Health Affairs

$7.5 million to Battle HIV/AIDS in the United States

Earlier this month, President Barack Obama set out a new domestic AIDS policy, which asked cities, states, federal agencies, and the private sector to find ways to cut new infections by 25 percent; get more patients treated quickly and consistently; and reduce the disproportionate impact of HIV/AIDS on gay and bisexual men, African Americans, and Latinos. According to the Centers for Disease Control and Prevention (CDC), more than one million people in the United States are living with HIV, which causes AIDS, and there are approximately 56,000 new HIV infections every year. And, in many cases, HIV is a silent epidemic: at least 21 percent of those infected are unaware that they are already living with HIV.

With a National AIDS Strategy just released and the recent International AIDS Conference in Vienna, we thought this was a timely opportunity to share some of our preliminary results from the Pfizer Foundation’s ConnectHIV program, which concludes this year. In 2007, the program selected twenty community-based organizations to receive a total of $7.5 million in funding and additional program support over three years with the overarching goal of building capacity in states disproportionately impacted by HIV. This funding was designed to “complete” local service networks that aimed to both prevent and treat HIV but were missing a key service component.

Program Strategy

We understood that prevention efforts need to serve both people with HIV and those most at risk and that focusing on the continuum of HIV prevention and care is critical in decreasing new infections and improving the quality of life of those who are HIV positive.

ConnectHIV partners were supported in four specific funding areas across the continuum of care:

(1) prevention for at-risk HIV-negative people,
(2) prevention for people living with HIV,
(3) linkage to care and treatment, and
(4) treatment adherence and delaying progression of the disease.

ConnectHIV grants supported innovative, evidence-based prevention initiatives that also often addressed other interconnected HIV/AIDS challenges, such as HIV-related stigma, substance abuse, and mental health issues.

Early Results

To evaluate the effectiveness of our partners’ strategies and to learn from their successes and challenges, Pfizer partnered with the Academy for Educational Development and Johns Hopkins Bloomberg School of Public Health to provide technical assistance and implement a national evaluation. Overall, the national evaluation aimed to answer questions such as:

(1) What impact did ConnectHIV have on clients’ HIV-related knowledge, risk behaviors, and health outcomes?

(2) What grantee best practices may be contributing to the client progress made in the different organizations?

(3) What grantee factors (that is, intensity of the intervention, staff–client ratio, level of service integration, best practices used) may be accounting for the progress in client outcomes?

(4) What did it cost per client to deliver these services, and what was the relative cost-effectiveness of the interventions?

To date, approximately 3,300 people have participated in the ConnectHIV national evaluation, which aimed to collect data at baseline, immediately post-program, and at three to six months after the end of the program. While a controlled evaluation design was not used, preliminary analysis of clients with matched data points has shown statistically significant positive results related to most ConnectHIV measures.

Results include

1) Increased knowledge and skills, such as knowledge of HIV transmission/prevention and HIV disease management; skills for condom negotiation and condom use with a main and nonmain partners; knowledge of partners’ HIV status and skills to disclose HIV-positive status to partners; and

2) Improved treatment adherence and health, as indicated by reduced injection drug use; fewer pills missed in the past seven days; improved health indicators (increased CD4 [specialized cells that help protect the body from infection] and reduced viral load); and overall perceived quality of life.

Final follow-up data are being compiled, and final outcome analyses are expected in late 2010.

Beyond those participating in the national evaluation, ConnectHIV has touched more than 17,000 people since the program began in 2007, through innovative public awareness campaigns, personalized outreach to HIV-positive drug users and to the incarcerated, peer-led sessions on drug adherence for people who are HIV positive, and group sessions targeting HIV-positive women from communities of color.

A specific ConnectHIV anecdote is “Positive Results for Positive People” from the Family Center in New York City. The wisdom of their family-based approach was seen with a client named Rona (name changed), who is an African American mother of four. Rona has a series of interlocking and complex health issues, including diabetes and high blood pressure. When she enrolled in 2008, she was often forgetting to take her evening HIV medicines, and her lab results reflected poor CD4 and viral-load numbers. Over several months, the Family Center team worked with the family and a home health aide and devised a strategy to mobilize various social and family supports. The team programmed Rona’s cell phone to remind her when it was time to take her twice-daily doses, educated the older children to remind their mother of her evening dose, and worked with the health aide to support Rona in taking her meds. Today, Rona’s lab tests show that she is living well with HIV.

Lessons Learned

Although the analysis of the ConnectHIV data is still ongoing and the final report is planned for early fall 2010, we feel we have learned these overarching lessons:

(1) It is difficult to find and to develop comprehensive and successful continuums of HIV/AIDS services—the lack of coordination among many AIDS service organizations and other related groups, such as those providing substance abuse prevention services and mental health care, is often a challenge. Better coordination of referrals between organizations supporting HIV clients is needed.  

(2) Especially for high-risk populations, it is important to consider creative recruitment and retention strategies, such as offering incentives for participation, providing child care, identifying multiple ways to contact clients, and ensuring that caring, culturally competent staff are employed by the grantees. 

(3) Beyond program grants, grantees appreciated the Pfizer Foundation’s emphasis on technical assistance and its additional support for program content, evaluation, organizational and staff development, and networking.

What’s Next?

