Com Med I

1.) Association of American Medical Colleges (Medical School Objectives Report);

• Physicians with population health perspective should have ability to: o Assess the health needs of a specific population o Implement and evaluate interventions to improve the health of that population o Provide care for individual patients in context of culture, health status, and health needs of the population of which that patient is a member.

3.5 Describe the three abilities of a physician practicing with a population health perspective as described by the AAMC (Medical School Objectives Report).

• Physicians with population health perspective should have ability to: o Assess the health needs of a specific population o Implement and evaluate interventions to improve the health of that population o Provide care for individual patients in context of culture, health status, and health needs of the population of which that patient is a member.

State at least one reason why attempts at reforming U.S. healthcare to provide universal coverage have failed.

• Piecemeal approach to healthcare reform o Medicare, Medicaid, children, medications o Too many stakeholders in current system o Not enough support for total overhaul • Medical industry is so large - over 17% of GDP • Too few underinsured; doesn't impact campaign finances

3.) Association of Faculties of Medicine of Canada Public Health Educators' Network;

• Population health can be viewed descriptively as the sum total of the health trends and determinants in a population. Alternatively, it can be seen analytically as a conceptual framework for thinking about why some people, and some peoples, are healthier than others. Population health has also been proposed as a unifying paradigm that links disciplines from the biological to the social, directing attention onto health as an important social goal and proposing policy approaches to promoting health.

3.3 Define the concept of population health.

• Population health: Approach to medicine that expands the scope of practice from an emphasis on the one -on-one physician-patient relationship (clinical medicine) to include a one-to one (or many) denominator focus; emphasizes the social determinants of health on a population level.

Perinatal mortality rate

"around the time of birth"; all fetuses that reach the 28th week of gestation are at risk; primary use to evaluate the care of pregnant women before and during delivery, as well as the care of mothers and their infants in the immediate postpartum period

- YPLL (years of potential life lost)

)→ way to describe severity of disease; measure of premature mortality/ early death; YPLL recognizes that death occurring in the same person at a younger age clearly involves a greater loss of future productive years than death occurring at an older age. o 2 steps: • In the first step, for each cause, each deceased person's age at death is subtracted from a predetermined age at death. • Second step, the "years of potential life lost" for each individual are then added together to yield the total YPLL for the specific cause of death. o Can assist in three important public health functions: • 1. establishing research and resource priorities • 2. surveillance of temporal trends in premature mortality • 3. evaluating the effectiveness of program interventions.

6.6 Define health disparity. Identify and discuss at least two examples of disparities in the United States for mortality, morbidity, healthcare access, and behavioral risk factors.

- "Differences in the incidence, prevalence, mortality and burden of diseases and other adverse health conditions that exist among specific population groups in the US." - Disparity in mortality: o Infant mortality - infant mortality rates higher for infants of black, Hawaiian, and American indian mothers than other races. o Homicide - leading cause of death for black males 15-25 yo. And second leading cause of death for young Hispanic males ; rate for young black males is 17 times the rate for non-hispanic white males o HIV disease - leading cause of death for black males 25-44 yo and third leading cause of death for Hispanic males 25-44 o Motor vehicle related injuries - injuries for young American Indian males 15-24 yo is about 80% higher than for young white males o Stroke - rates for Asian American males aged 45-54 and 55-64 are higher than for white males in same age groups o Suicide - rate for American Indian males double the rate for young white males - Disparity in morbidity: o Self-report of health - higher percentage of non-Hispanic black and Hispanic blacks report fair or poor health than non-Hispanic whites. o AIDS cases - fewer AIDS cases reported among non-Hispanic white population o Cancer - Disparity in health behaviors: o Cigarette smoking - higher in those without high school diploma; higher in rural vs central counties o Alcohol o Suicide attempts - girls 80-90 % more likely to consider suicide than boys, and 50% more likely to make suicide attempt. Adolescent boys 5 times more likely to die from suicide attempt than girls. - Disparity in preventative health care: o Prenatal care o Mammography - poor women less likely to get it done - Disparity in Access to Care o Health insurance coverage - 13% kids under 18 don't have coverage o Health care visits to an office or clinic - poor kids 2x as likely to be without health care visit. o No usual source of care

7.7 Identify and describe the 5As as a brief intervention for patients who smoke (and demonstrated in the two 5A videos provided and described in the USPSTF 5A reading). Describe the relationship between "assessing readiness" and the Stages of Change. Describe the connection between the 5As, the Georgia Tobacco Quit Line, and their efficacy to assist patients.

- 5As: 1. Ask about tobacco use 2. Advise to quit 3. Assess readiness to quit 4. Assist with medications 5. Arrange - -3-step GA cAARds Program: Ask/Advise/Refer - The Georgia Tobacco Quit Line is a public health service funded by the Georgia Department of Public Health (DPH) through the Georgia Tobacco Use Prevention Program (GTUPP). GTUPP partners with a national tobacco cessation vendor to provide telephone and web-based counseling services in accordance with the United States Public Health Service Treating Tobacco Use and Dependence Clinical Practice Guidelines. o What are the benefits of calling the tobacco quit line? • Receive FREE helpful quitting tips/techniques and support. • Eliminate barriers of traditional cessation classes such as waiting for a class to be held or having to drive to a location in order to be in a class. • Provide easy access for people who live in rural or remote areas. They can simply pick up the phone and call instead of having to drive long distances to attend a class. • Empower callers who may feel uncomfortable with seeking help in a group setting. • Evidenced-based Intervention o The Georgia Tobacco Quit Line (GTQL) offers effective, evidence-based interventions to help Georgians quit smoking and using any other smokeless tobacco products (i.e., dip or snuff). For Georgians whose primary language may not be English, there are qualified interpreters available. o Hours of Operation: Available every day, 24 hours a day,7 days a week (including holidays).

4.6 Identify the benefits of using adjusted mortality rates compared to using unadjusted mortality rates.

- Adjusted rates used for comparison, unadjusted mortality rate could be misleading - Direct age adjustment: standard population is used in order to eliminate effects of any differences in age between 2 or more populations being compared. - Indirect Age adjustment: Used when numbers of deaths for each age-specific stratum are not available.

6.10 Identify the criteria for a primary medical care health professional shortage area for the three different types of designations (i.e.: Geographic, Population, and Facilities).

- Any of three types: • Geographic Area • Population Group • Facilities (correctional institutions or public/non-profit medical facilities) o Each have their own designation requirements, but main point is that for a geographic area, if the ratio of population to full-time primary care physician is greater than 3,500:1, then it is an HPSA. 1.) Geographic a. Rational area for delivery of primary medical services b. Population to full time primary care physicians of 3500:1 OR >3000:1 and has unusually high need for primary care services c. Primary care physicians in the are are over utilized or otherwise inaccessible 2.) Population a. Area is rational for primary medical services (As above...) b. Access to primary medical care services is blocked c. The ratio of the number of personas in the population group to the number of primary care physicians practicing in the area and serving the population group is at least 3,000:1 d. OR Indians and Alaska Natives will be considered for designation as having shortages of primary care professional(s) as follows: i. Groups of members of Indian tribes (as defined in section 4(d) of Pub.L.94-437) will be designated if the general criteria in paragraph A are met. 3.) Facilities a. Federal and state i. At least 250 inmates ii. Internees to physician ratio is at least 1000:1 b. Public or nonprofit i. If its providing services to a population with a primary care shortage ii. Facility has insufficient capacity to meet the primary care needs of the group This website has all the criteria for each type clearly laid out: http://bhpr.hrsa.gov/shortage/primarycare.htm

6.2 Describe the relationship between health and lower socioeconomic resources across one's lifespan (as presented in Figure 2, page 9 of Adler et al).

- Basically, the higher up on the ladder you are, and the longer you stay there, the more health protection benefits accumulate. - Closer to the bottom, exposures to adverse conditions add up. Those who are persistently exposed to poor living conditions face increased odds of contracting serious disease. o Ex: heart and lung diseases are disproportionally found in low income households. - Diagram shows how parental socioeconomic resources affect kids and their health, which affects education in adolescence and later work/career in adult life, and lastly retirement income during old age. All of these affect health.

6.3 Identify factors associated with lower socioeconomic status that affect one's health before birth and throughout the life course. Describe the cumulative effects of lower socioeconomic resource on child development and health. Identify three environmental factors that may influence health inequalities in children.

- Beginning even before birth and continuing through old age, the resources we have at our disposal in the form of educational attainment, family income, and the quality of the jobs we hold determine our exposure to hazards and resources that impact health. - The consequences in living in a positive or negative one are not transitory; they are cumulative. The longer people remain on the lower rungs of the ladder, the worse their physical health and mental functioning will be later in life. - At birth: Even before children are born, the resources their families can command are shaping their health. Pregnant women who live on the lowest rungs of the ladder receive less prenatal care, experience higher levels of stress, and deliver more premature and low weight babies ...increased risk of infant death, slow cognitive development, hyperactivity, breathing problems, overweight, and heart disease. - Through childhood: children in families lower on the ladder develop health problems at younger ages than their more affluent counterparts. Chronic conditions, injuries, ear disease, asthma, and physical inactivity are most frequent among children whose families are at the bottom of the adder. Those whose parents are lowest in education, income and occupational prestige suffer most from these diseases, while those in the middle are less affected, and those at the very top have the lowest incidence. - Adulthood: cumulative damage manifests itself as disease. High blood pressure, excessive weight gain, and insulin resistance can evolve into heart disease, diabetes, cancer, arthritis, and other conditions that cut life expectancy. - Environmental factors that influence health inequalities in children: o toxins/ pollutants, including lead, dirty air, and noise → poor cognitive development, resulting in school performance problems o less access to playgrounds, parks and other safe places to exercise o libraries are scarcer, so less opportunity to read o unstable housing → disruptions in social support and lack of continuity in school attendance o greater consumption of fast food/less access to healthy food →Poor eating habits set the stage for childhood and adult obesity o Violence in school and on the street → exposes children to conflict and anxiety o Inadequate and delayed health care → increases the chance that injuries and illnesses will develop into permanent disabilities.

6.4 Explain how the characteristics of neighborhoods influence the health of its residents in terms of the biological/chemical environment, built environment, and social environment, as well as their specific health hazards and effects.

- Biological/chemical environment = air, water, soil. o Hazard: air and water pollution, noise, waste, lead paint, etc o Health effect: respiratory diseases, hearing loss, sleep deprivation, developmental delays, and impaired cognition. - Built environment = housing, transportation, commercial establishments, billboards, parks, libraries o Hazard: housing-related environmental toxins, allergens, inadequate access to healthy food, increased exposure to tobacco smoke, and lack or recreation o Health effect: asthma, obesity, alcohol and tobacco addiction (leading to liver, lung, and CVD), hypertension (due to obesity and lack of exercise), and compromised immune sys - Social environment = levels of neighborhood stress and support, enforcement of common rules for public behavior, behavioral norms o Hazard: violence, crime, social isolation, low levels of interpersonal trust, public disorder o Health effect: anxiety, fear, hyper-vigilance, depression, stress related behavior (over-eating, smoking, addiction)

Identify the major programs and services provided by the Health Department that serves the county where your preceptor practices. What clinical, social, behavioral, and preventive services are provided to which you would regularly refer adults and youth (e.g., immunizations, family planning, breast and cervical cancer screening, etc.)?

- Birth control and family planning - Birth and death certificates - Breast and cervical cancer screening - Immunizations - Heart disease testing and weight loss - HIV/AIDS testing - TB testing and treatment

3.9 Describe six roles in which a community responsive physician may engage.

- Clinician: utilize population health practices to provide direct care to patients in the context of the family and the community; - Educator: provide relevant information for understanding; offer advice and suggestions; identify - alternatives and their probable consequences with patients, students and the community; - Broker: identify, locate and link patients with community resources such as other health care options and providers, public health, and social services; partner with the community to enhance their mutual interests; - Advocate: advocate for the community on policy and community-based interventions; address barriers to care and socioeconomic influences; - Leader: take a lead in helping to transform the community; build an interdisciplinary team; - Researcher: contribute to a better understanding of the issues at stake in the community, state, and nation.

