Heart of New Ulm Project

Julie Long, RN, CNP 10/28/10

Clinical Lead, Heart of New Ulm Project

What is the Heart of New Ulm

(HONU) project

• HONU is a demonstration project

• designed to apply and establish evidence-informed

health improvement practices

• based on the community’s own level of risk and

customized to their preferences.

• It is primarily a systems-level intervention designed to

synchronize and bolster heart health improvement

efforts/resources across key areas within New Ulm,

MN

General Idea of the

Demonstration Project

„ Focus efforts in one zip code

to improve risk factors for heart

attacks.

„ Evaluate outcomes using

existing surveillance tools

where possible.

„ Intervention plan designed and

administered in a flexible,

evolving way.

„ based on community demands

and observed changes in risk

factors over time.

„ Adjusts intervention plan to

using current technologies,

more direct connection to the

healthcare system, and

emphasis on social marketing

to get the masses exposed to

health improvement programs.

Funding and Logistics

• To date, the Allina Center for Healthcare Innovation has invested

$3 million in the HONU project and will continue to invest several

million dollars over the coming years.

• Looking to match those funds via philanthropic grants from federal

agencies, private industry, health plans, foundations, and

individuals to extend the project to 10 years, possibly beyond.

• Project is implemented by the Minneapolis Heart Institute

Foundation, working in close partnership with Allina, the New Ulm

Medical Center, Minneapolis Heart Institute, and various

stakeholder groups in New Ulm.

Why New Ulm?

„ Geographically contained area

„ About 90% of residents are patients

at NUMC

„ Use of the EMR

St. Paul

New Ulm

New Ulm is about

100 miles away

from St. Paul

Why New Ulm

Continued…

„ The community is willing to change

„ The community has established

partnerships:

‟ NUMC working with employers and Park & Rec

‟ Childhood obesity curriculum in schools (DAAN)

‟ City working to have 100% of neighborhoods

walkable (sidewalks)

‟ Electronic medical record for prevention and

wellness follow-up

Getting to Know the 56073 • Agricultural area of south-

central Minnesota

• “The (statistically) most German town in America” *

• 17,199 residents, 13,594 within the New Ulm city limits

• Average age is 38 and adults account for 76% of the population

• 97% identify themselves as White

• 20% report obtaining a Bachelors degree or higher

• 95% report at least some form of health coverage

• Very stable year-over-year population

Why Heart Attacks?

„ The mortality rate from MI’s has dropped considerably over 50 years, but the

attack rate of MI’s has not dropped as much during that timeframe and is

projected to possibly rise in some subgroups due to obesity and diabetes

(e.g., young males, elderly females).

„ The result is that the prevalence of heart disease may also soon rise, along

with its associated healthcare costs. Therefore there is a need to restructure

the manner in which the healthcare system and communities partner so that

more heart attack “cases” can be prevented upfront (versus treated after the

fact).

Basic Rationale The mortality rate from MI’s has

dropped considerably over 50 years,

but the attack rate of MI’s has not

dropped as much during that

timeframe and is projected to

possibly rise in some subgroups due

to obesity and diabetes (e.g., young

males, elderly females).

The result is that the prevalence of

heart disease may also soon rise,

along with its associated healthcare

costs. Therefore there is a need to

restructure the manner in which the

healthcare system and communities

partner so that more heart attack

“cases” can be prevented upfront

(versus treated after the fact).

What is the average age a

male presenting with MI to

NUMC? Answer: 65

Primary Objectives

Long-term: To reduce the (age- and sex-adjusted) attack rate of hospitalized acute MI’s among 56073 zip code residents (age 30-79 years) over 10 years.