As a result of ConnectHIV, the Pfizer Foundation firmly believes that to decrease new infections, prevention and care efforts need to target both people who have HIV and those at high risk of contracting the virus. ConnectHIV attempted to address prevention, care, and health disparities in a way that is consistent with the National AIDS Strategy just released. Indeed, ConnectHIV was developed several years before the strategy was released, and we hope that some of the lessons learned from ConnectHIV can inform the implementation phase of the national strategy, which is now urgently under way.

This is just a sneak peek at the findings. The Pfizer Foundation and its evaluation team at the Academy for Educational Development and Johns Hopkins University are finalizing the ConnectHIV lessons and intend to share them this fall with our grantees, as well as other HIV/AIDS stakeholders.

We hope our ConnectHIV findings can help HIV/AIDS-focused organizations, as well as local policymakers, to understand that it is possible to round out local service delivery networks with the strategic use of resources from both the public and private sectors. We believe that our evaluations to date give an early validation of program effectiveness, and that, especially through our economic evaluation of the ConnectHIV grantees’ work, we will learn the per-client cost of the ConnectHIV services, so that local questions about affordability or the overall cost savings to local health care systems can be better understood.

We will post our findings on our Web site. In addition, we are compiling all of the resources gathered from the initiative onto a CD for distribution this fall; if you are interested in a copy, please email us at Pfizer.Foundation@pfizer.com.

Please note that the Pfizer Foundation does not accept unsolicited grant proposals.

On behalf of the Pfizer Foundation, we greatly appreciate the support from our ConnectHIV team—David Holtgrave from Johns Hopkins University, Susan Rogers from the Academy for Educational Development, and Sally Munemitsu from TCC Group—for their helpful comments and insights for this post.

With First Lady Michelle Obama’s interest in fresh produce from the garden, we are reminded of how good it is, especially this time of year, to indulge in fresh fruits and vegetables. Check out this four-color magazine recently released by a foundation in Pittsburgh.

The Heinz Endowments recently released the first “food issue” of its h magazine. (Yes, it is called simply “h.”) This Spring 2010 issue begins with an introduction by Teresa Heinz, chairman of the endowments, whose late husband was Republican Sen. John Heinz of Pennsylvania—he was tragically killed in a plane crash in 1991. (She is now married to Democratic Sen. John Kerry of Massachusetts.) Teresa Heinz comments, “Nowhere in our consumer-purchasing decisions are the stakes higher for our long-term health than in the choices we make about food.” This issue of h is “devoted to food as it relates to environmental issues and our health,” she explains.

According to the magazine, Heinz told attendees at the Women’s Health and the Environment 2010 conference (held in April and sponsored by the Heinz Endowments) about her “trials and tribulations of the past year with breast cancer and a series of other health calamities.” She advises readers, “We need to focus on the things we can control—the things that stand to make a real difference to our health.” And what we decide to eat and drink for ourselves and for our loved ones “is one of those areas.”

An article in h titled “Food for Thought,” by Christine O’Toole, says that “despite a national obsession with the ideal of eating and exercising for lifetime health, bad food and couch-potato lifestyles still rule.” The author, in previewing the issue, says that the stories are on “strategies to encourage farmers to produce more fresh foods for their local communities; foods that promote good health and help fight disease; national and local trends to promote consuming more nutritious food; and food-equity programs that provide low-income communities with access to healthy eating options.” Those communities,” she later observes, often have “few good supermarkets.”

The magazine also mentions a Carnegie Mellon University project that aimed to develop proposals for reducing obesity across Allegheny County, Pennsylvania. One recommendation of the team that worked on the project was to tax soft drinks. The team included students and professors. Read more about this project here. Questions? Call 412-268-2670.

Part of a Heinz grant was used to plant organic fruits and vegetables in three indoor courtyards of Magee-Women’s Hospital in Pittsburgh. The produce is used in healthy foods prepared for hospital staff and patients, the issue says. Also, the gardens are starting to be used for educating patients, staff, nursing students, and medical students about food.

The magazine concludes with some highlights of the Women’s Health and Environment 2010 conference, which, h said, attracted a “capacity crowd” to hear speakers including Regina Benjamin, U.S. Surgeon General.

The Heinz Endowments’ grant making includes programs in Environment and and in Children, Youth, and Families. Grant seekers: Please note that the Heinz Endowments “concentrates its efforts and resources in Southwestern Pennsylvania,” according to its Web site.

Just a few examples of other foundations doing related work:

The Aetna Foundation has a program area on obesity. Read the foundation’s funding guidelines here. According to an April 2010 e-alert, the foundation has awarded nearly $6 million to support “efforts to combat childhood obesity.”

Read about the Robert Wood Johnson Foundation’s (RWJF’s) program area on childhood obesity. The section of its Web site on obesity includes May 2010 videos, in English and Spanish, with Eduardo Sanchez, vice president and chief medical officer of Blue Cross and Blue Shield of Texas, discussing “Childhood Obesity and Latinos.”

Read about the W.K. Kellogg Foundation’s food strategy within its Healthy Kids funding area. Kellogg describes the locales in which it funds here.

The Paso del Norte Health Foundation, which funds in the El Paso, Texas, area, (including Ciudad Juárez, Mexico) awarded a three-year grant of more than $2.5 million to the El Paso Independent School District for implementation of “Get HIP (Health Initiative Program) Now.” The school system says that more than 43,000 kids in kindergarten through eighth grade, from seventy-four schools, “will benefit from this integrated approach to school health and childhood obesity prevention.”