8.2 Understand the concept of diversity-- both within and among communal groups.

- Diversity exists w/in every group but we still think of group as an entity - Diversity is not always apparent w/in a group

7.3 Define health promotion and identify the five action areas and the three main strategies of health promotion listed in the Ottawa Charter that corresponds with the concepts of the community responsive physician and population health practice. Generate examples of how physicians might become involved in each of the five action areas and how they might improve the lives of their patients and communities by "advocating, enabling, and mediating." List the eight fundamental conditions and resources that provide the foundation for a healthy society and its citizens (as described in the Ottawa Charter).

- Five action areas 1. Build Healthy Public Policy • Health promotion puts health on policy makers' agendas, making them be aware of health consequences of their decisions & accept their responsibilities for health. • Health promotion policy combines legislation, fiscal measures, taxation and organizational change and leads to health, income & social policies that foster greater equity. • Joint action contributes to ensuring safer and healthier goods and services, healthier public services, and cleaner, more enjoyable environments. • Health promotion policy requires identification of obstacles to adopting healthy public policies in non-health sectors, & ways of removing them. • Policy aim must be to make healthier choices the easier choices for policy makers 2. Create Supportive Environments • The inextricable links between people and their environment constitutes the basis for a socioecological approach to health. • The overall guiding principle for the world, nations, regions and communities, is our need to encourage reciprocal maintenance - take care of each other, our communities & our natural environment. • The conservation of natural resources throughout the world should be emphasized as a global responsibility. • Health promotion generates living and working conditions that are safe, stimulating, satisfying and enjoyable. • Systematic assessment of the health impact of a rapidly changing environment - especially in technology, work, energy production & urbanization - is essential and must be followed by action to ensure positive benefit to health of the public • Must address protection of the natural and built environments and the conservation of natural resources in any health promotion strategy 3. Strengthen Community Actions • Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. • At the heart of health promotion is the empowerment of communities - their ownership and control of their own endeavours and destinies. • Community development draws on existing human and material resources in the community to enhance selfhelp and social support, and to develop flexible systems for strengthening public participation in and direction of health matters. o This requires full and continuous access to information, learning opportunities for health, as well as funding support. 4. Develop Personal Skills • Health promotion supports personal and social development through providing information, education for health, and enhancing life skills. o It increases the options available to people to exercise more control over their own health & environments, & to make choices conducive to health. • Enabling people to learn, throughout life, to prepare themselves for all of its stages and to cope with chronic illness and injuries is essential. o Must be facilitated in school, home, work and community settings. o Action is required through educational, professional, commercial and voluntary bodies, and within the institutions themselves. 5. Reorient Health Services • Responsibility for health promotion in health services -shared among individuals, community groups, health professionals, health institutions & governments. o Must work together towards a health care system, which contributes to the pursuit of health. o Role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. o Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. o This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components. o Reorienting health services also requires stronger attention to health research & changes in professional education and training. o Must lead to a change of attitude and organization of health services which refocuses on the total needs of the individual as a whole person - 3 Strategies of health promotion: 1. Advocate 2. Enable 3. Mediate - 8 Fundamental conditions & resources for health: o Peace o Shelter o Education o Food o Income o Stable eco-system o Sustainable resources o Social justice o Equity

8.4 Compare and contrast the following pairs of terms: generalization/stereotyping; individualistic/collectivistic cultures; and primary/secondary characteristics of culture.

- Generalization → rules that groups adopt about other groups, healthcare provider must see if the individual fits the cultural pattern; used to summarize cultural beliefs and practices o advantage for healthcare providerà knows what questions to ask - Stereotyping → over simplified conception, opinion or belief about some aspect of an individual or group of people @ the intra-invidvual level, inter-individual level and inter-group level; infer that a person or a group of people fits a particular generalization o cognitive (categorization) and motivational components o can be + or - • advantage - save perceiver's mental resources to allow them to operate under a cognitive load - Individualistic → individualistic Western cultures, a person is a separate physical and unique psychological being and a singular member of society. The self is separate from others. - Collectivistic → in collectivist cultures, such as Korean, Chinese, Filipino, and Vietnamese to name a few, in group harmony is essential to in group loyalty and conformity to standards of behavior; collectivist Asian cultures, the individual is defined in relation to the family, including ancestors, or another group rather than a basic unit of nature. - Primary: what you cant change - race, color, religion, - Secondary: not perfect list; socioeconomic status etc. - things that you can change

9.8 State three reasons why writing accurate causes of death on death certificates is important to public health/population health [per the Improving Cause of Death Reporting video]. Identify four purposes of collecting mortality data via death certificates. Describe how death certificates are used for surveillance, outbreaks and emergency activities. Identify four different roles in death certificate completion. Distinguish between the Immediate, Intermediate, and Underlying Cause of Death and the major parts of the Cause of Death Section on a U.S. Certificate of Death (per Instructions for Completing COD and Campos-Outcalt reading). Describe a physician's professional obligation to completing this section as accurately as possible.

- Immediate, Intermediate, Underlying Cause of Death - Immediate cause: final disease or condition resulting in death - Intermediate cause: disease or condition that preceded and caused the immediate cause of death. - Underlying cause: disease or injury that initiated the events resulting in death; disease or condition present before, and leading to, the intermediate or immediate cause of death. It can be present for years before death. - Mortality Data - indicate community health concerns - Make pension and life insurance calculations - Track infant and maternal deaths - - Justify health spending - Importance of Fact of Death/accurate causes of death - Settling estates: claim life insurance, close bank accounts - Preventing fraud - health research - Roles 1. Pronouncer: authorized medical provider who documents date and time of death; not always present at moment of death but may review medical records of decedent; must biometrically sign case before death can be registered. 2. Certifier: authorized medical provider who determines and accurately records the sequence of medical conditions that resulted in death; signature indicates that individual died for reasons listed under cause of death; not always present at moment of death; must biometrically sign case before death can be registered. 3. Funeral director: completes demographic, next of kin, and burial info based on data provided by family members; hospital may act as funeral director. 4. Health Department Registers death; vital records: disposition, cremation or transport permit for body to funeral director; also responsible for death certificates and long term management of legal record. Vital statistics: responsible for statistical analysis si and reporting of mortality data

6.9 Define medically underserved area (MUA) and medically underserved population (MUP). Identify the four variables used in the calculation of the Index of Medical Underservice (IMU), the scale used to designate MUA/MUP. Describe how IMU is used by the Health Resources and Services Administration (HRSA) to designate MUA/MUP. Name at least one federal program that uses MUA/MUP designations.

- Medically underserved area (MUA): may be a whole county or a group of contagious counties, a group of county or civil divisions or a group of urban census tracts in which residents have a shortage of personal health services o Designation as an MUA takes into account four variables: • Ratio of primary medical care physicians per 1000 population • Infant mortality rate • Percent of the population with incomes below the poverty level • Percent of the population age 65 and older o These variables are given weighted values to obtain the area's IMU (Index of Medical Underservice) o Medically Underserved Populations (MUPs) may include groups of persons who face economic, cultural or linguistic barriers to accessing health care. o IMU <= 62 → underserved area - Rural: Territory, population and housing units not classified as urban. "Rural" classification cuts across other hierarchies and can be in metropolitan or non-metropolitan areas. (Metropolitan: refers to those areas surrounding large and densely populated cities or towns). o In GA, counties with a population less than 35,000 are considered rural (108 counties), and Liberty county (legislatively designated rural because without the military base they would have <35k) - MUP: o As MUA, except it's for a specific population, not area o IMU <= 62 → underserved population - IMU: o Scale 0-100 • 0 is completely underserved • 100 is least underserved o Four variables • Ratio of primary medical care physicians per 1,000 population • Infant mortality rate • Percentage of the population with incomes below the poverty level • And percentage of the population age 65 or over - MUA/MUP: o Used to designate funds for: • Community Health Center grant funds • Certifications for federally qualified health centers • Certifications for rural health clinics

2.9 Describe at least one difference between the role of state governments in funding Medicare and Medicaid.

- Medicare = federally funded, people pay premiums. o Limited long-term care coverage. o No dental, hearing aids, eyeglasses - Medicaid = federal and state partnership. Eligibility varies by state and there is "dual eligibility" with Medicare. o State money/state taxes o Covers most clinical services and prescriptions

5.10 Distinguish between modifiable and non-modifiable risk factors for disease and injury and their relationship to prevention activities.

- Modifiable - lifestyle, such as diet, smoking habits, etc. - Non-modifiable - genetics

6.7 Demonstrate an understanding of the relationship between modifiable behaviors and attitudes (e.g., smoking, diet, etc.) and leading causes of death in the U.S. (e.g., heart disease, cancer, influenza, etc.).

- Modifiable risk factors : o Obesity (Don't) o Smoking (don't) o Wearing seat belt (do) o Diet o Personal behavior - Nonmodifiable : o Genetics o Environment o Vision impairment - Leading direct cause of deaths in the US (in 2000) o Heart disease - 710,760 o Malignant neoplasm - 553,091 o Cerebrovascular disease - 167,661 - Leading "actual" cause of death in the US (in 2000) o Tobacco - 435,000 (18.1%) o Poor diet and physical activity - 400,000 (16.6%) o Alcohol - 85,000 (3.5%) - Modifiable behaviors : o Diet o Exercise o Tobacco use o Alcohol consumption o Drug abuse

8.7 List the 12 domains of the Purnell Model and describe how the model is used to competently and compassionately interact with culturally diverse patients.

- Once cultural data are analyzed, the practitioner can fully adopt, modify, or reject healthcare interventions and treatment regimens in a manner that respects the client's cultural differences. Such adaptations improve the quality of the client's healthcare experiences and personal existence. - Know each "wedge": 1. Healthcare practices 2. Healthcare practioners 3. Overview/Heritage 4. Communication 5. Family roles and organization 6. Workforce Issues 7. Biocultural ecology 8. High-risk behavior 9. Nutrition 10. Pregnancy 11. Death rituals 12. Spirituality

7.2 Explain how health viewed as "the ability to adapt and self-manage in the face of social, physical, and emotional challenges" relates to each of the three domains of WHO's traditional definition of health (Physical, Mental, Social well-being) as briefly described by Huber et al. (2011). Explain why Huber and colleagues believe this new definition may fit well in the modern era of advanced diagnostic capabilities, genomics, advanced therapies, longer life spans, and chronic disease. Identify three capabilities (in the Ottawa Charter) that an individual or group must be able to do in order to achieve health and well-being. Compare these capabilities to those proposed by Huber et al.

- Physical Health - capable of "allostasis"- the maintenance of physiological homoeostasis through changing circumstances. o When faced w/ stress, a healthy organism can: • Mount a protective response • Reduce potential for harm • Restore an adapted equilibrium - Mental Health - "sense of coherence" - a capacity to cope and recover from strong psychological stress and prevent PTSD o Sense of coherence includes the subjective faculties enhancing the comprehensibility, manageability, and meaningfulness of a difficult situation - Social Health - includes people's capacity of fulfill their potential and obligations, the ability to manage their life w/ some degree of independence despite their condition, and the ability to participate in social activities including work. o Have the ability to work/interact in social situations and feel healthy despite limitations mounted by their medical condition. - Ottawa Charter 3 capabilities: *see above (under objective 7.1 - Ottawa charter definition of health) o Identify aspirations o Satisfy needs o Change/cope with environment

6.1 Describe Adler and colleagues' concept that societies are structured like ladders and that one's position (i.e., rung) on the ladder predicts one's life expectancy, level of health, and quality of life. Explain the relationship between the lower, middle, and higher rungs of the "ladder".

