Arizona chronic disease plan: an integrated model for promoting health communities

              The Arizona Chronic Disease Plan







An Integrated Model For Promoting Healthy Communities















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Alone we can do so little; together we can do so much.







� Helen Keller















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i







Letter From Our Director















Dear Arizona Residents: Chronic disease accounts for seven out of the 10 leading causes of death in Arizona and is the most common and preventable of all health problems. During the 20th Century, our citizens saw the focus of public health shift dramatically from the communicable diseases that were so prevalent during the early part of the century to chronic disease as the primary cause of mortality and morbidity. Diseases such as heart disease, cancer, lung disease, and stroke rank highest on the list as the four leading causes of death for Arizonans. The Arizona Chronic Disease Plan: An Integrated Model for Promoting Healthy Communities is the culmination of a collaborative effort among members of the Chronic Disease Team who worked to combine the elements of six comprehensive disease-specific categorical plans into a cohesive and integrated model. It is an innovative and cutting-edge approach that promotes collective thinking and problem solving in addressing common elements of the disease-specific and primary risk factor categories. This plan represents the Arizona Department of Health Services' efforts to view chronic disease from a more comprehensive and integrated perspective. The Arizona Chronic Disease Plan is not meant to be the final answer; rather it is a beginning in the department's ongoing commitment to reducing the impact of chronic disease in our state and, thereby, enhancing the quality of life for our citizens.















Susan Gerard Director Arizona Department of Health Services















The Arizona Chronic Disease Plan















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Ta b l e o f C o n t e n t s















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Acknowledgments















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II. E x e c u t i v e S u m m a r y III. I n t r o d u c t i o n















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Vision for the Arizona Chronic Disease Plan: An Integrated Model for Promoting Healthy Communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 ADHS Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Chronic Disease Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Def inition of Chronic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Comprehensive Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Case for an Integrated Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Timeframe for the Arizona Chronic Disease Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17















IV. T h e P l a n















. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19















The Burden of Chronic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 The Need for an Arizona Chronic Disease Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Health Disparities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 The Cost of "Not Taking Action" . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 How This Plan is Different . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Purpose of the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 How to Use This Document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 Description of the Categorical Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29















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V. I n t e g r a t i o n















. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35















Healthy Lifestyles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Priorities for Chronic Disease Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 Implementing an Integrated Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 State Level Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Community Level Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Summary Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51















VI. A p p e n d i c e s







A. B. C. D. E. F. G. H.















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Sample Matrices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Tobacco Tax Statute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59 Healthy Eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 Priority Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70 Programs and Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .77 Culturally and Linguistically Appropriate Services Standards . . . . . . . . . . . . . . . . . . . . . . . . . .85 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93















The Arizona Chronic Disease Plan















Courtesy of Heard Museum















I







Acknowledgements















Acknowledgements







Chronic Disease Team







We would like to thank the members of the Chronic Disease Team for their dedication and commitment to the development of this plan. Their willingness to give of their time, energy, and expertise represents the true spirit of teamwork.















Primary Author







Janet Bourbouse Arizona Department of Health Services















Reviewers







Chronic Disease Team















Trust Commission







We would like to thank the members of the Tobacco Revenue Use, Spending, and Tracking (TRUST) Commission for supporting the development of The Arizona Chronic Disease Plan: An Integrated Model for Promoting Healthy Communities.















Consultants







Sincere gratitude to our technical consultants, Randy Kirkendall (Partnership for Prevention) and Tom Kean (Strategic Health Concepts) for their insight, direction, and support throughout the project.







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The Arizona Chronic Disease Plan















II







Executive Summary















Executive Summary







Chronic disease accounts for seven out of the 10 leading causes of death in the state of Arizona.1 This plan is intended to provide state level agencies, communities, health care providers, funding agencies, organizations, 2) The AzCD Plan will be used as a vehicle for establishing partnerships with local communities policy and decision makers, and organizations to develop programs to address and consumers direction and







the burden of chronic disease. suppor t in creating a system of care that proactively addresses the prevention, early detection and treatment of chronic disease in Arizona. It is hoped the framework presented will encourage the development of partnerships to promote a comprehensive and integrated approach to reducing mor tality and morbidity due to chronic disease. 3) The AzCD Plan will be used to establish funding















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priorities for a portion of the Arizona Tobacco Tax and Health Care Fund � Health Education Account. The funding priorities will address prevention and early detection of the four leading disease-related causes of death, i.e., heart disease, cancer, lung disease (chronic obstructive pulmonary disease or COPD), and stroke. 4) The AzCD Plan provides a framework for leveraging resources and exploring other funding streams.