Related resource:

Health Affairs, March 2010 issue with the theme of “Child Obesity: the Way Forward.” The issue was funded by the RWJF.

Stateline.org, the Pew Charitable Trusts’ online news site on state policy and politics, reported on July 19, 2010, that ”as states face their biggest fiscal challenge in modern history,” state funding of mental health is declining—for the first time in more than thirty years. Meanwhile, what have foundations been doing lately in mental health?

Recent report:

Justice for Immigration’s Hidden Population: Protecting the Rights of Persons with Mental Disabilities in the Immigration Court and Detention System, Texas Appleseed, released March 30, 2010. The report was funded by the Hogg Foundation for Mental Health; Texas Appleseed’s pro bono partner in preparing this report was the law firm of Akin Gump Strauss Hauer and Feld LLP. Texas Appleseed’s and Akin Gump’s “year-long investigation revealed that immigrants with mental disabilities fare poorly in all facets of the U.S. immigration system, from apprehension to detention, from adjudication to release.” Among this report’s policy recommendations for improving mental health diagnosis and treatment in the civil immigration detention system are (1) “Immigrants with mental disabilities should be detained only when required by law, for national security concerns, or for risks to health and safety” and (2) Detained immigrants with such disabilities should be put “in settings appropriate to their needs.”

The Web site of Texas Appleseed, a group that promotes justice for all Texans, notes, “A quarter of all immigrants apprehended each year in the U.S. are sent to detention facilities in Texas, however the problems documented in the report are not unique to Texas.”

Poll results:

“What Kentuckians Think about Treatment vs. Prison for People with Severe Mental Illnesses,” 2009 Kentucky Health Issues Poll, released March 2010. The poll was funded by the Foundation for a Healthy Kentucky and the Health Foundation of Greater Cincinnati. According to the poll, “Assuming that both treatment and incarceration cost the same, 72% of Kentuckians favor replacing prison sentences with mandatory mental illness treatment programs for people with severe mental illnesses who are convicted of nonviolent crimes.” Of course, the summary acknowledges, the cost of treatment versus that of incarceration varies “dramatically” depending on services are provided.

Recent Health Affairs GrantWatch article on mental health:

“Addressing Homelessness among People with Mental Illnesses: A Model of Long-Term Philanthropic Effectiveness,” Ruth Tebbets Brousseau, independent consultant, Health Affairs GrantWatch section, May/June 2009. The article, funded by the Conrad N. Hilton Foundation, is a follow-up to an assessment by Brousseau. The article focuses on the Corporation for Supportive Housing’s (CSH’s) work. The Hilton Foundation has been a long-time funder of the CSH, which also has received grants from a number of other foundations over the years.

Spotlight on three funders of mental health projects:

The Hogg Foundation for Mental Health, Austin, Texas. Please note that this foundation funds only in Texas.

The Ittleson Foundation, located in New York City, funds mental health projects. However, the funder has a staff of one and a “limited budget,” so read the Application Guidelines and Restrictions carefully to avoid wasting your time. Also, before contacting the foundation, see examples of past grants awarded in the mental health area. The foundation’s Web site says that “grants will only be made at the Fall [board] meeting” and that “initial letters of inquiry must be received before September 1, 2010.”

REACH Healthcare Foundation, located in Merriam, Kansas; mental health is one of this funder’s priorities. The foundation funds in Allen, Johnson, and Wyandotte Counties in Kansas; Cass, Lafayette, and Jackson Counties in Missouri; and in Kansas City, Missouri. Read general information about the foundation here. The foundation’s public policy and advocacy work is discussed here. Please note the foundation’s upcoming “Focused Grant Cycle.” This new grant application process will begin in August 2010.

Funding awarded recently:

“Hogg Foundation Fellowship Program Creates Mental Health Policy Advocates,” Hogg Foundation for Mental Health, press release, July 21, 2010. The foundation awarded a grant to each of five nonprofit advocacy groups “to hire an in-house fellow” who will work on “specific projects to improve mental health policy in Texas,” the release said. Each grant also covers provision of an experienced mentor for the fellow. Among the grantees is Mental Health America of Greater Houston.

Rethinking Mental Health: Improving Community Wellbeing. This was “a competition for new ideas and practices that challenge the status quo in terms of how we think about and address mental health care needs,” according to an e-alert. The Robert Wood Johnson Foundation (RWJF) sponsored the competition and worked in partnership with Ashoka’s Changemakers. The three winners of this competition were announced in late 2009.

Survey report:

Adults: Mental Health Issues and Disparities in Arizona, Flavio F. Marsiglia, Wendy L. Wolfersteig, Stephanie Ayers, Jaime Booth, and Alex Wagman of Arizona State University’s Southwest Interdisciplinary Research Center, April 2010. Funded by St. Luke’s Health Initiatives (SLHI), a foundation in Phoenix. This report is based on data from the 2008 Arizona Health Survey, which was conducted by telephone and funded by SLHI, the Virginia G. Piper Charitable Trust, the Valley of the Sun United Way, and the Arizona Community Foundation. The 2010 Arizona Health Survey is being fielded in the summer of 2010. Watch for results to start coming out later in 2010. (See the Stateline.org article mentioned below for recent information on Arizona and mental health services.)