- Societies are structured like ladders - rungs on ladder represent resources that determine if ppl can live a good life - prosperous, healthy, secure - or a life with difficulties - low income, poor health, vulnerability. o TOP rungs → best educated, most respected jobs, ample savings, and comfortable housing. o BOTTOM rungs → poorly educated, long bouts of unemployment or low wage jobs, have nothing to fall back on in the way of savings, and live in substandard homes. - Predicts how long you live and how healthy you are during your lifetime. The more advantaged our lives, the longer we live and the healthier we are from birth to old age. People who group up on the bottom die younger and are sicker throughout their lifetimes than those who are born to the rungs above them. - The consequences of living in a positive setting or a negative setting are not transitory; they are cumulative. The longer people remain on the lower rungs of the ladder, the worse their physical health and mental functioning will be later in life. - The lower the rung on the ladder, the more children are subject to: toxins/pollutants, less access to playgrounds/parks/safe places to exercise, libraries are scarcer, unstable housing, greater consumption of fast food, violence in school and street (conflict and anxiety), inadequate and delayed healthcare - Which rung a particular community occupies tells us a lot about the health problems residents are likely to face. o Ex: Some communities are blessed with parks and playgrounds, buildings in good repair, safe streets, libraries; and others are not. - Neighborhoods can also be arrayed on ladders - Those standing higher on ladder have less exposure to toxic stress and its biological consequences. - Lower on ladder → higher stress → greater disease risk → poorer health. - Perceived stress decreases as income increases; perceived stress decreases with higher levels of education

5.7 Describe at least one clinical reason why screening may be impractical or of no benefit.

- Some diseases do not have a diagnosable preclinical stage or the preclinical stage is too short to be detectable, therefore there is no need to screen - Screening would not have any benefit, such as genetic screening for Huntington disease (no cure/treatment available) - If none of the preclinical cases progress to clinical cases, there is no need to perform screening tests - If there is no preclinical phase, no reason to screen

10.4 Identify the specific databases (secondary data sources) used to collect information about their community or county. Describe the process for gathering input from community stakeholders (primary data sources).

- Stakeholder→ interview - secondary data→ data collected by other sources, - primary data → data collected by you, surveys, interviews - Community meetings

8.6 Identify strategies to promote self-awareness about attitudes, beliefs, biases, and behaviors that may influence clinical care.

- Ways to improve cultural communication: o Touch: observe how comfortable your patient is with touch from the same and opposite gender; take cues from the patient. o Observe how easily your patient shares feelings, thoughts, ideas. o Take cues for maintaining a comfortable distance. o Take cues from your patient when greeting him/her. o Recognize that voice volume can vary by culture and gender. - Organizations and individuals who understand their clients' cultural values, beliefs, and practices are in a better position to be co-participants with their clients and provide culturally accept- able care. Accordingly, multidisciplinary healthcare professionals can use the Purnell Model as a guide for assessing, planning, implementing, and evaluating interventions. Through a systematic appraisal for each client and individualizing care, improved opportunities for health promotion, illness and disease prevention, and health restoration occurs. - Cultural general knowledge and skills ensures that providers have a process for becoming culturally competent - Strategies identified by healthcare providers in Hendson Paper: o Seeking to understand another's perspective. Health care providers described strong feelings of empathy for the new immigrant family. They described the importance of stepping back, being humble, and listening to families' perspectives. In so doing, health care providers portrayed a sensitivity, responsiveness and reflexivity to the reality and experiences of the new immigrant family. o Facilitating knowledge. o Health care providers realized that families from different background are all unique and that people differ in their adherence to cultural norms, hence care needs to be individualized. o Relationship building as an aspect of care that was found to be rewarding. Regardless of the cultural background of the families, health care providers described the importance of forging genuine relationships, being respectful of all individuals, and empowering parents.

9.6 Define surveillance and distinguish between active and passive surveillance of disease/conditions.

- Surveillance is a fundamental role of public health. - Carried out to monitor changes in disease frequency or to monitor changes in prevalence of risk factors. - Provides much of the information about morbidity or mortality from disease o Most frequently used for infectious diseases o Monitor completeness of vaccination coverage o Drug¬resistant organisms o Cancer, asthma, chemical poisoning, injuries and illness from natural disasters o Carried out to assess changes in levels of environmental risk factors for disease - CDC definition of epidemiologic surveillance o Ongoing systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice closely integrated with the timely dissemination of these data to those who need to know - Provides decisionmakers with guidance for developing and implementing the best strategies for programs for disease prevention and control x Surveillance in developing countries have additional problems o o E.g. Difficult to reach areas; difficult to maintain communication between decision makers and rural areas o Result is often under¬reporting of observed clinical cases - Passive surveillance: o Involves using available data on reportable diseases, which are reported by the health care provider or district health officer o Completeness and quality is dependent on the reporting practices and can miss local outbreaks due to lack of reporting and relatively small number of cases in that particular area in comparison to total population o o Inexpensive and fairly easy to develop initially - Active Surveillance : o Project staff make periodic field visits to health care facilities such as clinics and hospitals to identify new cases of disease, diseases, or deaths from diseases that have occurred o "Case finding" o May involve interviewing physicians and patients, reviewing medical records, and surveying villages and towns to detect cases either on routine basis or after an index case has been reported o Reporting is generally more accurate o Local outbreaks identified o More expensive to maintain and more difficult to develop

9.4 Describe the notifiable disease/condition reporting process as required by the Georgia Department of Public Health. Explain the physician's role in the process. Identify the different registries and surveillance systems such as SENDSS that healthcare workers use to report different disease and conditions.

- The purpose of reportable disease surveillance is to: o Timely Identify any diseases/conditions that may require immediate public health intervention & follow up o Detect changing trends or patterns in disease occurrence o Identify areas/communities requiring special public health response as result of changes in disease patterns o Assess & evaluate control & prevention interventions - Physicians, labs, & health care providers role: o Required by law to report patients w/ specific public health concerns to allow public health follow- ups w/ patients, identify outbreaks, & understand disease trends in GA o A list of notifiable diseases is available along w/ the time frame you have to report specific diseases - By law Dr must report all notifiable conditions; both clinical & lab-confirmed diagnoses - Dr's must complete a standard form & send it in w/in an allotted amount of time - How to report: o HIV/AIDS • <13 y.o. at diagnosis, complete CDC form 50.42B • >13 y.o. at diagnosis, complete Georgia Adult HIV/AIDS Confidential Case Report Form o STD • Complete Notifiable Disease Report Form Fax/Mail in envelope marked CONFIDENTIAL to District Health Office o TB & latent TB infection in children < 5 yrs. old • Complete Notifiable Disease Report Form or report in SENDSS Main Form if Approved TB user in SENDSS • For District TB Coordinators and county health department TB nurses that are TB • Users in SENDSS, fill out the Report of Verified Case of Tuberculosis in SENDSS o Benign brain and central nervous system tumors • Report cases to the Georgia Comprehensive Cancer Registry (GCCC) o Birth Defects • Report cases to the Georgia Birth Defects Reporting and Information System (GBDRIS) o Cancer • Report cases to the Georgia Comprehensive Cancer Registry (GCCC) o Hearing Impairment • Report cases to the Children 1st Program o Maternal Death • Report cases to Maternal and Child Epidemiology o All other Notifiable Diseases • To Report Immediately- Call the District Health Office • To Report Within 7 Days- Report cases electronically thru State Electronic Notifiable Disease Surveillance System (SENDSS) • Complete Notifiable Disease Report Form, Mail in an envelope marked CONFIDENTIAL to District Health Office, or call your County Health Department or District Health Office

10.5 Using the CHNA from Phoebe Worth Medical Center, identify at least one priority identified by Key Stakeholder Interviews for each of the 8 prioritized needs. Identify, if any, a common theme in the stakeholder comments across the 8 prioritized areas (page 98).

- There is a need to increase awareness and patient education across all 8 priority areas. See previous objective for the 8 health priorities and priorities identified by stakeholders w/in each priority need

8.5 Identify key reasons why cultural competency is important to healthcare practitioners.

- Understanding the 'community' you serve - Healing relationships o Physician-patient interactions, communication - Blurred lines between practice/community o A 'medical neighborhood - Rationale for cultural competence: o Growing racial and ethnic disparities in health. o Providing CLAS has the potential to improve access to care, improve quality of care, and reduce health disparities. o Patients are less likely to comply with treatment if they do not understand it or if they have conflicting health beliefs. o Improve patient trust → patient-provider alignment. o Administrative and operational efficiencies, reduced malpractice costs, compliance with legal requirements, more positive image in the community. - Benefits of cultural competence: o Higher cultural competency scores predicted higher quality of care for children with asthma (Lieu et al., 2004) o A group provided with a culturally competent smoking cessation intervention adapted for African Americans had a significantly higher rate of smoking cessation than the standard group (Orleans et al.,1998) o Physicians self-reporting more culturally competent behaviors had patients who reported higher levels of satisfaction and were more likely to share medical information (Paez et al., 2009) o Cultural competence in health care is the ability of systems to provide care to patients with diverse values, beliefs, and behaviors and to tailor delivery to meet patients' social, cultural, and linguistic needs

9.3 Explain the physician's public health role in the reporting of vital statistics (e.g., death certificates, immunization records, reports of notifiable diseases).

- Vital records & events: births, deaths, fetal deaths (stillbirth), induced termination of pregnancy, marriage & divorce certificates & reports. (reports recorded & maintained w/in county jurisdictions where event occurred) - Death Certificates?: o Dr. performs final act of care to patient by providing closure w/ well-thought out & complete death certificate that allows family to close person's affairs. At same time, Dr. performs service for community o B/c statistical data from death certificates can be no more accurate than info on certificate, it is very important that all concerned (Dr's) w/ registration of deaths strive not only for complete registration - Birth certificates -Accurate & comprehensive reporting on them enhances ability to analyze & track crucial indicators of maternal & child health (demographic characteristics, health care use, outcomes) o Examples include: • influence of fertility therapy on twin and triplet/+ births • Maternal medical risk factors • Neural tube defects • Induction of labor • Participation in the WIC program • Prenatal care utilization • Socio-economic differentials • Newborn need for intensive care • Teen childbearing • Non-marital childbearing • Preterm birth • Low birth weight • Cesarean delivery

7.1 Compare the World Health Organization's (WHO) traditional definition of health with newer conceptions described by Huber et al. (2011) and the Ottawa Charter. Identify the seven criticisms of the WHO definition expressed by Sharma & Romas (2012); compare and contrast these to the three criticisms by Huber et al. (2011). Explain why the word "complete" has received criticism as part of the WHO definition of health. Explain whether anyone can truly be considered healthy if health is defined as "a state of complete wellbeing." Explain how newer concepts of health may change the concept of what is considered an appropriate "health outcome."

- WHO definition of health (1948) describes health as - "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." - Ottawa Charter states - Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being - Sharma & Romas criticisms of WHO definition: 1. The use of the word "state" is misleading because health is dynamic and changes from time to time 2. The dimensions mentioned in the definition are inadequate to capture the variations in health 3. The word "well-being" is very subjective 4. The way in which health is defined makes it very difficult to measure 5. The WHO definition presents an idealistic or utopian view and it would be impossible to find anyone who embodies all the attributes presented in the definition → the definition of health lack practical applications 6. The WHO definition is presented as an end product, whereas most people perceive health as a means of achieving something that they value more highly. 7. It is written from an individualistic perspective and lack a community orientation - Huber criticisms: 1. The absoluteness of the word "complete" - it unintentionally contributes to the medicalization of society. The requirement of complete health would leave most of us unhealthy most of the time. a. Lowers threshold for intervention b. Could lead to large groups of people becoming eligible for screening or for expensive interventions even when only 1 person might benefit c. Might result in higher levels of medical dependency and risk 2. Since 1948, the demography of populations and the nature of disease have changed a. Disease patterns have changed due to improved nutrition, hygiene, sanitation and more powerful healthcare interventions. b. Increasing number of people with chronic diseases living longer 3. The operationalization of the WHO definition - the definition remains impracticable because complete is neither operational nor measurable. - Newer Concepts can support doctors in their communications w/ patients b/c these concepts focus on patient empowerment (i.e. lifestyle changes), which the doctor can explain instead of just removing symptoms

6.5 Describe the relationship between socioeconomic status/resources, allostatic load, and stress.

- When people are fearful, frustrated, or angry, their bodies mobilize to meet the threat. Hormones rush into bloodstream, hearts beat faster, BP and blood sugar rises. Fight or flight Environments and experiences that provoke this stress rxn too often, for too long, or repeatedly, lead to chronic release of these hormones, which alter the nervous sys. Body produces high levels of chemicals like cholesterol, cortisol, glucose, and NTs that can cause a range of diseases. - Toxic levels of stress produce high BP, susceptibility to infection, buildup of fat in blood vessels and around the abdomen, and cause the atrophy of brain cells. - Smoking, sedentary lifestyle, and poor diet exacerbate impact of stress hormones, and the combination disrupts the optimal functioning of the body. - Allostatic load - the cumulative biological damage of long-term wear and tear on the body. - Allostatic load: developed to capture the cumulative biological damage that results from long term wear and tear on the body. o Reflects how well or poorly the cardiovascular, metabolic, nervous, hormonal and immune systems are functioning. o Lower scores = less disruption and better functioning. o Higher scores = greater dysregulation and greater vulnerability to disease. o Scores decrease at each rung up the ladder.