Primary Objectives

Shorter-term: Improve the proportion of 56073 zip code

residents (age 30-79 years with an active Allina electronic health record) with controlled modifiable risk factors for incident MI’s over 5 years. ‟ Elevated blood lipids (i.e., total chol, LDL chol, HDL

chol, triglycerides)

‟ High blood pressure

‟ Uncontrolled glucose (i.e., type 2 diabetes and pre-diabetes)

‟ Obesity

‟ Tobacco use

‟ Physical inactivity

‟ Low fruit/vegetable consumption

‟ Uncontrolled stress

‟ Medication (i.e., anti-platelet, anti-dyslipidemia, anti-hypertension,anti diabetes) underutilization/non-adherence

Community Penetration

• Screened 5,198 individuals (82% from

the 56073 zip code)

• Enrolled 3,400 individuals in the Move

to Improve community challenge

program

• Over 800 individuals attended at least

one community health education

seminar, worksite lunch-n-learn lecture,

or women’s walking club event

• Engaged 62 employers or civic

organizations in a screening and/or

wellness planning activities

Community Challenge

Move to Improve

Free eight-week challenge to help New Ulm community

members get out, get active and help reduce their risk for

heart attacks.

Participants were given a booklet and a “passport” to help

track their minutes of activity each week. The overall goal

was to get participants moving for at least 150 minutes

through physical activity each week.

Community Challenge Findings

„77% of participants who returned their passports felt they were

confident that they would accumulate at least 150 minutes of

physical activity each week.

„During the first week 94% of participants accumulated 150

minutes or more of physical activity!

„Throughout the entire eight week program, 90% or more

participants accumulated at least 150 minutes of physical

activity.

The Good

The Not-So-Good

• Obesity is particularly problematic in New Ulm, along with some medical risks, particularly high LDL.

• This is supported by observations of low fruit/vegetable consumption, a high proportion of participants with metabolic syndrome, and significant underutilization of preventive medical therapies (e.g., aspirin, statin, blood pressure medications).

• Intervention efforts should most heavily focus on improving the food environment (as it relates to obesity) and medical management of those at high cardiometabolic risk.

“Community Diagnosis” (from screening)

How to Impact the

Community „ Healthcare

„ Community

‟ Special events

‟ Community challenge

‟ Grocery stores and restaurants

„ Worksites

‟ Health promotion

‟ Policy change

HONU spreads awareness regarding heart health through

many programs year round.

•Go Red for Women

•Jingle Bell Jam

•Community Challenge

•Community Leaders Event

Community Leaders

Event with Bob Harper

Bob Harper, Health and Motivational Expert from NBC’s the Biggest

Loser, spoke during the Heart of New Ulm Summit in 2009 at the

District 88 Administrative Center Auditorium in New Ulm.

Go Red for Women Event

The Go Red for Women event has brought

hundreds of women together over the past two

years to celebrate Heart Health Month.

Participants enjoy a heart healthy meal, listened

to inspiring presentations and learn about the

HONU project all while wearing Red!

Go Red for Women

Workout with Chris Freytag

Freytag is a self proclaimed fitness addict from Minneapolis. She has been in

the health and fitness industry for over 20 years. Chris lead a group of New Ulm

residents in a Go Red for Women workout at the New Ulm recreation center

prior to the evening event.

Jingle Bell Jam On December 12, 2009, the Jingle Bell Jam

walk/run attracted over 600 joyful participants!

Community Challenge

2010 • 18 month challenge.

• Divide New Ulm into districts.

• Each district has leaders designed

to promote healthy behaviors.

• Quarterly changes in focus

• Creating Ripple Effect—sustainable

change

Food Works

„ Grocery store tours

„ NEMS (nutrition environment

measures surveys)

„ Restaurant and grocery tours

„ Cooking presentations

What’s Cooking New Ulm?

„ Cable access cooking show with

guest cooks from the community.

„ Project update and Fit in 5 segment

is included in each 30 minute

episode.

„ A different show each week.

In the Worksites

„ Work with worksites to help

implement health promotion

programs.

„ Help worksites implement policy

change. ie healthy food and/or

tobacco policies.

Implementation Process

„ Screenings done at worksites.

„ Aggregate data collected and

shared with committee.

„ Suggestions are made for

programming.

„ Programming options are provided.