Recent Health Affairs GrantWatch article on mental health:

“What Do We Really Know about Foundations’ Funding of Mental Health?” Ruth Tebbets Brousseau, independent consultant, and Andrew D. Hyman, RWJF, Health Affairs GrantWatch section, July/August 2009. Brousseau’s work was funded under a contract from the RWJF. Readers: Do the trends reported by these authors still hold true? Do you believe that foundations are funding enough mental health programs? If not, where should additional foundation funds be targeted? We encourage you to respond by clicking on the comment button next to this blog post.

Related resources:

“As Economy Takes Toll, Mental Health Budgets Shrink,” Christine Vestal, Stateline.org of the Pew Charitable Trusts, July 19, 2010. The article gives “some examples of states that have made big cuts” to mental health budgets: Arizona, Illinois, and Mississippi.

“Of Medical Specialties, Demand for Psychiatrists Growing Fastest,” Stephanie Steinberg, USA Today, July 1, 2010.

“Press Charges or Press for Change? The Criminalization of Mental Illness,” Michael J. Fitzpatrick, NAMI (National Alliance on Mental Illness) Blog, July 14, 2010. Fitzpatrick is executive director of NAMI, a grassroots advocacy group.

Earlier in July 2010, the White House released a new strategy for combating HIV/AIDS in the United States. Then, this week, the XVIII International AIDS Conference kicked off in Vienna, Austria. As we know, the disease affects people around the world. I decided to pull together some information in today’s post on what philanthropy has been doing to prevent and treat HIV/AIDS. This is only a sampling, not a comprehensive listing.

HIV/AIDS in the United States

New Ford Foundation initiative announced in June 2010.

The Ford Foundation, which is based in New York City, announced “a $25 million effort to fight the disproportionate yet largely hidden impact of HIV/AIDS on marginalized communities in the United States,” according to a foundation press release. Ford, which has funded efforts to stop HIV/AIDS for twenty-five years, is focusing on nine states in the southern United States, plus the District of Columbia. Also, it will fund “efforts to address the spread of HIV among African Americans, women, gay and bisexual men and Latinos.” Ford says it aims to combat “the discrimination that allows the epidemic to spread.” The $25 million commitment falls under Ford’s Human Rights funding area and is slated for five years.

Luis Ubiñas, Ford’s president, said in the release, “This initiative aims not only to help stop the spread of HIV, but also to address the stigma and discrimination” that let the epidemic grow in marginalized communities in the first place, such as in certain communities in the South and in minority communities. Terry McGovern, a Ford program officer, added, “If we’re serious about addressing HIV in the United States, we have to focus on the places and the populations where it is spreading the fastest.”

The release also noted that Ford will fund national and regional groups to do advocacy work in communities most impacted by HIV—or, as Ford says, it will help communities “to shape policy decisions that determine how and where AIDS funding and services are deployed” across the United States.

For more information on this initiative, read the press release here. A request for proposals (RFP) related to Southern states will be posted on the Southern REACH section of the National AIDS Fund’s Web site in August 2010. To apply for other types of grants mentioned above, go to the Ford Foundation’s Web site.

Recent three-year grant awarded:

“$1.7 Million Initiative to Bring Vulnerable People with HIV/AIDS into Care,” press release from the New York Community Trust (a large community foundation), June 2, 2010. This grant aims “to bring primary medical care to 1,650 New Yorkers living with HIV/AIDS who are not in treatment,” and help primary care providers to ensure that these patients stay engaged in a comprehensive health program. Bristol-Myers Squibb, through the National AIDS Fund, is funding a partnership called ACCESS NY to achieve these aims. The New York City AIDS Fund, a funding collaborative within the New York Community Trust, is the recipient of the grant. Len McNally, program director for health at the trust, is chairman of the New York City AIDS Fund.

Related resources:

Grantseekers: Potential Funder?

Ittleson Foundation. Please note that this foundation, located in New York City, has a very small staff. Read its guidelines and restrictions carefully. In 2010 Ittleson will award grants at its fall meeting (only); initial letters of inquiry regarding funding must be received before September 1, 2010. Here are examples of AIDS grants that the foundation has awarded in the past.

For funders interested in domestic advocacy:

Domestic Advocacy Working Group (DAWG) of Funders Concerned About AIDS (FCAA). This group for funders interested in supporting advocacy work on issues in the United States held its first meeting in March 2010; one of its recommendations was to “encourage large international funders,” such as the Bill and Melinda Gates Foundation and the Clinton Foundation, to fund domestically. DAWG plans to meet again in December 2010.

New National Strategy:

“Obama Promises Commitment to Combating HIV/AIDS,” Julie Pace, Associated Press, on WTOPNews.com, July 13, 2010. This AP story discusses the administration’s new National HIV/AIDS Strategy for the epidemic in the United States.

Syringe Exchange

Syringe Access Fund. Leading funding partners of this initiative are the Irene Diamond Fund, Elton John AIDS Foundation (a charity), and the National AIDS Fund. The next RFP expected to be in August 2011.

“Expanding Access to Evidence-Based Services for Injection Drug Users,” R. Gil Kerlikowske, director of the Office of National Drug Control Policy, and Jeffrey S. Crowley, director of the Office of National AIDS Policy (ONAP), post on the White House’s ONAP Blog, July 16, 2010. The authors point out that syringe services programs, which are a component of the administration’s National HIV/AIDS Strategy (mentioned above), as well as its National Drug Control Strategy, are also cost effective.