7.8 Download and demonstrate the use of the AHRQ ePSS app (Electronic Preventive Services Selector) for iPhone and Android phones or tablets. Demonstrate its use to determine an appropriate preventive service for a specific patient. Describe the role of the United States Preventive Services Task Force (PSPSTF) as well as the five grade definitions that it gives to its widely-used recommendations. Identify two Grade A and two grade B screening and/or counseling recommendations for Mr. Hunt in Case 3. Describe the risk factor information provided by the ePSS app for each of these.

- ePSS is an application designed to help primary care clinicians identify clinical preventive services that are appropriate for their patients • It is based on based on the current recommendations of the U.S. Preventive Services Task Force and can be searched by specific patient characteristics, such as age, sex, and selected behavioral risk factors - Grade definitions: • A - USPSTF recommends the service; high certainty that the net benefit is substantial; suggestions for practiceà offer or provide this service • B - USPSTF recommends the service; high certainty that the net benefit is moderate or ther is moderate certainty that the net benefit is moderate to substantial ; practice should offer • C - USPSTF recommends AGAINST routinely providing the service; there may be considerations that support providing the service in an individual patient ; there is atleast moderate certainty that the net benefit is small • D - USPSTF recommends AGAINST the service; moderate or high certainity that the service has no net benefit or that the harms outweigh the benefits ; discourage the use of service • I - USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of service; Evidence is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined ; suggestions for practiceà read the clinical considerations section of USPSTF recommendation statement and if the service is offered patients should understand the uncertainty about the balance of benefits and harm - Case 3 examples: • A= Aspirin to prevent CVD & high blood pressure screening • B= Alcohol misuse & depression screening

3.13 Differentiate among the following types of advocacy: 1.) community participation; 2.) political involvement; and, 3.) collective advocacy, as described by Gruen et al. (2004) in the Dent monograph.

1. Community Participation: providing health related expertise to local community organizations such as school boards, parent-teacher organizations, athletic teams, and local media. 2. Political Involvement: involvement in health-related matters at the local, state, or national level (other than voting). 3. Collective advocacy: encouraging/participating in medical organizations to advocate for the public's health or policy issue that is not primarily concerned with physician welfare. *Voting is not advocacy

10.2 Identify and describe the seven-step process of the Community Health Needs Assessment as conducted by Phoebe Worth Medical Center in Worth County, GA. (page 7-8)

1. Forming the hospital's steering committee → executing, start to finish, help with who to contact (key informant interviews) 2. Definition of service area→ to help hospital/ patient population 3. Identified community leaders to participate→ to assess needs of community, review available community resources, and prioritize health needs of the community ; groups/ individuals who represent medically-underserved populations, low income populations, minority populations, and populations with chronic diseases were included 4. Identifying and Engaging Community Stakeholders → Community stakeholders, also called key informants, are people invested or interested in the work of the hospital, people who have special knowledge of health issues, people important to the success of any hospital or health project, or are formal or informal community leaders. 5. Community Health Profile → written to reflect the major health problems and needs of community 1. Access to preventive health services 2. Underlying causes of health problems 3. Major chronic diseases of the population 6. Community Input → community meetings and stakeholder interviews conducted to obtain community's input into health needs 7. Hospital Prioritization of Needs

7.4 Identify the five factors/levels of the socio-ecological model that influence health and health behavior as described in the monograph by Devereaux. Identify potential health promotion activities that a physician could employ at each of the levels of the socio-ecological model.

1. Intra-personal/Individual - personality, awareness, knowledge, attitudes, beliefs, behaviors, habits, skills, and biophysical characteristics. a. Physicians can influence patients at this level to modify behaviors 2. Inter-personal - factors related to the patients social support network that may reinforce attitudes toward/against engaging in particular behaviors. 3. Institutional/Organizational - policies such as those against smoking in the workplace that may promote/reinforce an individual decisions a. Doctors can advocate for such policies and other institutional structures by providing public support and technical assistance to organization/community decision 4. Community - social structures/networks that citizens may join or belong to → church/school/professional groups that influence attitudes, norms, behaviors, and beliefs. 5. Public Policy - local, state, and national laws, policies, and regulations that may reinforce an individual's health decision, i.e. increased taxes on cigs./bans on smoking in public places - **"Complex human behavior does not occur in a vacuum and that an individual person's behavior is influenced by factors ranging from the personal to the political. Our perspectives on what motivates another person must not be confined to one of the levels. We must truly appreciate the complex web of influences that shape our lives!" **

9.5 Using the Notifiable Disease Report Form, identify diseases/conditions/events that are notifiable and the different timeframes for reporting them to the Georgia Department of Public Health.

1. Report cases for all diseases, except those noted below, electronically through the State Electronic Notifiable Disease Surveillance System at: http://sendss.state.ga.us OR Complete reverse of this Notifiable Disease/Condition Report Form and mail, in an envelope marked CONFIDENTIAL, to District Health Office 2. Fill out the form as completely and as timely as possible, including laboratory submissions. 3. Include treatment information for sexually transmitted diseases. 4. Report symptoms and tests needed to establish the diagnosis for viral hepatitis and Lyme disease and other tick-borne diseases. 5. If you mail the form, photocopy the form as your record of reported disease/condition. 6. Report a suspect case of hearing impairment (under age 5) by completing the Children 1st Screening and Referral Form. Report a confirmed case of hearing impairment (under age 5) by completing the Surveillance of Hearing Impairment in Infants and Young Children Form 7. For Birth Defects, DO NOT USE THIS FORM, Refer to the Georgia Birth Defects Reporting and Information System (GBDRIS) Reporting Guidelines 8. For Cancer and Benign Brain Tumor, DO NOT USE THIS FORM, Refer to the GCCR Policy and Procedure Manual 9. For HIV infections and AIDS, DO NOT USE THIS FORM, Complete the Georgia HIV/AIDS Confidential Case Report

6.8 Describe five social determinants of health that can affect patients and physicians during a clinical encounter (as presented in the video by the Colorado Coalition for the Medically Underserved).

1. Transportation: late arrivals, missed appointments, hesitancy to make follow-up appointments 2. Low-income patients might have to be forced into more expensive treatments because of transportation issues. 3. Literacy: patient comprehension compromised, difficulty reading instructions for prescriptions, etc. 4. Language: interferes with patient interaction. 5. Affordability: decreased visits/treatment because of prescription and visit costs. 6. Complex Health Needs: low income people more likely to suffer from chronic illness than affluent.

3.14 Describe three reasons physicians should be involved in advocacy and other areas of public life as described by Gruen et al. (2004) in the Dent monograph.

1. community and socioeconomic characteristics affect many health problems and access to health care; 2. physicians' expertise is essential for addressing major quality, access, public health and policy concerns; 3. clear and visible leadership in the interest of the public's health is regarded by many as the best way for the medical profession to regain and retain the public trust.

3.15 Identify and describe six basic steps for integrating population-based medicine into routine clinical practice.

1.) Define the population - including information on the population's dynamic, health care ulitilization patterns, community health and SES indicators. 2.) Create an office information system - supports identification, tracking, and monitoring functions of a population-based medicine approach to care. a. Should permit: (1) tracking comprehensive health maintenance protocols for individual patients; (2) identifying populations of patients with the characteristics of interest who are involved in population-based medicine interventions, tracking progress, and monitoring outcomes; (3) providing health maintenance reminders for patients and providers; and (4) producing data reports on both individual-level and population-level information on a timely basis for quality improvement purposes 3.) Identify/prioritize the patient groups - the groups of patients for whom the PBM intervention would be most effective, considering preventable illnesses or complications of certain diseases 4.) Identify effective interventions 5.) Adapt office systems → actually implement the plans; develop protocol; appoint a staff member as the coordinator of the process; develop or adapt tools; choose start date. 6.) Monitor and assess - obtaining feedback from all persons involved in the intervention and conducting a periodic review of the data being collected through the data information system

8.1 Understand connections between communities and collective identities.

8.1 Understand connections between communities and collective identities. - Community & collective identity: o Black community, LGBT community, Latino community o Assumptions: certain characteristics are important; people who share these characteristics are similar o Benefits: shorthand understanding of a person; sense of belonging; power o Costs: downplays differences, disguises conflicts/differences within a group - Community → group of people having a common interest or identity and living in a locality; includes the physical, social and symbolic characteristics that cause people to connect - Family → 2 or more people who are emotionally connected, may live close proximity but don't have to -In individualistic Western cultures → a person is a separate physical and unique psychological being and a singular member of society Collectivist cultures →individual is defined in relation to the family, including ancestors or another group rather than a basic unit of nature

• Prevalence

o (# of affected persons present in population at a specific time)/(# of persons in population at that time) o Point prevalence: prevalence of disease at certain point in time.** o Period prevalence: How many people have had the disease at any point during a certain time period.

• Attack rate

o Does not explicitly specify the time interval

4.7 Interpret the following concepts used to determine the association between an exposure to a risk factor and the development of a disease or outcome: absolute risk; relative risk; and attributable risk. Describe how specific risk measures are used to explain the risk of a disease or outcome to a patient.

Absolute risk → incidence of a disease in a population; can indicate the magnitude of the risk in a group of people w/ certain exposure, but b/c it does no take into consideration the risk of disease in the nonexposed & doesn't indicate if exposure is associated w/ increased risk of disease Attributable risk→ amount/ proportion of disease incidence or disease risk that can be attributed to specific exposure; gives info on how much of the risk is due to a specific exposure → useful for eliminating risk factors - number of McDonalds in area vs obesity in area Relative risk → risk b/w exposed: to non-exposed; defined as the probability of an event (developing disease) occurring in exposed people compared to the probability of the event in non-exposed people→ ratio of the probabilities - Interpretation of relative risk: o equal to 1: risk in exposed is same risk in non-exposed → no evidence of increased risk based on exposure o >1: risk in exposed persons > risk in non-exposed persons → + association o <1 : risk in exposed persons < risk in non-exposed → - association; may be indicative of protective effect

10.6 Identify the IRS criteria and requirements for conducting a Community Health Needs Assessment (CHNA) and the penalties for non-compliance per the short video overview by Strategy House. Identify and review the items on IRS Form 990, Schedule H, Part V (page 4) that should be included in the CHNA paying close attention to items 3a-3j, 5, 7, 8, 10, 11, and 12.

Began w/ fiscal years beginning March 23rd 2012 and must be updated every 3 years , requires action plan and budget, and must be published Looks outward at needs of community Penality → Min $50,00 per hospital per year 3. During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? a A definition of the community served by the hospital facility b Demographics of the community c Existing health care facilities and resources within the community that are available to respond to the health needs of the community d How data was obtained e The significant health needs of the community f Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups g The process for identifying and prioritizing community health needs and services to meet the community health needs h The process for consulting with persons representing the community's interests i Information gaps that limit the hospital facility's ability to assess the community's health needs j Other (describe in Section C) 5. In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted . . . . . . 5 7 Did the hospital facility make its CHNA report widely available to the public? . . . . . . . . . . 7 If "Yes," indicate how the CHNA report was made widely available (check all that apply): a Hospital facility's website (list url): b Other website (list url): c Made a paper copy available for public inspection without charge at the hospital facility d Other (describe in Section C) 8. Did the hospital facility adopt an implementation strategy to meet the significant community health needs identified through its most recently conducted CHNA? If "No," skip to line 11 . . . . . . . . . . 8 10. is the hospital facility's most recently adopted implementation strategy attached to this return? 11. Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed. 12. Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? b If "Yes" to line 12a, did the organization file Form 4720 to report the section 4959 excise tax? c If "Yes" to line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $

5.6 Provide one example of primary, secondary, and tertiary prevention. Given a specific disease, identify preventive measures (i.e., primary, secondary, and tertiary) appropriate for each stage of the disease.