Behavior Change Program

Holiday Trimmings

Eight-week incentive program designed to help employees prevent

weight gain during the holiday season.

The program started one to 10 days prior to the Thanksgiving

holiday (November 16 to November 25) and ended in January

(January 4 to January 15).

Holiday Trimmings Results

Holiday Trimmings 2009

Report

Total

How many total participants

submitted weight online or at

weigh in?

255

How many Locations 13

Average pre-program weight 177.08 lbs

Average post-program weight 173.20 lbs

Normal Weight

30%

Overweight 35%

Obese 35%

Pre- Program BMI Distribution Among Holiday Trimmings Participants

Normal Weight

39%

Overweight 29%

Obese 32%

Post-Program BMI Distribution Among Holiday Trimmings Participants

Policy Change

„ Smoking Cessation

„ Healthy food policy

„ Alternative work schedules

„ Ergonomic evaluation

Stakeholders

•NUMC

•Brown County Health Department

• City Council

• Festival Organizers

• Fitness Centers

• Parks & Recreation

• Schools

• Worksites: Windings, Kraft, 3M, Associated Milk

Producers Inc, August Schell Brewery

Project Partners „ NU Park and Recreation

„ Fitness facilities like Anytime Fitness and SNAP

„ Chamber of Commerce

„ NUCAT

„ Brown County Health (SHIP)

„ Service groups like Sertoma, Optomist Club,

Rotary

„ Grocery stores

„ Restaurants

Park and Recreation

Partnership „ Provide screening site.

„ Support on steering committee.

„ Promotion of programs.

Results So Far -

Community „ 94 percent are aware of HONU.

„ Increase in fruits and veggies 17

percent to 22 percent.

„ 94 percent are confident HONU will

succeed.

Results So Far-Worksite

„ Windings

‟ WOHS (Windings Optimal Health

Score)

‟ Physical activity increased to 140 mins

‟ Fruit and vegetable consumption up 1

point

‟ Productivity up 10 percent

‟ Average total cholesterol down 10

points

HEARTBEAT CONNECTIONS

PROGRAM

In Summary

„ HONU is designed to help improve

the health of an entire community.

„ The goal is the prevention of early

age MI.

„ Being able to replicate the project

will provide a template for

prevention in other communities.

The Goal of Partnerships

„ The project will only succeed with

community and worksite input.

„ Partnerships are vital to the

sustainability of the project

programs and impact.

„ Partnerships with community are

important for replication in other

communities.

Early Keys to Success (i.e.,

take-away’s) 1. Use your own data

2. Align your community’s existing

resources

3. Extend the primary care relationship

4. Push for support from those who benefit

WHAT IS HEART DISEASE?

Heart Disease

„ Definition: Broad term to describe several

types of cardiovascular disease

„ 1. CAD (coronary artery disease)

„ 2. CHF (congestive heart failure)

„ 3. Heart Arrhythmia

„ 4. Cardiomyopathy

What is CAD?

„ Major form of Cardiovascular Disease

„ Occurs when arteries are narrowed by

fatty deposits leading to plague build up

„ Blood supply is restricted to heart muscle

thereby causing a heart attack

Heart Disease Statistics

„ Every 34 seconds a person in the United States dies from heart

disease.

„ More than 2,500 Americans die from heart disease each day.

„ Every 20 seconds, a person in the United States has a heart attack.

„ At least 250,000 people die of heart attacks each year before they

reach a hospital.

„ Studies show that under-educated people are more likely to suffer

heart attacks.

„ Almost 6 million hospitalizations each year (in the United States) are

due to cardiovascular disease.

„ Since 1900, Cardio Vascular Disease has been the number 1 killer

in the United States for every year but 1918.

„ Men suffer heart attacks about 10 years earlier in life than women

do.

