnifying the impact of the foundation’s grant-making activities.

Given all of these benefits, our clients have found that with the support of experienced evaluators, the typically onerous process of grant reporting becomes a win-win for foundations and grant recipients.
[1] http://data.foundationcenter.org (most current data)

Wednesday, September 6, 2017

ICH Response to the DACA Program

At ICH, we would like to extend our support to the 800,000 young people affected by the recent decision about the Deferred Action for Childhood Arrivals (DACA) program. The DACA program allows undocumented immigrant youth who were brought into the US by their parents at a young age to obtain legal status to work and go to school. These young people are contributing members to our society and are integral parts of our community.

We would like to share the below statement from one of our partners, Parenting Journey, regarding the recent news about the DACA program:
Today, Parenting Journey reaffirms its commitment to immigrant families. We are disheartened by Attorney General Jeff Sessions' actions today on Deferred Action for Childhood Arrivals (DACA), but we maintain our sincere support of the young people and families affected by Mr. Sessions' announcement.
Parenting Journey unequivocally stands with the 800,000 young people who are DACA beneficiaries and their families. The DACA program allows undocumented immigrant youth to obtain legal status for work or school, and to fully contribute to the fabric of our communities. At Parenting Journey, we believe that families are stronger together. We believe that America is great because of the contributions of immigrant families, and we are firmly opposed to any actions or policies that would deport nearly a million people and tear families apart.
To our partners and friends involved in efforts to protect and support immigrant families, thank you. We stand with you.”

If you would like to show support for the DACA program here are a few things you can do today:
  1. Contact your state senators and local representatives. To find out who your senators and representatives are click here.
  2. Support local organizations that are committed to protecting immigrant rights. You can volunteer, organize, donate, or attend peaceful protest and rallies.
  3. Share your story of how this will affect you or someone you know.

Thursday, August 17, 2017

ICH Response to Charlottesville

At ICH, we have witnessed the increasing visibility of racist hate groups in the U.S. with extreme concern. As leaders and followers of these groups emerge, they pose significant danger to the safety, health and well-being of vulnerable minorities and people of color, as we saw this weekend in Charlottesville. As with all terrorism, the fear stoked by this violent ideology reaches far beyond the actual victims of violence, impacting the well-being of people in widespread communities. Remaining silent, or making only general statements that fail to specifically condemn racism and hatred, encourages and validates these groups.
At ICH we have a deep appreciation for the experiences and perspectives of diverse communities and believe that racial equity is essential to community health. These hate groups stand in direct opposition to these values. We condemn these hate groups, their racist ideologies, and their terrorist violence in the strongest possible terms. We call upon all our leaders to do the same, and to use all available resources to protect the health and safety of our communities.