Cervical Cancer: - Primary - Gardasil vaccine - Secondary - pap smears - Tertiary - treatment for cervical cancer

5.) CDC Foundation Working Group on Population Health and Medical Education; and

Characteristics of a Physician with a Population Health Perspective Ecologic Model of Health • Sees a problem in the context of social determinants • Sees health as a human right • Considers the influence of the home, work, and environment on the patient's health • Demonstrates systems thinking and actions Community Oriented Health • Ability to identify and work with community resources on behalf of a patient • Ability to zoom in and out from individual to population • Practices prevention, health promotion and protection for individuals and populations Technical Skill Sets • Participates with public health systems • Ability to collaborate, work with, and participate on teams • Ability to analyze and interpret health-related data

3.7 List the three domains and ten characteristics that define a physician with a population health-based practice.

Ecologic Model of Health • Sees a problem in the context of social determinants • Sees health as a human right • Considers the influence of the home, work, and environment on the patient's health • Demonstrates systems thinking and actions Community Oriented Health • Ability to identify and work with community resources on behalf of a patient • Ability to zoom in and out from individual to population • Practices prevention, health promotion and protection for individuals and populations Technical Skill Sets • Participates with public health systems • Ability to collaborate, work with, and participate on teams • Ability to analyze and interpret health-related data

4.1 Define epidemiology and describe its five main objectives.

Epidemiology: study of how disease is distributed in populations and the factors that influence or determine this distribution. 1.) Identify etiology (cause) of a disease & relevant risk factors (factors that increase person's risk for a disease) a. How disease is transmitted from 1 person or from nonhuman reservoir to a human population b. Ultimate aim = intervene to reduce morbidity and mortality from the disease. c. If we can identify the etiologic or causal factors for disease and reduce or eliminate exposure to those factors, we can develop a basis for prevention programs. 2.) Determine the extent of disease found in the community. a. What is the burden of disease in the community? b. Critical question for planning health services & facilities, and for training future health care providers. 3.) Study the natural history and prognosis of disease. a. Want to define the baseline natural history of a disease in quantitative terms so that as we develop new modes of intervention, either through treatments or through new ways of preventing complications, we can compare the results of using such new modalities with the baseline data in order to determine whether our new approaches have truly been effective. 4.) Evaluate both existing and newly developed preventive and therapeutic measures and modes of health care delivery. a. Ex: Does screening men for prostate cancer w/ PSA test improve survival? 5.) Provide foundation for developing public policy relating to environmental problems, genetic issues, & other considerations regarding disease prevention & health promotion. • Ex: Is electromagnetic radiation emitted by electric a hazard to health

4.8 Identify examples of physicians using, applying, and interpreting epidemiological measures in medical practice.

Ex: ePSS, generalization, evidence based medicine -To assess the risk of disease for their patients - The findings from studies may be used to estimate risks of disease associated with specific exposures & answer questions of disease etiology or cause - Epidemiology can be used to assess the relative contributions of genetic and environmental factors to the causation of human disease—which has major clinical and public health policy implications

10.3 Explain the process used by Memorial University Medical Center (MUMC) in Savannah and the Phoebe Worth Medical Center in Worth County to conduct their required Community Health Needs Assessment (CHNA). Describe the overall findings of their CHNAs as presented in the Executive Summary for each hospital. Identify their defined community of interest, their stated purpose for conducting a CHNA, the scope of the assessment, the methods used for collecting data about their community, and their prioritized health needs as described in the CHNAs.

Memorial Savannah: Method's/process 1. Needs evaluation survey 2. Input from leaders providing health and social services to residents in Chatham County, GA 1. Scope of Assessment :The Community Health Needs Assessment was conducted in Chatham County, Georgia, the primary service location for Memorial Health. Savannah, the first city established in Georgia, is the county seat of Chatham County. The county is the most populous one in Georgia outside the Atlanta metropolitan area. Other municipalities within the county are Bloomingdale, Garden City, Pooler, Port Wentworth, Tybee Island, Thunderbolt, and Vernonburg. The U.S. Census Bureau's American Community Survey 2013 population estimate for the county is 279,103. 2. Chatham County Health Department Chatham County Safety Net Planning Council Savannah-Chatham Community Indicators Coalition Youth Futures Authority 3. Sources and dates of information used: 1. Primary collection→ online paper needs surveys in English and Spanish 2. Secondary collection→ online resources and Safety Net Providers' Annual Reports • The Coalition purchased the Healthy Communities Institute web-based information system, which includes more than 100 health and quality of life indicators from more than 20 sources, including: U.S. Census Bureau, American Survey, Healthy People 2020, County Health Rankings, Centers for Disease Control and Prevention, Georgia Department of Public Health OASIS, Georgia Statistics System, National Cancer Institute, U.S. Department of Agriculture and The Food Environment Atlas. This information is uploaded to one data platform that is easy to read and understand and is updated as new information is made available. The initial list of community health needs was compiled using the HCI: Community Indicators. 3. Other info→ Online references and research 4. Identification of service gaps (unmet needs) that may impact the community's ability to access a service 5. Collaborative efforst and partnerships in the study → St. Joseph's/Candler, Chatham County Safety Net Planning Council, Savannah Chatham Community Indicators Coalition 6. Professionals and their qualifications who participated in the CHNA process 7. Input from community 8. Input from public health leaders and leaders who sever vulnerable polulations 9. Prioritization of methods for needs identified • Executive summary (Memorial): Area: Chatham County, Georgia is on the southeastern coast of the United States. • Its total estimated population in 2013 is 279,103 people, with estimates of 109,067 households and 68,496 families. • Females account for 51.8 percent of the total population. • Caucasians are the largest racial group (52.35 percent), followed by African Americans (39.90 percent) and Hispanics (6.19 percent). • The median household income in Chatham County is $42,679. • The ZIP Code with the highest number of people living in poverty is 31401. • The highest numbers of people, families, and children are concentrated in Chatham County ZIP codes 31401, 31404 and 31415. • Chatham County's unemployment rate is 8.3 percent, compared to Georgia's unemployment rate of 8.2 percent. Birth and Deaths • Chatham County recorded 3,928 births in 2011. Of those, 1,757 births were to Caucasian mothers and 1,657 to African-American mothers. There were 2,109 deaths in Chatham County in 2011. The leading cause of death was heart disease, which is also the leading cause of death in Georgia. Chronic Diseases • The Centers for Disease Control (CDC) lists heart disease, stroke, cancer, diabetes, and arthritis as the five most common chronic diseases in Georgia. These chronic diseases can be managed better by increasing physical activity, focusing on good nutrition, eliminating tobacco use, and limiting alcohol consumption. Access to Healthcare • The Governor's Office of Planning and Budget issued a report, "Georgia in Perspective 2013," and identified Chatham County as one of the five largest safety net providers in the state. • In total, there are 12 free, reduced rate, or federally qualified health care center locations in Chatham County. Despite the large number of safety net providers identified, finding a doctor willing to care for an adult or child without insurance is a significant concern for the population. Social Determinants • The term "Social Determinants of Health" is used to describe the conditions in which a person is born, grows, lives, and works that affect his or her overall health. These conditions include education, workforce development, work environment, employment, and housing, as well as other living and working conditions. • Survey participants in the community survey indicated their greatest determinants to be understanding health, health management, and money management. • Community Leader and Stakeholder Findings • A variety of feedback was received from community leaders and stakeholders in Chatham County. In particular, the Chatham County Health Department, Savannah Chatham Community Indicators Coalition, and the Chatham County Safety Net Planning Council were asked to help Memorial Health and St. Joseph's/Candler identify the most important needs, pinpointed through primary and secondary data collection. Conclusions • the following indicators on health and the social determinants of health are the most pressing needs in Chatham County. They appear in ranked order: o Community Health Needs • Adults with Health Insurance* • Age-adjusted Death Rate Due to Prostate Cancer* • Age-Adjusted Death Rate Due to Colorectal Cancer** • Breast Cancer Incidence Rate** • Lung and Bronchus Incidence Rate** • Children with Health Insurance** • Adults with Diabetes** • Babies with Low Birth Weight** • Preterm Births** • Infant Mortality Rate** • Babies with Very Low Birth Weight*** • Age Adjusted Death Rate Due to Cerebrovascular Disease (stoke) *** • Affordable Medications Affordable Dental Health Childhood Obesity and Health o Social Determinants of Health Needs • Homeownership* • People Spending More Than 30 Percent of Income on Rent* • Poverty - People Living in Poverty** • Access to Healthy Food** • High School Graduation** Legend: * represents the "lowest" quartile ** represents the 25th to 50th percentile *** represents the top 50th percentile **** represents a need identified by the community Prioritized list of health and social needs: • Phoebe Worth: • Executive summary: o About the Area : Worth County is located in the southwestern part of Georgia and has a population of 21,630. It is home to Phoebe Worth Medical Center, a 25 bed critical access hospital that is affiliated with Phoebe Putney Health System. The hospital is located in the county seat of Sylvester and is approximately 20 miles from Phoebe Putney Memorial Hospital (Phoebe Putney Health System's main campus). The surrounding areas of Sylvester are diverse as far as population of rural and urban areas. The cities of Poulan, Oakfield, Sumner, and Warwick are far less populous in comparison to Sylvester. The population distribution among rural and urban areas is 30.8 percent urban and 69.2 percent rural. Nearly 100 percent of Worth County's land area is rural while less than one percent is urban. • Worth County's population is predicted to increase to 22,258 residents by 2015. The percentage of residents aged 55 and older increased from 2000 to 2010. This increase identified an immediate need for delivery of healthcare that serves individuals with chronic conditions. The Hispanic population also increased, although this segment remained a small portion of the population. • Condition of Health (Morbidity and Mortality) • CANCER : The most prevalent types of cancers can usually be detected the earliest, due to known risk factors. Cancer had a lower death rate in Worth County when compared to both the U.S. and Georgia. There is a need for cancer prevention programming in Worth Count due to the various modifiable risk factors. Lung cancer, for instance, had higher incidence rates in Worth County compared to Georgia and the U.S. Cigarette, cigar, and pipe smoking are the leading risk factors for lung cancer. • HEART DISEASE AND STROKE :Heart disease and stroke typically affect individuals age 65 and older. Heart disease was the number one leading cause of death in Worth County. The death rate in Worth was significantly higher than in Georgia. Stroke was the fourth leading cause of death in Worth County. The stroke rate for Worth was higher than both Georgia and the U.S. Stroke has similar modifiable risk factors to heart disease, and the two can be grouped together when developing community benefit implementation strategies. • MATERNAL, INFANT, AND CHILD HEALTH :Birth rates, infant mortality rates, and teen birth rates provide a snapshot of the overall health of a community. The teen birth rate in Worth County was significantly higher than in Georgia and the U.S. The teen birth rate among Black females was higher than White females, which brings attention to a health disparity in the community. The infant mortality rate in Worth County was higher than Georgia. • ALCOHOL, TOBACCO, AND DRUG USE :Abused substances have an impact on the overall health of the community, family, and individual. The use of cigarettes and alcohol decreased from 2007 to 2011 in young adults in Georgia. Marijuana and methamphetamine use increased in Georgia. Community members attributed substance abuse to lack of family support and poverty. • SEXUALLY TRANSMITTED DISEASES :Georgia reports some of the highest sexually transmitted disease (STD) rates in the country. In 2010, Worth County's rates for chlamydia were lower than the Georgia and U.S. rates. Gonorrhea rates were lower than the State rates but higher than the U.S. rates. Worth County chlamydia rates among Blacks were 18 times the rate of Whites.Gonorrhea rates among Blacks were over 25 times higher than the rate of Whites.In Worth County, human immunodeficiency virus (HIV) hospital discharge rates were higher among Blacks compared to Whites.Community members cited teenage behaviors as a key indicator for increased prevalence of STDs. • ACCESS TO CARE : Access to healthcare is impacted by level of income, educational attainment, and insured status. In 2006-2010, Worth County's population consisted of 17.4 percent living in poverty. This was a higher percentage than the State and National average. o Uninsured individuals often face limited resources for treatment and face delays in seeking treatment. In 2012, 22 percent of adults were uninsured in Worth County. In 2010, 12 percent of children were uninsured in Georgia. Education also affects an individual's ability to access care. In 2006-2010, only 66 percent of Worth County residents were high school graduates. Individuals with low educational attainment are less likely to access healthcare because they do not obtain jobs with health insurance. They are also more likely to engage in risky behaviors, such as substance abuse and unprotected sex. o Local infrastructure and public transit affect access to healthcare. Without a public transit system, many Worth County residents rely on friends and family members for transport Community Prioritization of Needs • Information gathered from community meetings, stakeholder interviews, discussions with the hospital leadership team, review of demographic and health status, and hospital utilization data was used to determine the priority health needs of the population. Health priorities were further developed by the CHNA Hospital Steering Committee (CHSC) after careful review of community resources available for these priorities and the future value of the priority. The following priorities were identified by the CHSC: 1. Adolescent Lifestyle-Including Alcohol, Tobacco, and Drugs 2. Obesity and Diabetes 3. Access to Care-Providers and Prevention 4. Mental Health 5. Heart Disease and Stroke 6. Senior Health 7. Access to Care-Transportation 8. Teen Birth Rate Collection of data: • Description of Major Data Sources Bureau of Labor and Statistics The Bureau of Labor and Statistics manages a program called Local Area Unemployment Statistics (LAUS). LAUS produces monthly and annual employment, unemployment, and labor force data for census regions, divisions, states, counties, metropolitan areas, and many cities. This data provides key indicators of local economic conditions. For more information, go to www.bls.gov/lau. • Behavioral Risk Factor Surveillance System The Behavioral Risk Factor Surveillance System (BRFSS) is a state-based surveillance system, administered by the Georgia Department of Human Resources, Division of Public Health, and the Centers for Disease Control and Prevention (CDC). The data is collected in the form of a survey that is comprised of questions related to the knowledge, attitude, and health behaviors of the public. For more information, go to www.cdc.gov/brfss. • Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) publishes data that is collected by various surveillance and monitoring projects including: o National Vital Statistics System: collects and disseminates vital statistics (births, deaths, marriages, fetal deaths). For more information, go to www.cdc.gov/nchs/nvss.htm. o National Health and Nutrition Examination Survey (NHANES): assesses the health and nutritional status of adults and children in the U.S. For more information, go to www.cdc.gov/nchs/nhanes.htm. o Sexually Transmitted Disease Surveillance: collects and disseminates data derived from official statistics for the reported occurrence of nationally notifiable sexually transmitted diseases (STDs) in the United States, test positivity and prevalence data from numerous prevalence monitoring initiatives, sentinel surveillance of gonnoccal antimicrobial resistance, and national services surveys. For more information, go to www.cdc.gov/std/stats10/app-interpret.htm. • County Health Rankings : County Health Rankings is published online by the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation. These rankings assess the overall health of nearly every county in all 50 states using a standard way to measure how healthy people are and how long they live. Rankings consider factors that affect people's health within four categories: health behavior, clinical care, social and economic factors, and physical environment. Information is based on the latest publicly available data from sources such as National Center for Health Statistics (NCHS) and Health Resources and Services Administration (HRSA). • Georgia Department of Public Health - The Georgia Department of Public Health manages a system called OASIS (Online Analytical Statistical Information System). OASIS is currently populated with Vital Statistics (births, deaths, infant deaths, fetal deaths, and induced terminations), Georgia Comprehensive Cancer Registry, Hospital Discharge, Emergency Room Visit, Arboviral Surveillance, Risk Behavior Surveys (Youth Risk Behavior Survey (YRBS), Behavioral Risk Factor Surveillance Survey (BRFSS), STD, and population data. For more information, go to http://oasis.state.ga.us. • Georgia Department of Education - The Georgia Department of Education collects and analyses student health data through an annual survey. The Georgia Student Health Survey II (GSHS II) is an anonymous, statewide survey instrument developed by collaborations with the Georgia Department of Public Health and Georgia State University. The survey covers topics such as school climate and safety, graduation, school dropouts, alcohol and drug use, bullying and harassment, suicide, nutrition, sedentary behaviors, and teen driving laws. For more information, go to http://www.doe.k12.ga.us. • Healthy People 2020 - Healthy People 2020 provides science-based, 10 year national objectives for improving the health of all Americans. It identifies nearly 600 objectives with 1,200 measures to improve the health of all Americans. Healthy People 2020 uses a vast amount of data sources to publish its data. Some examples of these data sources include the National Vital Statistics System and the National Health Interview Survey. The data used is formed into objectives: measurable objectives and developmental objectives. Measurable objectives contain a data source and a national baseline value. Baseline data provide a point from which a 2020 target is set. Developmental objectives currently do not have national baseline data and abbreviated, or no operational definitions. For more information, go to www.healthypeople.gov/2020. • Kids Count Data Center - Kids Count Data Center is managed and funded by the Annie E. Casey Foundation. This foundation is a private charitable organization dedicated to helping build better futures for disadvantaged children in the U.S. The Kids Count Data Center receives data from a nationwide network of grantee projects. They collect data on, and advocate for the well-being of children at the state and local levels. For more information, go to www.datacenter.kidscount.org. • National Cancer Institute - The National Cancer Institute manages an online tool called State Cancer Profiles. State Cancer Profiles provides access to interactive maps and graphs, and cancer statistics at the national, state, and county level. This data can be further displayed by geographic regions, race/ethnicity, cancer site, age, and sex. For more information, go to www.statecancerprofiles.cancer.gov. • U.S. Census Bureau - The U.S. Census Bureau manages an online tool called the American FactFinder. American FactFinder provides quick access to data from the Decennial Census, American Community Survey, Puerto Rico Community Survey, Population Estimates Program, Economic Census, and Annual Economic Surveys. The data from these sources includes a wide variety of population, economic, geographic, and housing information at the city, county, and state level. Priority Health Needs: • Adolescent Lifestyle-Including Alcohol, Tobacco, and Drugs o There is a need for family oriented education on the dangers and consequences of underage drinking and binge drinking. o There is a need for more education and monitoring of adolescent behavior in the schools. o Adolescents have easy access to alcohol in the community. There is a need for collaboration among community agencies to help prevent underage access to alcohol. • Obesity and Diabetes o There is a need for education and awareness on the causes, prevention, and intervention for diabetes and obesity. o There is a need for specific education on how to purchase and cook healthy foods on a budget. o There is a need for more resources to help individuals adopt an active lifestyle. • Access to Care-Providers and Prevention o There is a need for free or low cost care options for the working poor, uninsured, or underinsured. i. There is a need for a convenient care clinic for non-emergent health issues. o There is a need for education and awareness regarding prevention of chronic illnesses. o There is a need for centralized resource directory. • Mental Health o There is a shortage of providers and services. o There is a need for education and awareness regarding depression. • Heart Disease and Stroke o There is a need for education and awareness on prevention and signs and symptoms of cardiovascular risk. • Senior Health o There is a need for more local services and specialists. o There is a need for education and awareness of Senior health conditions. o There is a need for education and awareness on Senior abuse and neglect. • Access to Care Transportation o Transportation to healthcare providers is an issue for all population groups, especially the young, the poor, and the Senior residents. • Teen Birth Rate o There is a need for education and awareness for adolescents concerning sex education and contraceptive use Hospital Input In determining the priority health needs of the community, the Community Health Steering Committee (CHSC) met to discuss the observations, comments, and priorities resulting from the community meetings, stakeholder interviews, and secondary data gathered concerning health status of the community. The CHSC debated the merits or values of the community's priorities, considering the resources available to meet these needs. The following questions were considered by the CHSC in making the priority decisions: » Do community members recognize this as a priority need? » How many persons are affected by this problem in our community? » What percentage of the population is affected? » Is the number of affected persons growing? » Is the problem greater in our community than in other communities, the state, or region? » What happens if the hospital does not address this problem? » Is the problem getting worse? » Is the problem an underlying cause of other problems? Identified Priorities After carefully reviewing the observations, comments and priorities of the community, as well as the secondary health data presented, the following priority needs were identified by the CHSC: 1. Adolescent Lifestyle-Including Alcohol, Tobacco, and Drugs 2. Obesity and Diabetes 3. Access to Care-Providers and Prevention 4. Mental Health 5. Heart Disease and Stroke 6. Senior Health 7. Access to Care-Transportation 8. Teen Birth Rate Diff communities diff outcomes