Causes of Death in US „ Number of deaths for leading causes of death

„ Heart disease: 616,067

„ Cancer: 562,875

„ Stroke (cerebrovascular diseases): 135,952

„ Chronic lower respiratory diseases: 127,924

„ Accidents (unintentional injuries): 123,706

„ Alzheimer's disease: 74,632

„ Diabetes: 71,382

„ Influenza and Pneumonia: 52,717

„ Nephritis, nephrotic syndrome, and nephrosis: 46,448

„ Septicemia: 34,828

„ Source: Deaths: Final Data for 2007, table B

http://dying.about.com/od/causes/ss/death_causes_2.htm

HEART DISEASE

„ #1 CAUSE OF DEATH FOR MEN AND

WOMEN

Contributing Factors for Heart

Disease „ Tobacco Use

„ Obesity

„ Inactivity

„ Diabetes/Prediabetes

„ Hypertension

„ Metabolic Syndrome

Smoking(Per US Surgeon General-”the leading

preventable cause of disease and deaths in the US”)

„ Contributor of Heart Disease that is MOST Preventable

„ Increases risk 2-4 times of developing CAD

„ Increase Risk of sudden cardiac death

„ In the United States, an estimated 24.8 million men (23.1 percent) and 21.1 million women (18.3 percent) are smokers. These people are at higher risk of heart attack and stroke. The latest estimates for persons age 18 and older show...*

„ Among whites, 23.5 percent of men and 20.6 percent of women smoke (2008).

„ Among blacks, 25.6 percent of men and 17.8 percent of women smoke.

„ Among Hispanics, 20.7 percent of men and 10.7 percent of women smoke.

„ 9.9 percent of Asian adults smoke.

„ 24.3 percent of American Indian/Alaska Native adults smoke.

„ * National Health Interview Survey (NHIS), 2008, National Center for Health Statistics

How does smoking affect CAD

„ Increases BP

„ Decreases exercise tolerance

„ Increases tendency for blood to clot

„ Decreases HDL

Obesity

„ The Heart has to work harder in people who are overweight, putting more stress on the heart

„ Also, obese tend to have higher LDL, increase BP, and increased risk for diabetes

• Obesity by Race/Ethnicity 2006-2008

• New Obesity Data Shows Blacks Have the Highest Rates of Obesity

• Blacks had 51 percent higher prevalence of obesity, and Hispanics had 21 percent higher obesity prevalence compared with whites.

• Greater prevalences of obesity for blacks and whites were found in the South and Midwest than in the West and Northeast. Hispanics in the Northeast had lower obesity prevalence than Hispanics in the Midwest, South or West.

• For this study analysis, CDC analyzed the 2006−2008 BRFSS data.

BMI

„ Weight in pounds divided by 2.2

„ Then, multiply height in inches by 0.254

„ Normal: BMI 18.5-24.9

„ Overweight: BMI 25-30

„ Obese: BMI greater than 30

„ Morbid obesity: BMI greater than 40

1999

Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2009

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2009

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Cost of Obesity

„ Obesity-a contributing factor in 100000-

400000 deaths per year

„ 117 Billion dollars in direct cost and

indirect cost

Lack of Physical Activity/Exercise

„ Contributes to weight gain

„ Activity Benefits the heart

„ -activity Helps lower cholesterol and blood

pressure

„ Goal is 30 minutes 5 times per week

Benefits of exercise

„ Improves circulation and help your body use oxygen better.

„ Strengthens Heart muscle

„ Improved energy -allows you to do activities without becoming tired or short of breath.

„ Improved endurance.

„ Lowers blood pressure.

„ Improves muscle tone, strength, flexability and balance.

„ Help bones be stronger

„ Prevent weight gain, helps with weight loss

„ Exercise is helpful in reducing stress, tension

„ Improved self esteem and self image.

„ Improved sleep, rest and relaxation

Your target heart rate isn't one rate but a

range of rates (beats per minute, or bpm),

expressed as percentages of your maximum

heart rate, that are safe for you to reach

during exercise. For most healthy people, the

American Heart Association recommends an

exercise target heart rate ranging from 50% to

75% of your maximum heart rate, which is

normally calculated as the number 220 minus

your age.

