FY 2017 Annual Performance Plan and Report - Goal 3 Objective D

Topics on this page: Goal 3. Objective D | Table of Related Performance Measures | Analysis of Results | Plans for the Future | FY 2014 Strategic Review Objective Progress Update Summary

Goal 3.  Objective D:  Promote prevention and wellness across the lifespan

HHS is focusing on creating environments that promote healthy behaviors to prevent chronic diseases and health conditions including tobacco use, being overweight or obese, and mental and substance use disorders.  These conditions result in the most deaths, disability, and substantial human and fiscal costs for Americans.  HHS works to promote prevention and wellness across its programs, with CDC identified as the nation’s principal prevention agency.  CDC‘s goals for chronic disease prevention and health promotion include reducing the onset of chronic health conditions; improving health equity; accelerating the translation of scientific finding into community practice; and promoting social, environmental, and systems approaches that support healthy living.

Across HHS agencies including ACF, ACL, AHRQ, CDC, FDA, HRSA, IHS, NIH, OASH and SAMHSA contribute to prevention and wellness.  For example, FDA has committed to increasing compliance with tobacco products regulations.  IHS is striving to reduce heart disease among American Indian and Alaska Native patients.  The Office of the Secretary led this Objective’s assessment as a part of the Strategic Review.

Objective 3.D Table of Related Performance Measures

Reduce the annual adult combustible tobacco consumption in the United States (cigarette equivalents per capita) (Lead Agency - OASH; Measure ID - 1.5)

Reduce the proportion of adults (aged 18 and over) who are current cigarette smokers.  (Lead Agency - CDC; Measure ID - 4.6.3)

The total number of tobacco compliance check inspections of retail establishments in states under contract.  (Lead Agency - FDA; Measure ID - 280005)

Reduce the proportion of adolescents (grade 9 through 12) who are current cigarette smokers.  (Lead Agency - CDC; Measure ID - 4.6.5)

Increase the number of calls answered by the suicide hotline (Lead Agency - SAMHSA; Measure ID - 2.3.61)

Increase the percentage of adults with severe mental illness receiving homeless support services who report positive functioning at 6 month follow-up (Lead Agency - SAMHSA; Measure ID - 3.4.02)

Increase the number of individuals referred to mental health or related services (Lead Agency - SAMHSA; Measure ID - 3.2.37)

Increase the percentage of Early Head Start children completing all medical screenings.  (Lead Agency - ACF; Measure ID - 3.6LT and 3B)

American Indian and Alaska Native patients, 22 and older, with Coronary Heart Disease are assessed for four cardiovascular disease (CVD) risk factors.  (Lead Agency - IHS; Measure ID - 30)

Statin Therapy for the Prevention and Treatment of Cardiovascular Disease among American Indians and Alaska Natives.  (Lead Agency - IHS; Measure ID - 51)

Analysis of Results

Smoking and second hand smoke kills an estimated 480,000 people in the U.S. each year.  For every smoker who dies from a smoking-attributable disease, another 30 live with a serious smoking-related disease.  Smoking costs the U.S. $133 billion in direct medical costs and more than $156 billion in lost productivity each year.  An estimated 88 million nonsmoking Americans are exposed to secondhand smoke, which causes an estimated 7,330 lung cancer deaths and more than 33,900 heart disease deaths in nonsmoking adults each year.  The Department’s comprehensive tobacco control strategy, Ending the Epidemic – A Tobacco Control Strategic Action Plan, is designed to mobilize HHS’s expertise and resources in support of proven, pragmatic, achievable actions that can be aggressively implemented at the federal, state, and community levels to reduce the incidence of smoking.  HHS established this effort as a Priority Goal for FY 2014 – 2015 and will continue to address the challenge as a Priority Goal for FY 2016 – 2017.  In FY 2014, the annual adult combustible tobacco consumption in the United States failed to meet the target of 1,212 cigarette equivalents per capita, falling just short. 

However, HHS did make positive progress in other related measures.  Two complementary efforts by the CDC also target smoking reduction in two populations, adults (18 and over) and adolescents (grade 9 – 12).  The percentage of current adult smokers decreased to 16.8 percent in FY 2014, exceeding the target.  The FY 2013 result for teen smokers (15.7%) represents the lowest teen smoking rate ever recorded with the Youth Risk Behavior Surveillance System (YRBSS) since data collection began in 1991.  Because YRBSS data is only available every other year, CDC sought to glean data in the interim years with data from the National Youth Tobacco Survey (NYTS).  NYTS data tracked closely with YRBSS data until FY 2012 results showed an unacceptable variance.  Therefore, the YRBSS will once again be the sole data source for CDC reporting of teen smoking rates as of FY 2014.  FDA’s fights adolescent smoking with its program to conduct compliance checks to assure that retailers refuse sales of tobacco to adolescents under the age of 18.  In FY 2015, under contracts with 45 states and territories, FDA conducted 162,873 compliance check inspections of retail establishments, substantially exceeding its target.  Although this was a much higher number than expected, it reflects the high level of variability inherent in this goal requiring the estimation of the number of compliance checks that each state will be able to conduct.