 “[U.S.] Department of Health and Human Services [HHS] Implementation Guidance for Syringe Services Programs,” July 2010. This document is posted on the Centers for Disease Control and Prevention’s (CDC’s) Web site.

Testing

National HIV and STD Testing Resources, a service of the CDC.

AIDS 2010 (XVIII International AIDS Conference) Vienna, Austria, July 18-23, 2010

Official conference homepage, including a blog and a Twitter feed reporting on what is going on at the conference—eyes and ears for those not attending.

FCAA Guide to Vienna: The XVIII International AIDS Conference. This spreadsheet from Funders Concerned About AIDS has information on more than seventy conference sessions that are focused on private- and public-sector funding in the areas of AIDS and global health, the affinity group says. Sessions include “Winning the AIDS Fight: How Countries Can Take the Lead,” featuring Eric Goosby, U.S. Global AIDS Coordinator, and Jen Kates, vice president and director of HIV policy at the Henry J. Kaiser Family Foundation (KFF); and “Making the Case for Stigma Reduction and Moving to Action: The Experience of South Asia,” featuring Nancy Mahon of the M.A.C. AIDS Fund. Tabs at the bottom of the spreadsheet will direct you to lists of sessions during different time periods. FCAA also is tweeting from the conference.

 “Bill Gates: World Has Historic Opportunity to ‘Change the Face of AIDS’: In Keynote Speech to AIDS Conference, Gates Outlines Roadmap to Reduce Annual New HIV Infections 90 Percent by 2031.” Bill and Melinda Gates Foundation press release, July 19, 2010, regarding a speech by Bill Gates at the conference in Vienna. Watch the video of his speech.

“Online Coverage of XVIII International AIDS Conference to Include Daily Webcasts, Live Coverage, Podcasts and News Recaps: International AIDS Society and Kaiser Family Foundation Partner to Offer Daily, Comprehensive Coverage of Conference for Free,” KFF press release, July 9, 2010.

Diabetes has been in the news this week what with a Food and Drug Administration (FDA) advisory panel ruling on the diabetes drug Avandia. So, today’s post focuses on a foundation-funded program to reduce disparities in care for people who have this chronic disease.

The Alliance to Reduce Disparities in Diabetes, which is funded by the Merck Company Foundation, has the goal of supporting multifaceted, community-based programs that address the key factors important in reducing disparities and improving health outcomes for people with diabetes, according to the alliance’s Web site.

The site gives some background on this whole problem of health disparities in diabetes. With 8 percent of the population in the United States “already diagnosed with diabetes and the costs associated with this disease skyrocketing, it is critical not only to understand how and why disparities exist, but also to invest in prevention and management initiatives that can address the special needs of underserved communities,” the alliance says. It points out that Type 2 (adult-onset) diabetes “disproportionately affects people of certain racial and ethnic groups, including African-Americans, American Indians, Asian Americans, Hispanics/Latinos and Pacific Islanders.” Lifestyle changes can prevent or delay diabetes, the alliance reports, and good management of diabetes once it is diagnosed “can significantly delay or prevent its numerous complications.” Thus, disparities in prevention and treatment among certain racial and ethnic groups can “contribute to the higher prevalence of diabetes and its complications among these populations.”

The alliance awarded grants to five organizations (University of Chicago, Chicago, Illinois; Camden Coalition of Healthcare Providers, Camden, New Jersey; Baylor Health Care System, Dallas, Texas; Wind River (American Indian) Reservation, Fort Washakie, Wyoming; and Healthy Memphis Common Table, Memphis, Tennessee) in February 2009. Each grantee is located in a community that “serves low-income and underserved [adult] populations with a high prevalence of type 2 diabetes.”

Also receiving a grant was the national program office for the alliance; the office is located at the Center for Managing Chronic Disease at the University of Michigan, in Ann Arbor. Noreen Clark of Michigan’s public health school directs the program. Its national advisory board includes José Escarce of the University of California, Los Angeles, and RAND, and Sara Rosenbaum of the George Washington University.

The Merck Company Foundation has committed $15 million for this diabetes and disparities effort through 2013.

The alliance is focusing on patients—educating and empowering them; clinicians—getting them to communicate better with diverse patients and be more aware of cultural beliefs; and systems—using disease management. Improving communication between patients and health care providers is very important, the alliance says.

In a December 2009 e-alert, Escarce, who chairs the alliance’s advisory board, pointed out two ways to help people.

1. Because patients of color with diabetes have a disproportionate share of complications directly linked to blood pressure and lipid control, improved access to care and treatment for controlling blood pressure, lipids, and blood sugar could narrow the health gap for underserved populations.

2. Because the obesity epidemic is disproportionately affecting people of color and is closely linked to the prevalence of Type 2 diabetes, providing proven interventions to decrease obesity and overweight in these groups could mitigate disparities in diabetes outcomes.

The alliance has produced a useful factsheet here titled “Disparities in Diabetes Prevention and Care.”

Related resources:

Chronic Care: Making the Case for Ongoing Care, Gerard Anderson of the Johns Hopkins Bloomberg School of Public Health, released February 2010 by the Robert Wood Johnson Foundation (RWJF). This is an update of the RWJF’s 2002 chartbook on this topic.