8.3 Understand the concept of cultural competency in relation to patient care and community diagnosis/Community Health Needs Assessment.

The way healthcare providers perceive themselves as competent providers is often reflected in the way they communicate with clients. - Cultural self awareness is a deliberate and conscious cognitive and emotional process of getting to know yourself: your personality, your values, your beliefs, your professional knowledge standards, your ethics, and the impact of these factors on the various roles played when interacting with individuals who are different from yourself - Ethnocentrism, the universal tendency of human beings to think that their ways of thinking, acting, and believing are the only right, prop- er, and natural ways, can be a major barrier to providing culturally competent care. - Cultural competence is a process, not an endpoint o One progresses: • (a) from unconscious incompetence (not being aware that one is lacking knowledge about another culture), • (b) to conscious incompetence (being aware that one is lacking knowledge about another culture), • (c) to conscious competence (learning about the client's culture, verifying generalizations about the client's culture, and providing culturally specific interventions), and finally • (d) to unconscious competence (automatically providing culturally congruent care to clients of diverse cultures). • Unconscious competence is difficult to accomplish and potentially dangerous because individual differences exist within specific cultural groups. - To be even minimally effective, culturally competent care (really an individualized plan of care) must have the assurance of continuation after the original impetus is with- drawn; it must be integrated into and valued by the culture that is to benefit from the interventions.

Maternal Mortality Rate

based on # of pregnancy related deaths

Infant Mortality

can be used as overall index of health status of a nation since health of infants sensitive to maternal health practices, environmental factors, and quality of health services; is age specific

Crude Birth Rate

number of live births divided by the midperiod population

• Incidence Rate

o # of new cases of a disease that occur during specified period of time in population at risk for developing the disease. o Measure of events - the disease is identified in a person who develops the disease and did not have the disease previously. o Measure of risk o (# of NEW cases occurring in population during specified time)/(# of persons who are at risk of developing the disease during that period of time)

7.9 Describe the SmokefreeTXT mobile text messaging service for smokers in terms of eligibility to participate, the length of the program, and the number and type of text messages received. Identify at least three strategies, resources, or tools featured on the NCI QuitPal mobile phone application (iPhone and Androids). Describe a patient management plan that would include the use of the smokefree.gov website, the SmokefreeTXT service, the NIC QuitPal app, the Georgia Tobacco Quit Line, and 5As to provide smoking cessation counseling and tools to patients.

o SmokefreeTXT is a mobile text messaging service designed for adults/young adults across the US that are trying to quit smoking (surprise...) - 6 - 8 week program during which users receive 1-5 messages/day and can receive additional quit support by texting one of SmokefreeTXT's "keywords" -3 strategies: videos/graphs/texts

Describe the state of the American healthcare system in 2015 in terms of percent of Gross Domestic Product (GDP) devoted to healthcare and the World Health Organization (WHO) ranking of U.S. healthcare.

• 17.5% of GDP is devoted to healthcare • WHO ranking = 37/191 • Hospital spending represented 34% of overall health spending in 2013, and physicians/clinics represent 21% of total spending. Prescriptions accounted for 10% of total health spending in 2013.

5.9 Describe the epidemiology of disease patterns in the U.S. from 1900 to present. Compare the ten leading causes of death in 1900 to 2009, especially in terms of infectious vs. chronic diseases. Compare and contrast the number of years of life remaining after birth and after age 65 for the years 1900, 1950, and 2007. Identify the groups and time periods where medicine and public health have made the greatest strides for this outcome.

• 1900: Leading causes of death: heart disease, cancer, chronic lower respiratory diseases, and stroke (cerebrovascular disease) • 20th century: chronic diseases that are not communicable or infectious in origin. • But even with industrialized countries, HIV infection has emerged and incidence of TB has increased; infectious diseases are again becoming major public health problems. • • Shows remaining years of expected life in US at birth and at age 65 years for the years 1900, 1950 and 2007 by race and sex. • Number of years of life remaining after birth has dramatically increased in all of these groups with most of the improvement occurring from 1900-1950 and much less having occurred since 1950. • If we look at the remaining years of life at age 65 years, very little improvement is seen from 1900 to 2007. • What primarily accounts for increase in remaining years of life at birth are decreases in infant mortality and in mortality from childhood diseases. • In terms of diseases that afflict adults, less success in extending the span of life and this remains a major challenge.