Another significant cause of early death in the U.S. is suicide.  The National Center for Health Statistics (CDC) reported in 2013 there were 41,149 suicides, ranking as the 10th leading cause of death among persons ages 10 years and older nationally.  The National Suicide Prevention Lifeline (Lifeline), sponsored by SAMHSA, routes callers from anywhere in the U.S. to the closest certified crisis center within Lifeline’s network of more than 150 centers.  Trained counselors provide crisis counseling, link callers to emergency services, and offer behavioral health referrals.  SAMHSA has increased efforts to promote Lifeline broadly to the public, in order to enhance awareness of this resource.  The success of this outreach effort is reflected in the 1,502,573 calls answered in FY 2015, an increase of almost 200,000 over the previous year.  Targets have been exceeded each year.

In addition to suicide prevention, SAMHSA works through multiple programs to support those adults who may be severely mentally ill and homeless.  A significant portion of persons who are chronically homeless have mental and/or substance use disorders.  Grants under the Homelessness Prevention and Housing Programs initiative are awarded to organizations that assist severely mentally ill adults who are homeless or at risk of becoming homeless in gaining access to sustainable permanent housing, treatment, and recovery support.  A measure of the performance of these grantees is the self-reported sense of positive functioning by the individual 6 months after beginning to receive homeless support services.  In FY 2015, 70.8 percent reported improved functioning, exceeding the target.  This was a result of a combination of factors including, but not limited to, grantees engaging and providing services to the population of focus in collaboration with community consortia, improved reporting, and support to grantees via technical assistance on housing, evidence based practices and other relevant topics.

ACF, through the Early Head Start program, aims to promote prevention and wellness early in the life span.  For the 20143-2015 program year, 80.7 percent of Early Head Start program children completed medical screenings expected for their age, missing the target of 93 percent.  The Early Head Start program underwent a large expansion under the American Recovery and Reinvestment Act, which resulted in expanded enrollment and many new programs.  However, in the FY 2013-2014 program year, many Head Start and Early Head Start programs were still experiencing the effects of cuts from sequestration.  Depending on when during the year programs are funded, some programs experienced the impact of sequestration during the FY 2013 program year while others experienced most of the impact from the reductions during the FY 2014 program year.  That said, when analyzing the data at enrollment compared with at the end of enrollment, the percentage of children who were up-to-date on medical screenings increased 18 percent.  This result demonstrates that Early Head Start program are making a significant progress in assisting children get age-appropriate medical screenings during the program year.   

HHS manages a number of programs to reduce health disparities for minorities, including prevention and wellness.  Modifying the following risk factors offers the greatest potential for reducing CVD morbidity, disability, and mortality: high blood pressure, high cholesterol, smoking tobacco, excessive body weight, and physical activity.  IHS seeks to address these risk factors in patients 22 and older diagnosed with coronary heart disease by assessing all five of these risk factors.  In FY 2015 the target was 47.3 percent of coronary heart disease patients receiving all 5 assessments and the result was 55 percent, exceeding that target by 7.7%.  IHS used national webinars to highlight each of the five assessments to improve the 2015 results.  In FY 2016, the measure numerator does not include "Patients with LDL completed during the report period, regardless of result."  The new American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelines no longer recommend treating to LDL targets.  Statin medication therapy is recommended instead.

Plans for the Future

The ACF Office of Head Start is also doing more to analyze the data regarding medical screenings to understand which programs and geographic areas are struggling with this particular measure and determine a strategy to provide targeted support.  In the interim, the Office of Head Start has completed a toolkit for Head Start and Early Head Start programs to assist them in the tailored use of an online, web-based Well Visit Planner (WVP), which is a free online pre-visit planning tool designed to engage parents in planning for and partnering more fully in their child’s well visit.  Studies continue to show gaps in the quality of well-child care.  Improving care means improving communication and partnerships with parents and meeting the unique needs and priorities of each child and family.  The WVP helps parents and caregivers to customize the well-child visit to their family’s needs by helping them identify and prioritize their health risks and concerns before the well-child appointment.  This means that parents and health care professionals are better able to communicate and address the family’s needs during the well-child visit.

The CDC will continue to support the National Tobacco Control Program (NTCP) in 50 states and the District of Columbia, eight territories/jurisdictions, eight tribal support centers, and six national networks.  NTCP grants support evidence-based efforts by state, tribal and territorial health department to prevent initiation of tobacco use among young adults, promote tobacco use cessation, eliminate exposure to secondhand smoke, and identify and eliminate tobacco-related disparities.  It will also provide national leadership for a comprehensive, broad-based approach to reducing tobacco use which involves: preventing young people from starting to smoke; eliminating exposure to secondhand smoke; promoting quitting; and, identifying and eliminating disparities in tobacco use among population groups.