“The Economic Burden of Diabetes,” Timothy M. Dall, Yiduo Zhang, Yaozhu J. Chen, William W. Quick, Wenya G. Yang, and Jeanene Fogli, Health Affairs. This article was published online January 13, 2010 and in the February 2010 issue.

“Evaluating Interventions to Reduce Health Care Disparities: An RWJF Program,” Amy E. Schlotthauer, Amy Badler, Scott C. Cook, Debra J. Pérez, and Marshall H. Chinn, GrantWatch section, Health Affairs, March/April 2008. Read about an RWJF program called Finding Answers: Disparities Research for Change. The program awards funding for “evaluation of health care interventions that hold promise” for reducing disparities and improving care for minority patients with one or more of these conditions: cardiovascular disease, depression, and diabetes. A list of diabetes interventions evaluated under this program, based at the University of Chicago, can be found here.

Improving Diabetes Prevention and Management, a priority area of the New York State Health Foundation. As its name indicates, the foundation funds in New York State.

Medtronic Foundation’s Patient Link program. According to this corporate foundation’s Web site, “Patients with chronic conditions often seek information and a means to act.” Through this program’s grants, the foundation partners “with national and international patient organizations that educate, support and advocate on behalf of patients and their families to improve the lives of people with chronic diseases.”

Monthly Update on Health Disparities, Henry J. Kaiser Family Foundation, May 2010.

“The $174 Billion Question: How to Reduce Diabetes and Obesity,” Alliance for Health Reform briefing in Washington, D.C., Friday, July 23, 2010, 12:15 p.m. until 2 p.m. Cosponsored by the United Health Foundation. Click here for more information and to register for this event.

Racial and Ethnic Health Care Equity, a program of the Aetna Foundation.

News article:

“FDA Panel’s Vote on Avandia Reveals Mixed Opinions on Diabetes Drug’s Safety,” Rob Stein, Washington Post, July 15, 2010.

Why are people saying that we don’t know how to contain health care costs? I’d argue that we do know how. What we don’t know is how to get better practices accepted and spread. Behavior change is difficult, even when we can advance quality of care and contain costs.

Let me give you one potent example: Get the pills right. A small experiment that the Jewish Healthcare Foundation, in Pittsburgh, funded over ten years was an eye-opener and started us down a promising path.

The foundation, which I direct, is made up of four different parts. We are a grant-making foundation with our own endowment, but we are also a “think, do, and teach” tank. We have our own regional quality improvement coalition called the Pittsburgh Regional Health Initiative (PRHI) Our mission: spreading high-quality care to contain costs . So, I will describe here how the foundation’s four parts came together to explore the value of clinical pharmacy.

We funded a team of health services researchers more than a decade ago. They proposed to have a pharmacist review the medication mix of every patient on a hospital unit who had been prescribed four or more medications. To our surprise, no patients left the hospital with the original prescription list; in fact, they invariably left with fewer meds, more generics, and a more potent and compatible mix of drugs. We also educated patients about their drugs, aiming for better compliance. The demo suggested that we could save money and make patients happier and healthier, if we included pharmacists as part of the treatment team.

We remembered this experiment when we turned our attention to the management of chronic illness, which currently accounts for more than 75 percent of our nation’s health care costs. We reasoned that a good medication protocol, more patient education about their meds, and better compliance would result in fewer costly hospitalizations, emergency room (ER) visits, and illness exacerbations. In 2009 we took our improvement methodology (Perfecting Patient Care), taught Lean quality improvement (QI) techniques to nine willing “Pharmacy Agents for Change,” and set each of them off on a project of their own to demonstrate the financial and clinical value of good medication management.

We weren’t disappointed—to say the least! We were dazzled at how much room for improvement exists in the management of chronic disease with the intervention of a clinical pharmacist and the accompanying attention and respect of the overall medical team. Each pharmacist had the support of his or her institution. Each attended our four-day Perfecting Patient Care University and received on-site coaching as their research projects progressed. For this initiative, we had the full support of every dean of pharmacy in our region . In fact, we were unaccustomed to how little opposition these behavior changes generated; there was enthusiasm all around.

We focused on improving communications between doctor and pharmacist and between the hospital and the primary care practice; we instituted more patient education and enlisted pharmacists to review and reconcile medications for the best possible result.

Each project yielded excellent results. However, in health care, good practices don’t often spread. One difficulty is getting physicians to enlist and value independent pharmacy assessments, and this is related to another hurdle—getting reimbursement for this service. These challenges exist in spite of the fact that almost everyone involved in our work acknowledged the problems with medication management and integration. For instance, 90 percent of the patients in a comprehensive lung center were discovered to have a suboptimum daily medication regimen, and more than 30 percent of the patients hospitalized with mental illness in many settings are readmitted within sixty days. (This last problem is greatly remedied when patients receive education and when they leave the hospital with their medications instead of just a written script of their meds.)

So, how do we institutionalize best practices like these? One opportunity is the Patient Protection and Affordable Care Act (PPACA), which was signed into law in March 2010. Provisions of the legislation provide some hope that we could move the needle. The key is to make sure that provisions of the law that extend the role of, and achieve reimbursement for, clinical pharmacy are activated.

There are carrots and sticks in the law. New Medicare financial penalties apply to frequent hospital readmissions and recurring medication errors. A new federal grant program supports medication management services, and there are telehealth provisions that incorporate annual medication reviews for Medicare patients with chronic illnesses. The value of clinical pharmacy is acknowledged.