2.7 Discuss the link between the individual mandate and insurance policy provisions that exclude patients for preexisting conditions.

• 2009- Legislation to require most companies to cover workers; mandate everyone get covered or pay fine; require insurance accept all, regardless of pre-existing conditions & assist those who can't afford insurance • Individual mandate o Anyone who can afford it, must pay for health insurance o If can't afford it, government will subsidize the coverage from a state for federal exchanges o Individuals will be required to have health coverage that meets minimum standards in 2014 o Individual mandate spreads costs among whole population o Mandate enforced through the tax system o Penalty for not having insurance: greater of $695 (up to $2085 for family) or 2.5% of family income o Exemptions for certain groups and if people cannot find affordable health insurance • Individual mandate & Insurance policy excluding patients with preexisting condition- • Insurance co's want individual mandate b/c ppl don't buy insurance if don't get it thru job/aren't sick • Insurance would be cheaper if everyone had it • Insurance has less of a risk- cost per capita is lower • Currently exclude people with pre-existing conditions because costs more money • Get more healthy people in pool b/c get more people who pay but don't use so can cover people who are covered for more than they pay (pre-existing conditions) • Insurance couldn't get rid of policies of pre-existing conditions w/o individual mandate • Makes sense from insurance company that can provide coverage if they have a larger healthy pool

3.1 List the following percentages found in the monograph by Dent (2015): 1.) MUSM graduates who practice in GA; 2.) MUSM graduates who practice in health professional shortage areas (HPSA) in GA.

• 65% of MUSM graduates practice in Georgia • 83% of MUSM graduates practice in a health professional shortage area in Georgia

5.5 Explain the preclinical phase of a disease in terms of advancing the diagnosis of the disease to an earlier point in its natural history. Describe the preclinical phase and its relationship to screening in terms of the detectable preclinical phase, lead time, earlier diagnosis, and the critical point (as represented in Chapter 18, Figure 18-2; Figure 18-3 of Gordis).

• At some point during preclinical phase, it becomes possible to detect disease by using currently available tests; interval from this point → development of signs and symptoms is detectable preclinical phase of disease. • Lead time: interval by which time of diagnosis is advanced by screening and early detection of disease compared to usual time of diagnosis • Critical point: point in natural history before which treatment is more effective and/or less difficult to administer. - Preclinical phase - the period from biologic onset of disease to the development of signs/symptoms. Screening (secondary) is utilized to detect diseases in this stage in order to more effectively treat the disease. - Lead time - the interval by which the time of diagnosis is advanced by screening and early detection of disease compared to the usual time of diagnosis. - Critical point- point in the natural history before which treatment is more effective and/or less difficult to administer. **There can be more than 1 critical point**

5.1 Explain the natural history of disease from normal to biologic onset to disease outcome (e.g., recovery, disability, or death) as represented in Chapter 18, Figure 18-1 of the Gordis text.

• Biologic onset of disease occurs (Preclinical Phase) • Disease becomes symptomatic/clinical signs develop (Clinical Phase)

5.2 Describe the preclinical and clinical phases and their relationship to the natural history of disease in terms of biologic onset, onset of symptoms, timing of diagnosis and start of therapy, and outcome (as represented in Chapter 18, Figure 18-1 of Gordis).

• Clinical Phase: period from the time when signs and symptoms develop to an ultimate outcome (death or cure) • Preclinical Phase: Period from biologic onset of the disease to the development of signs and symptoms

3.2 State the current MUSM mission statement.

• Current Mission: To educate physicians and health professionals to meet the primary and health care needs of rural and medically underserved areas of Georgia

State at least one reason why employer-based health insurance became dominant in America.

• Employee-sponsored insurance o Offered by employers as part of benefits package o Administered by private insurance companies (for-profit and non-profit) o Employer pays bulk of premium; employee pays remainder. o Tax benefits to employer and employee. o Decreased use because of rising cost of insurance premium. • Tax policy favors employee-based benefit. o They do not pay tax on the "profit" of the money spent on health care benefits. o Employees are not taxed on benefits. • "Adverse selection" and individual insurance. o People who are sick are more likely to buy health insurance → individually purchased healthcare is more expensive than what an individual would pay for "group rating" employer based health care.

4.2 Explain the dynamics of disease transmission in a population in terms of the epidemiologic triad, concepts of clinical and subclinical disease, endemic, epidemic, and pandemic disease outbreaks. Recognize types of exposure, attack rates, incubation periods, and the role of herd immunity.

• Epidemiologic triad: product of an interaction of the human host, an infectious or other type of agent, and the environment that promotes the exposure. o Vector (e.g. mosquito or deer tick) is often involved • Clinical and Subclinical Disease o Clinical Disease: signs and symptoms o Nonclinical (Inapparent Disease) • Preclinical Disease: Disease that is not yet clinically apparent but is destined to progress to clinical disease. • Subclinical Disease: Disease that is not clinically apparent and is not destined to become clinically apparent. • Often diagnosed by serologic (antibody) response or culture of the organism. • Persistent (Chronic) Disease: A person fails to shake off the infection and it persists for years, at times for life. • Example: Adults who recovered from poliomyelitis in childhood are reporting severe fatigue and weakness - post-polio syndrome in adult life. • Latent Disease: An infection with no active multiplication of the agent; only genetic message is present in host, not the viable organism. • Endemic v. Epidemic v. Pandemic Outbreaks o Endemic: habitual presence of a disease within a given geographic area; refers to usual occurrence of given disease within such an area. o Epidemic: Occurrence in a community or region of a group of illnesses of similar nature, clearly in excess of normal expectancy, and derived from common or propagated source. o Pandemic: worldwide epidemic • Types of Outbreaks o Vignette: food becomes contaminated with microorganism • Common vehicle exposure: outbreak occurs in group of people who have eaten the food • Single exposure: food may be served only once (catered luncheon) • Multiple exposures: Food may be served more than once o Vignette: water supply is contaminated with sewage because of leaky pipes • Periodic contamination: causes multiple exposures as result of changing pressures in water supply system that may cause intermittent contamination • Continuous contamination: constant leak leads to persistent contamination. • Herd Immunity o Resistance of a group of people to an attack by a disease to which a large proportion of the members of the group are immune. o Certain conditions must be met: • Disease agent must be restricted to single host species within which transmission occurs • Transmission must be relatively direct from one member of the host species to another. • Infections must induce solid immunity. • Operates optimally when populations are constantly mixing together. • Incubation Period o Interval from receipt of infection to the time of onset of clinical illness; may reflect the time needed for organism to replicate sufficiently until it reaches critical mass needed for clinical disease to result. o Also relates to site at which organism replicates - superficially or deeper in body o Dose of infectious agent received at time of infection may also influence the length of the incubation period (large dose = shorter incubation period) o Black Death; Ragusa; 40 day incubation period (quarante giorni) = quarantine o Epidemic Curve • Distribution of times of onset of disease • In single exposure, common-vehicle epidemic: epidemic curve represents distribution of incubation periods; rapid, explosive rise in number of cases within 1st 16 hours - suggests single exposure, common-vehicle epidemic. • If curve is plotted against logarithm of time rather than against time, the curve becomes a normal curve • Attack Rate o (# of people at risk in whom a certain illness develops)/ (Total # of people at risk) o Primary case: person who acquires the disease from that exposure o Secondary case: person who acquires disease from exposure to primary case o Secondary attack rate: Attack rate in susceptible people who have been exposed to a primary case; good measure of person to person spread.

7.5 Identify the four guiding principles of motivational interviewing (MI) as described in the article by Clark and Vickers (and demonstrated in the Effective and Non-Effective Physician videos) and identify a specific MI principle employed in a clinical vignette.

• Express empathy o Accepting a patient can facilitate that patient making change; accept patient's perspectives and feelings. o Reflective listening without judging, blaming or criticizing is key for expressing empathy. • Develop discrepancy o Between current patient behavior and broader goals and values of patient; underlie motivation toward change • Roll with resistance o Emphasizes need to avoid arguing with patients or trying to force a change • Support self efficacy o Reflects confidence of patients in own ability to successfully make and maintain a change.

3.11 Describe the five levels of the Medical College of Wisconsin's population-based model of patient-centered care. Describe the differing views of Meuer and Gruen regarding which domains should be considered as part of the professional obligations of a physician (Dent monograph).

• First level: relationship between physician and patient, with each bringing biological and personal history factors to the care relationship between the two. • Second level: health system; access to care and may include issues related to insurance coverage, availability of care, geographic distribution of services • Third level: community (schools, workplaces, neighborhoods), includes the direct socioeconomic influences in the social/physical environment, and local policies (smoking bans, helmet laws) • Fourth level: society; addresses the broader societal impacts that are related to health status, but efficacy of physician action in affecting these influences is weak. • Fifth and outermost domain: global perspective; regarding global distribution of resources, knowledge and opportunity. • Meuer: physicians have professional responsibilities across all domains • Gruen: physicians have professional responsibilities to Patient/Physician, Health system, and Community domains o Physicians may have professional aspirations in outer two domains but have no more responsibility than any other citizen.

3.6 Describe four components of population health as delineated in the Clinical Prevention and Population Health Curriculum Framework.

• Foundations of Population Health: Descriptive epidemiology; etiology and health research evaluation; evidence based practice; implementation of health promotion and disease prevention interventions. • Clinical Preventive Services and Health Promotion: Screening; counseling; immunization; preventive medication; other preventive interventions. • Clinical Practice and Population Health: incorporating population health into clinical care; partnering with the public to improve health; environmental health; occupational health; global health issues; cultural dimensions of practice; emergency preparedness and response systems. • Health Systems and Health Policy: organization of clinical and public health systems; health services financing; clinical and public health workforce; health policy process.

4.) Clinical Prevention and Population Health Curriculum Framework;

• Foundations of Population Health: Descriptive epidemiology; etiology and health research evaluation; evidence based practice; implementation of health promotion and disease prevention interventions. • Clinical Preventive Services and Health Promotion: Screening; counseling; immunization; preventive medication; other preventive interventions. • Clinical Practice and Population Health: incorporating population health into clinical care; partnering with the public to improve health; environmental health; occupational health; global health issues; cultural dimensions of practice; emergency preparedness and response systems. • Health Systems and Health Policy: organization of clinical and public health systems; health services financing; clinical and public health workforce; health policy process.

6.) David Kindig/Greg Stoddart

• Health outcomes of a group of individuals, including the distribution of such outcomes with the group.

3.12 Describe four advocacy activities in which a physician may engage as described by Earnest et al. (2010).

• Medical society affiliation: State Health Care Reform • Practice management: Coalition and Board Leadership/Reallocation of Resources • Parent education: School Board Advisor • Policy advocate: Coalition Building and Leadership • Patient advocate: Health Care Advisor for a Policy Maker/Liaison to Media and Health Reporter • Hospital physician: Leader in Injury Prevention • Physician advocate - Discussion

2.8 Describe at least one difference in the populations served by Medicare and Medicaid.

• Medicare o Federally-funded program for ages 65 and older; End Stage Renal Disease, ALS, other disabilities o Part A: Hospital, some skilled nursing facility costs o Part B: Physician, RN, equipment, tests, other o Part C: Medicare Advantage plans • Allows Medicare beneficiaries to enroll in private plans; mainly HMOs; contract with Medicare and receive payments from the government. o Part D: RX drug plan • Medicaid o Federal-State Partnership o Eligibility: state by state basis; generally poor + children, parents of dependent children, pregnant women, disabled • Dual eligible with Medicare -chronically ill, long term care. o Covers most clinical services + Rx

3.8 Explain why the concept of population health is particularly important to practicing physicians.

• Physicians hold a position of respect and privilege, which empowers them to leverage public opinion in domains other than strictly medical. There is an implied social contract: society grants the medical profession special social status and certain privileges; in return, the medical profession is expected to promote society's health beyond providing care to individual patients.

5.11 Describe why epidemiology is important to clinical practice and why, according to Gordis, "medicine is dependent on population data" for diagnosis, prognosis, and selection of therapy.