The suicide hotline (Lifeline) has seen a yearly increase in calls answered, a trend that SAMHSA projects to continue.  During FY 2013, SAMHSA awarded a new 3-year cooperative agreement with a continued focus on serving callers in distress, as well as expanding capacity of the Crisis Chat service for individuals seeking help online.  The growth in average quarterly Lifeline calls can likely be attributed to the following: continued outreach and marketing of the National Suicide Prevention Lifeline service; wide distribution of the Lifeline number by third party organizations seeking to provide their clients with a 24/7 emergency resources; heavy promotion of the Lifeline through social media outreach on Facebook and other social media sites; and significant marketing and outreach to veterans of the Veterans Crisis Line, which also uses the 1-800-273-TALK (8255) Lifeline number.

SAMHSA’s suicide prevention activities provide states, colleges, consumer groups and other organizations with resources that build national capacity for preventing suicides.  For example, SAMHSA supports statewide or tribal youth suicide early intervention and prevention services through the Suicide Prevention Resource Center (SPRC) and other programs.  SPRC builds national capacity for preventing suicide through research, technical assistance, and policy development.  One important aspect of this program is referring individuals for proper mental health intervention following prevention screening. 

CDC is continuing to conduct applied research on the health effects and patterns of use of emerging tobacco products to inform the American public as well as decision makers.  CDC is also modifying its surveillance systems to ensure it is able to capture relevant data on new products and shifting patterns of use.  CDC will continue to communicate about these evolving issues to the American public, through media, such as the Tips from Former Smokers national education campaign.

Based on clinical practice and new treatment guidelines, the IHS has elected to discontinue the CVD risk factors measure after September 30, 2016.  The comprehensive CVD measure evaluates 5 data elements related to cardiovascular disease risk, prevention, and treatment.  New guidelines from the American College of Cardiology and the American Heart Association no longer recommend yearly LDL assessment as a basis for cardiovascular disease prevention.  In 2016, LDL assessment will be dropped from the current measure.  Starting in 2017, the IHS will begin to report on a new measure that aligns with new national guidelines by evaluating the management of cholesterol.  This measure, Statin Therapy for the Prevention and Treatment of Cardiovascular Disease, will assess the number of patients who are at risk of cardiovascular disease and prescribed statin therapy during the reporting period or have a documented contraindication against receiving it.

FY 2014 Strategic Review Objective Progress Update Summary

Please note that this section summarizes the result of the FY 2014 HHS Strategic Review process, limiting the scope of content to that available prior to spring of 2015.  Due to this constraint, the following may not be the most current information available.

Conclusion:  Progressing

Analysis:  Progress has occurred in this objective in the areas of smoking rates, physical activity, and the rate of rise of obesity.  HHS is working to help programs incorporate evidence-based and evidence-informed models into their settings, using an expanded body of scientific literature.  There are challenges posed by infectious threats (e.g. Ebola, MERS), electronic nicotine delivery systems, prescription opioid abuse, and legalization of marijuana in more states.  HHS also faces a changing communication landscape which requires us to modernize our approach to public education.

To achieve positive results HHS needs to overcome some obstacles.  Although there is a growing body of research on evidence-based prevention models, programs may need additional resources, training and technical assistance to incorporate evidence-based or evidence informed practices into their settings.  Local adaptations to existing programs may be necessary, but also may influence the effectiveness of programs in unknown ways.  It is difficult to balance the need for scientific rigor and the constantly expanding body of published scientific literature, with the public’s demand for rapid and up-to-date reviews of the literature. 

The introduction of emerging products, such as electronic nicotine delivery systems, and shifting patterns of tobacco use are presenting challenges to tobacco prevention and control.  The Department has modified its surveillance systems to better capture shifting patterns of tobacco use among both youth and adults.  While the overall tobacco use rate in the US has been decreasing, rates for individuals with behavioral health disorders, who comprise approximately 25 percent of the US population, have not decreased.  A major effort for the Department is the continuation of the Agency Priority Goal focused on combustible tobacco consumption with a focus on reducing youth smoking and e-cigarettes.  The Department plans to conduct applied research on the health effects and patterns of use of emerging tobacco products to inform the American public as well as decision makers.  A State Policy Academy for Tobacco Control in Behavioral Health will provide an opportunity for behavioral health leadership teams in five states to build a collaborative action planning process to address the high rate of tobacco use by persons with behavioral health disorders.

In collaboration with the White House Conference on Aging, the Go4Life Month is launching in September 2015.  Activities nationwide will encourage older adults to include exercise and physical activity as part of their daily routine.  Healthfinder.gov has established a partnership with CVS Health in 2015 that could increase the uptake of clinical preventive services and increase the continuity of prevention care.  CVS is encouraging its customers to get preventive services their Minute Clinic offers and to get other recommended preventive services at their primary care provider.