Room for Improvement

Less than 50% of Adults get the

recommended amount of daily activity

Hypertension

„ Often called the “Silent Killer”

„ Normal is considered less than 120/80.

„ High Blood pressure is 140/80

„ High risk population goal is 130/85

„ Blood pressure (BP) is the pressure

exerted by circulating blood upon the

walls of blood vessels

How to control Blood pressure?

• Weight management

• Exercise

• Salt restriction

• Don’t Smoke

• Limit Alcohol

• Stress Management

Incidence of HTN

• 36% of African Americans

• 20% of Caucasians, Hispanics and

Native Americans

• Asians have lowest incidence < 10%

• African Americans have earlier onset

and more severe consequences of HTN

Diabetes and PreDiabetes

Age-adjusted total prevalence of diabetes in

people aged 20 years or older, by

race/ethnicity—United States, 2002

Health Interview Survey and 1999-2000 National Health and Nutrition Examination Survey estimates projected to year 2002. 2002 outpatient database of the Indian Health Service.

Incidence of DM(2007)

• Total 23.6 million people have diabetes

• 17.9 million diagnosed

• 5.7 million undiagnosed

Diabetes by State

Keys to Management

• Blood pressure

• Asa

• LDL

• Smoking

• A1c

Metabolic Syndrome

• Triglycerides > 150

• HDL <40 for men, < 50 for women

• Blood pressure > 130/85

• Fasting glucose >100

• Abd. Circumference > 40 males, >35

women

Cholesterol Management

ATP III Guidelines ( Adult treatment Panel)

Step 1

LDL Cholesterol-Primary Target of Therapy

< 100-optimal

100-129-Near Optimal/above optimal

130-159-Borderline High

160-189-High

> 190- Very High

Total Cholesterol

< 200-Desirable

200-239 Borderline High

> 140-High

HDL Cholesterol

< 40- Low

> 60- High

(National Institutes of Health)

Step 2

• Identify presence of clinical atherosclerotic disease that confers high risk for Coronary Heart disease (CHD ) events

* Clinical CHD

* Symptomatic carotid artery disease

* Peripheral Arterial disease

* Abdominal Aortic aneurysm

* Diabetes (National Institutes of Health)

Step 3

• Determine presence of Major risk factors

(other than LDL) that modify LDL goals

* Smoking

* HTN BP >140/90 or on TX

* Low HDL (<40)

* Fam HX of premature CHD (1st degree male

relative < 55y/o; Female < 65 y/o

*Age (men > 45; women > 55)

Step 4

• If 2+ risk factors (other than LDL are

present without CHD or CHD risk

equivalent, assess 10 year CHD risk

(Framingham tables)

* > 20%-CHD risk equivalent

* 10-20%

* 10 %

Step 5

• Establish LDL goal of therapy

• Determine need for TLC (therapeutic

lifestyle changes

• Determine Level for drug considerations

Treatment Guidelines

• CHD or CHD risk Equivalents (10 yr risk

> 20%)

*LDL Goal less than 100

-Consider TLC if LDL > 100

-Drug Therapy > 130, drug therapy

optional if LDL 100-129

Treatment Guidelines Cont.

• 2+ Risk Factors (10 year risk <20 %)

* LDL Goal < 130

- TLC if LDL > 130

- Drug Therapy:

if 10 yr risk 10-20% >130

if 10 yr risk < 10% and LDL > 160

Treatment Guidelines Cont.

• 0-1 risk factor

* LDL Goal < 160

- TLC if LDL > 160

- Consider Drug Therapy if:

LDL > 190

LDL 160-189-Drug Therapy Optional

TLC (Therapeutic Lifestyle

Changes)

• Diet:

* Saturated fat < 7% of calories,

cholesterol < 200mg/day

* Fiber 10-25 mg/day

* Plant Stanols and sterols (2grams/d)

Weight Management

Increased Physical Activity

Metabolic Syndrome

Treat as High Risk???

NON HDL???

Triglycerides??

HDL???

Thank You

QUESTIONS??