Also encouraging is the Patient Protection Act’s approval of Accountable Care Organization (ACO) demonstrations, in which practices and providers will eventually go “at risk” for managing their high-risk populations and preventing hospitalizations, ER visits, and exacerbations of illness. Bundled payments could support the prevention activities of clinical pharmacy while measuring more broadly the return on investment when comparing the cost of pharmaceutical interventions against hospitalizations averted.

The PPACA also establishes a Medicare-based Community Care Transition Program that emphasizes medication review, including counseling and self-management support. Reimbursement for clinical pharmacy by Medicaid agencies and commercial insurers has been growing over the past few years as well.

So, let’s not accept that we don’t know how to contain costs in health care. Take the case of clinical pharmacy. What we don’t know how to do is to get acceptance for new and better ways to care for patients, to change behavior, to effect spread, and to achieve payment reforms.

Related resource:

“Why Pharmacists Belong in the Medical Home,” Marie Smith, David W. Bates, Thomas Bodenheimer, and Paul D. Cleary, Health Affairs, May 2010 issue.

Read something else by Karen Feinstein:

Feinstein couthored an article in the June 2010 issue of Health Affairs.

Here are links to some recent health-related posts on other philanthropy blogs.

Health Disparities

Report Shows Health Disparities between White and Minority Boys and Young Men: This June 30, 2010, post by Daniel Weintraub describes a collection of five reports funded by the California Endowment (TCE), which were released that day. The findings show that neighborhoods have an important influence on the health of African American and Latino boys and young men. The reports “highlight specific challenges to the health of boys and young men of color and provide recommendations for improving their health outcomes,” TCE’s Web site says. The endowment focuses “on the connections between place and health,” funded RAND, Drexel University’s College of Medicine, PolicyLink, and others to do the research on which the reports are based, Weintraub said in the California Health Report blog. (This blog is part of the HealthyCal.org Web site, which  received initial funding from the endowment.) The research will help inform TCE’s new initiative, Building Healthy Communities, which has now officially launched. 

Related resource:

“This Week in PubHub: Health Care and Language Services,” Foundation Center’s PhilanTopic blog, June 20, 2010. Kyoko Uchida summarizes and provides links to four recent reports on this topic.

For background on health disparities, see Health Affairs’ March/April 2008 issue.

Maternal-Child Health

On the Colorado Trust’s blog called CommunityConnections, Christie McElhinney, vice president of communications and public affairs at this Denver-based foundation, writes about David Olds founder of the Nurse-Family Partnership (NFP). Olds is a professor at the University of Colorado Denver. This June 30, 2010, post, titled “Dr. David Olds’ Continuing Inspiration: the Nurse-Family Partnership Marks Its Tenth Year,” describes this “remarkable program.” According to its Web site, the NFP is “a nurse home visitation program for first-time, low-income moms and their children.” McElhinney notes that Olds “has worked diligently to see his evidence-based research thoughtfully translated into [this] effective program, and implemented in community after community.” The Colorado Trust and others have provided funding for the NFP, which has even spread to other countries. President Barack Obama has recommended, according to McElhinney, “that the NFP be expanded to serve every low-income first-time mother” in the United States, and federal support “will help to make this possible.”

Flu

“It’s Flu O’clock Somewhere,” which is posted on the Official google.org Blog, reminds us that below the equator, flu season is now. This June 8, 2010, post announces that Google.org was going to bring its Google Flu Trends tool “to eight additional countries in the southern hemisphere”; winter has now begun there. “Google Flu Trends “uses aggregated Google search data to estimate current flu activity around the world in near real-time.” Graphs and maps show activity. Interesting concept! Google.org is Google’s philanthropic arm.

Substance Abuse Prevention

On the Health Foundation of Greater Cincinnati’s blog, staffer Ann Barnum has a June 30, 2010, post titled “How Are Alcohol, Tobacco, and Other Drugs Like Oil?” Barnum, who hails from Louisiana and is, of course, distressed about the BP oil spill, comments, “It’s sad to see what happens when people forget that we can prevent many problems by making good plans, [they] ignore warning signs, and [they] tend to think that bad things only happen to other people.” In her opinion, the Gulf of Mexico situation is similar to addiction. “With individuals, we tend to ignore the signs [of addiction], think that we have to wait to intervene, and believe that it will never happen to us or our family.” One of the Health Foundation’s funding interests is substance use disorders. Barnum also discusses a recent essay by Joe Califano, chairman of the National Center on Addiction and Substance Abuse (CASA) at Columbia University and former U.S. secretary of Health, Education, and Welfare during the Carter administration. The Health Foundation awards funding in Cincinnati and twenty surrounding counties in Indiana, Kentucky, and Ohio.

Mental Health

In another Health Foundation post, Janice Bogner writes about the integration of behavioral health and primary care. In her June 10, 2010, post titled “We Have Come a Long Way,” Bogner comments that a decade ago, it would have been unlikely to find a meeting about integration of care, such as one that was held in Cincinnati recently. She states that “early on, the Health Foundation recognized that people with severe mental illnesses had terrible health”; the funder learned that “from anecdotal reports from grantees.” Subsequently, research confirmed this, she says. “The Foundation decided to promote integrated care and has been a pioneer in the field.” Progress at achieving integration of care has been made, but barriers remain, she explains. Thankfully, “there is interest in integration at many levels—local, state, and national,” Barnum reports. Read more about the Health Foundation’s funding in the area of severe mental illness.