• Practice of medicine is dependent on population data. • Diagnosis is based on correlation of clinical findings with findings of surgical pathology or autopsy with results of catheterization or angiography studies in large group of patients. • Prognosticate based on experience with large groups of patients who had same diseases, observed at same stage of disease, and received same treatment. • Selection of therapy is also population based; randomized clinical trails that study the effects of a treatment in large groups of patients are ideal means of identifying appropriate therapy. • To determine whether an association exists between exposure to a factor or a characteristic of a person and the development of the disease in question • To try to derive appropriate inferences about a possible causal relationship from the patterns of the associations that have been found

7.6 Define and describe the five stages of change, processes of change, decisional balance, and self-efficacy as delineated in the article by Clark and Vickers. Describe how these concepts can be employed by a physician and his staff to develop "stage-matched" counseling that is tailored to an individual patient's level of motivation to engage in a specific behavior. Explain why it is important for physicians to appropriately choose, and use, counseling models and approaches with evidence of effectiveness (based on research and real world practice) rather than "just winging it." Identify the Stage of Change of a patient least likely to be affected by simply handing them a health information pamphlet. Describe how a physician might advance his/her patient to the next stage of change in which pamphlets, mobile health applications, and detailed instructions and plans might be more appropriate.

• Precontemplation: no consideration of change o Individual is not considering stopping tobacco use • Contemplation: some limited motivation to change o Person is seriously considering stopping in next 6 months • Preparation: making small changes o Intention to stop smoking in next 30 days and having made an attempt at quitting in past year • Action: the first 6 months of change • Maintenance: period after first 6 months of change • Processes of Change - Individuals in different stages of change use different strategies and techniques to change. o includes behavioral and cognitive strategies that an individual uses to implement change o Cognitive strategies are employed during pre-contemplation and contemplation stages o Behavioral strategies are used in the action stage • Decisional Balance - the perceived gains and perceived losses of a behavior change, divided into perceived positive and perceived negative aspects of a behavior • Self-efficacy (aka self-confidence) - the individuals perceived ability to perform a specific behavior or task o Important in terms of initiating and maintain motivational readiness • The Transtheoretical Models proposes that interventions tailored to the motivational readiness of the individual will enhance the effectiveness of the intervention.

4.4 Explain the relationship between incidence, prevalence, mortality, and cure.

• Prevalence v. Incidence o Prevalence: snapshot or slice through population at point in time at which we determine who has the disease and who does not; not determining when disease developed; do not take into account duration of disease. • Numerator includes mix of people with different durations of disease; not measure of risk. o Incidence: Only includes new cases and specified time period during which events occurred; measure of risk. • Prevalence→ current amount of disease; number of affected people present in the population at specific time divided by the number of people in the population total ; can be viewed as a slice through the population at a point in time at which we determine who has the disease and who does not; doesn't determine WHEN disease developed o Prevalence rate= total # of cases (new +old) in a given time frame/ total population (in a given time frame) o Point prevalence→ prevalence at a certain point in time (" do you currently have asthma?") o Period prevalence→ how many people have has the disease at any point in time ("have you had asthma during the last (n) years?") o Cumulative incidence→ "have you ever had asthma?" • Incidence→ amount of new disease that occurs during a specified period of time in a population at risk for developing the disease ; measures how fast something is happening ; a high incidence rate can help define an epidemic , considering baseline of disease Incidence rate=# of new cases (in a given time frame)/ population at risk for developing - Relationship b/w incidence & prevalence: o Within a steady state situation in which rates do not change & in-migration = out migration: Prevalence = Incidence x Duration of disease - Mortality & Survival are when the "diseased" are no longer diseased. o Mortality annual death rate: = (total # deaths from all causes in 1 yr)/ (# of persons in population @ mid year) x 1000 Midyear in denominator because # of persons in population change over time.

Primary/Secondary/Tertiary

• Primary - no disease, measure intend to reduce exposure or increase resistance. o Ex: isolation, lifestyle modification (healthier eating/exercise for diabetes prevention), immunization • Secondary - have medical condition but are not yet symptomatic. Screen for asymptomatic disease w/ a goal of early detection/TX. o Keeping diabetes from causing end organ damage o Ex: screen for diabetes, pap smears, mammograms • Tertiary - patient has medical condition and is getting treatment for that condition in order to prevent recurrence, prevent complication, rehab o Ex: insulin therapy for diabetes, antibiotics for infection, chemo for cancer o Limiting end organ damage from diabetes

5.3 Describe the relationship between primary, secondary, and tertiary prevention and the natural history of disease including the normal preclinical and clinical phases of an illness/disease (as represented in Chapter 18, Figure 18-1 of Gordis).

• Primary prevention: preventing development of disease by reducing exposure to disease causing agents or by immunization; denotes intervention before a disease has developed. • Secondary prevention: Detecting disease at an earlier stage than usual (screening) takes place during preclinical phase of an illness; after disease has developed but before clinical signs and symptoms have appeared. • Tertiary prevention: Treating clinically ill individuals to prevent complications of the illness including death of the patient.

2.6 State at least one of the main goals of the Patient Protection and Affordable Care Act (ACA) and describe the effect of the ACA on this goal.

• Reduced number of underinsured • Improved coverage for insured o Reduce or eliminate exclusions/rescissions o Rescission: retroactive cancellation of health insurance policy; illegal except in cases of fraud or intentional misrepresentation. • Improve access to and quality of care o Preventative care o Comparative efficacy • Control rising costs

2.5 Distinguish between universal healthcare and socialized medicine.

• Socialized medicine: All health care delivery comes through government-owned facilities through government-employed doctors. • Universal healthcare: Healthcare is available to everyone.

10.11 Describe the process of gathering qualitative data from key stakeholders in the community.

• Stakeholder interviews provide subjective information from a cross section of community leaders/key informants/stakeholders regarding health in the community that supplements the mortality and morbidity data (quantitative data) that you have already obtained and organized. o Problems cited by local leaders might include a situation or health condition that is considered undesirable, is likely to exist in the future, and is measurable such as death, disease, or disability. • interviewing individuals from a cross section of the community who can provide insight into the concerns, issues and/or problems experienced by the community. • This step provides you with subjective information from a cross section of community leaders/key informants/stakeholders regarding health in the community that supplements the mortality and morbidity data (objective data) that you have already obtained and organized. • methodologies which are most useful in conducting the interviews. o Face to face, not telephone, Establish rapport, Formulate questions ahead of time, Ask same/similar set of questions to each, Take notes, use a standard format for recording pertinent information, Semi structured interview: ask each interviewee same set of questions, but explore items of interest. • What preliminary information should you collect prior to conducting a community interview? o You should have a basic understanding about the stakeholder's organization and position. o You should have a grasp of the county's leading causes of death, mortality and morbidity patterns, health indicators, basic demographic information, some history of the community and the Community • Ask to identify and rank 5-10 health problems o You might start by asking them to name the top three health-related problems and then ask the leader to rank those three. o After you have discussed those problems, ask for three more, discuss and ask for a ranking. o Continue until the stakeholder has no further observations/ranking of the problems

9.7 Identify a physician's legal obligations for signing death certificates.

• The death certificate is the source for State and national mortality statistics and is used to determine which medical conditions receive research and development funding, to set public health goals, and to measure health status at local, State, national, and international levels. • The physician is to: o Be familiar w/ State & local regulations on medical certifications for deaths w/o medical attendance or involving external causes that may require Dr. to report case to a medical examiner or coroner o Complete relevant portions of the death certificate o Deliver signed or electronically authenticated death certificate to funeral director promptly so the funeral director can file it w/ State or local registrar w/in the State's prescribed time period o Assist State or local registrar by answering inquiries promptly. o Deliver a supplemental report of COD to the State vital statistics office when autopsy findings or further investigation reveals COD to be different from what was originally reported • The attending Dr. is responsible for certifying COD. Dr. pronounces death & certifies COD, except: o When attending Dr, is unavailable to certify COD at the time of death, & State law provides for a pronouncing physician, will a different physician pronounce death. o If practice partner takes over call, the practice, and your patients while you are on vacation etc, then your practice partner completes the death certificate • Box 37 on the death certificate (located in the right lower corner) should always be completed o As a GA physician you can only put "natural" in box 37. If you have a question or doubt that the death you are certifying is anything other than natural, you should call the Medical Examiner/jCoroner/Coroner Office and discuss the case with him or her o The medical examiner/Coroner may assume jurisdiction if the circumstances fall within the guidelines of "Georgia Death Investigation Act • Note: The cause of death line (26 part 1) should never be left blank o Invalid causes of death: Cardiorespiratory arrest, respiratory failure, heart failure, cardiac arrest, shock, sepsis, blood loss, bowel perforation, liver failure and renal failure are all modes of dying, not diseases or injuries- b/c all are MODES of dying NOT disease or injury • If the Medical Examiner/ Coroner assumes jurisdiction, as in a case of death from un-natural causes such as trauma, drug overdose, drowning etc, the physician will not sign the death certificate • If Medical Examiner/Coroner declines jurisdiction for patient whom you treated in last 30 days (this includes office visits/ communication or prescription medication), you're required to sign death certificate w/in 72 hrs o If you have any questions about what to list as the COD, the Medical Examiner/Coroner Office can help you. Check yes for "Case reported to the Medical Examiner/Coroner? o When Dr. refuses to sign death certificate, body can't be interred/cremated o Georgia Law authorizes funeral director to contact GA Composite Medical Board for disciplinary action. Refusing to sign a death certificate does not enable a physician to avoid liability • In GA, NOT required Dr. present when pt dies. GA licensed Dr may sign death certificate for attended death o "Attended" does not mean present at the bedside or > 30 days after decedent was last treated by a Dr., except where death was medically expected as certified by an attending physician o Key word is "treated" not "seen" or "visited." Treated includes office visits/communication or current prescriptions and usually involves a potentially life threatening illness or extreme old age. o For example, a 90 y.o. patient w/ angina has not been in office for 4 mo. Dies in his sleep w/ a current refilled bottle of drug you prescribed. Police call & inquire about decedent informing you there are no signs of foul play. This is considered attended death & you are legally obligated to sign death certificate. Dr. signing death certificate is following thru w/ statutory obligations as Dr. • If patient dies in ER, the primary care Dr (not E.R. Dr) signs death certificate, in natural death situations • Medical examiner will NOT settle dispute of which Dr signs death certificate of pt cared for by multiple Dr's

State the predominant method for paying for U.S. healthcare in 1910.

• Trade goods for services

2.) American Medical Association (as delineated in the Roadmaps for Clinical Practice);

• View of care that places the patient as central while recognizing that the patient exists in specified context with geopolitical boundaries as well as sociocultural definition each of which creates major effects on care.

Case Fatality

→ # of deaths w/in a certain time with same disease ; what percentage of people who have certain disease die w/in a certain time after diagnosis

Crude Mortality Rate

→ aka annual death rate; mortality rate from all causes of death for a population in a specific time o Annual mortality rate for all causes (per 1,000) = (total # of deaths from all causes in 1 year/ # of persons in population at midyear) X 1000

Age Adjusted Mortality Rate

→ eliminated the age difference b/w populations so the difference in mortality b/w populations can be compared under assumption that age compositions of populations are the same o age is the single most important predictor of mortality & may differ b/w 2 populations being compared & can lead to misleading mortality rates o Weighting process used which uses detailed info about age structure of population o Show what the level of mortality would be if no changes occurred in age composition of the o population from year to year o There are 2 approaches for dealing w/ this problem, direct & indirect age adjustment; they provide a way to eliminate age difference b/w populations so that difference in mortality b/w populations can be compared under the assumption that the age compositions of the populations are the same o Crude mortality can reflect both differences in the force of mortality and differences in the age o composition of the population

Specific Mortality Rate

→ mortality rate w/ a restriction placed on it (can be any number of restrictions) o When putting a restriction on rate, same restriction must apply to numerator & denominator, so that every person in denominator group will be at risk for entering numerator group o Specific rates when not interested in rate for entire population, but certain age/gender/ethnic group • ex. Age specific mortality rate

Proportionate Mortality

→ not a rate; proportion of deaths due to heart disease for example out of all deaths; demonstrates proportionate mortality from condition but does not indicate risk of death from condition