Related resource:

“Specialty Care Medical Homes for People with Severe, Persistent Mental Disorders,” Vidhya Alakeson, Richard G. Frank, and Ruth E. Katz of the U.S. Department of Health and Human Services, Health Affairs, May 2010.

Health Reform

In a June 30, 2010, post on the New Health Dialogue blog of the New America Foundation, Sam Wainwright mentions some recent survey data, including results of a Henry J. Kaiser Family Foundation (KFF) Tracking Poll. In the post, “In the News: Polls Show Growing Support for Health Reform,” Wainwright states, “To be sure, not all polls are coming up with the same findings but, as [a] chart from pollster.com shows, the overarching trend is toward decreasing opposition” to reform. Go to the KFF’s portal on health reform for more information on its work on this topic; the KFF is an operating foundation. The New America Foundation is a nonprofit public policy institute, not a philanthropy.

Related resource:

Health Affairs, June 2010 issue, which has the theme “Moving Forward on Health Reform.”

“How Will the Health Care System Change under Health Reform?” Karen Davis, president of the Commonwealth Fund, on the Commonwealth Fund Blog, June 29, 2010. In this commentary, Davis describes some good things that “patients will be more likely to have” under the new health reforms, such as “better access to community health centers to serve more patients.”

From elsewhere in the blogosphere:

In the something-else-to-worry-about category, read this July 2, 2010, post titled “Health Care: In Aisle 3: Unintended Consequences,” by Joanne Kenan. Writing on the New America Foundation’s New Health Dialogue blog, Kenan reminds us that “those reusable shopping bags we’re all carting around” to the grocery store “may be full of bacteria.”

A new GrantWatch paper, “A Philanthropy Tackles Growth in Health Costs at the State Level” was released today as part of the July 2010 issue of Health Affairs. Authors David Sandman, senior vice president of the New York State Health (NYSHealth) Foundation, and Anthony Kovner, a professor of public health and health management at the Robert F. Wagner Graduate School of Public Management at New York University, describe the NYSHealth Foundation’s program—Strategies to Contain Health Care Costs in New York State. The foundation has committed nearly $7 million “to stimulate the development of innovative and replicable methods to contain health costs in the state,” the article says. New York State “is faced with particularly staggering health care expenses,” the authors add.

Why does the foundation think cost containment is so important? Sandman and Kovner say NYSHealth “considers containment of health system costs to be integrally linked to efforts to expand coverage.” If efficiencies in delivering care were realized, they point out; dollars could then be freed up for coverage expansions. Also, they note that “the importance of achieving savings is even greater in an environment in which state budget deficits loom large.” Cost containment is also needed so that people who have coverage can maintain it.

The article also describes how the NYSHealth Foundation chose the six projects that received funding under this program—providing a bird’s-eye view of a foundation’s thinking! Grants were awarded in the following areas: payment reform; reducing hospital readmissions; improving care transitions from hospital to a postacute setting; using arbitration to resolve disputes over medical injury; assessing which cost containment approaches would save the most money in New York State; and increasing the use of palliative care in hospitals.

“Philanthropy alone can hardly solve [the cost containment] problem,” the authors conceded. However, “it has an important role to play . . . because of its obligation to tackle big, seemingly intractable problems.”

The NYSHealth Foundation, a private foundation located in New York City, resulted from Empire Blue Cross Blue Shield’s conversion from a nonprofit to a for-profit entity; the foundation received a portion of the proceeds from that conversion. The foundation funds projects in New York State; its priority areas are reducing the number of uninsured; improving diabetes prevention and management; and integrating mental health/substance use services.

For some background on cost containment, make sure to check out the September/October 2009 issue of Health Affairs, which has the theme “Bending the Cost Curve.”

The most-read GrantWatch Blog post during this time period reported that the philanthropic community had a terrific showing in the June 2010 issue of Health Affairs. Numerous articles published in that issue, which had the theme of “Moving Forward on Health Reform,” were related in some way to foundations: Foundation staffers were authors of some articles, and foundations funded several articles in this Volume 29, no. 6.

Check out Maureen Cozine’s piece on the mental health needs of veterans—an important topic in this day and time. It came in as the third most-read post during June 2010. She reports from a symposium in New Paltz, New York, which was part of a statewide training initiative funded by the New York State Health Foundation. Cozine is director of communications for that foundation and holds a master in public health degree. In the past, she coauthored a GrantWatch Essay on “Addressing the Nurse Shortage to Improve the Quality of Patient Care,” which appeared in the January 2006 issue of Health Affairs. She wrote that article with Sue Hassmiller; they were colleagues then at the Robert Wood Johnson Foundation.

Here are links to the top three GrantWatch Blog posts during June 2010:

Health Affairs June 2010 Issue on Health Reform: Wide Participation by Health Philanthropy

by Lee-Lee Prina (date of post: June 8, 2010)

More Foundation-Funded Efforts Related to Primary Care

by Lee-Lee Prina (date of post: June 3, 2010)

Understanding and Supporting Veterans’ Health Needs

by Maureen Cozine of the New York State Health Foundation (date of post: May 28, 2010)

Have a good and safe holiday weekend!