Vision for The Arizona Chronic Disease Plan:







An Integrated Model for Promoting Healthy Communities







1) The Arizona Chronic Disease (AzCD) Plan is a blueprint for developing a coordinated and integrated approach to chronic disease management in Arizona.















The Arizona Chronic Disease Plan















Health Disparities







Despite the advances in medical technology impacting the early detection, diagnosis, and treatment of chronic disease, minority groups and other vulnerable populations still experience health care barriers and significantly higher rates of disease and mortality. Eliminating these disparities has become a priority for the health care system nationally and in Arizona.















Healthy Lifestyles







This AzCD Plan supports the promotion of healthy lifestyles as primary prevention strategies in combating the key risk factors for chronic disease, i.e., poor nutrition, physical inactivity, and use of commercial tobacco products. The role of tobacco prevention and cessation programs is critical in the management of chronic disease. The burden of overweight and obesity contributes to premature death and disability, increased health care costs, lost productivity, and social issues. While not all chronic diseases are addressed in this plan, promoting a healthy lifestyle that includes good nutrition, physical activity and no use of commercial tobacco products will positively impact many chronic diseases not specifically included in the plan.















How This Plan is Different







This plan is different than many other planning documents. The scope of the plan is very broad, encompassing several distinct disease categories: heart disease, cancer, lung disease (COPD and asthma), stroke, and diabetes and the risk factor categories of poor nutrition, physical inactivity, and use of







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Summary







This plan represents the Arizona Department of Health Services' ongoing commitment to reducing the mortality and morbidity of chronic disease through collaboration among all stakeholders. It is hoped that the plan will encourage the development of partnerships among state agencies, policy and decision makers, communities, organizations, health care providers, and consumers to promote a comprehensive and integrated approach to improving the health of all Arizonans.















commercial tobacco products (see definition of "tobacco" in glossary). Each of the disease-specific entities and risk factor categories has developed a comprehensive and integrated planning document that outlines evidenced-based objectives and strategies. The goal of the AzCD Plan is to effectively merge the many elements of the categorical plans into a coordinated, cohesive, and integrated model of the proposed system of care for the prevention and management of chronic disease in Arizona.















II







Executive Summary







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III







Introduction















Introduction







Chronic disease accounts for seven out of the 10 leading causes of death in the state of Arizona.1 Over the past several years, there has been an expansion of chronic disease programs within the This plan is intended to provide state level agencies, Public Health Services Division communities, health care providers, funding agencies, of the Arizona Department organizations, policy and decision makers, and of Health Services (ADHS).







consumers direction and support in creating a system Until recently, those chronic disease programs functioned independently without coordination among the various chronic disease initiatives, due in part to categorical funding requirements. With the expansion of chronic disease prevention, management, and control efforts, a need was identified to develop a more comprehensive and integrated approach. There is neither funding to implement every strategy in the categorical plans, nor funding to support all of the initiatives addressed in this comprehensive plan. The reality is there are rarely sufficient financial resources to fully fund any plan. Many of the items in this comprehensive plan do not require funding, but a more effective coordination of state and community level efforts that are already in progress. ADHS is committed to dedicating human resources, time, and leadership to support implementation of the plan. of care that proactively addresses the prevention, early















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detection and treatment of chronic disease in Arizona. It is hoped the framework presented will encourage the development of partnerships to promote a comprehensive and integrated approach to reducing mortality and morbidity due to chronic disease.















Vision for The Arizona Chronic Disease Plan:







An Integrated Model for Promoting Healthy Communities







1) This Arizona Chronic Disease (AzCD) Plan is a blueprint for developing a coordinated and integrated approach to chronic disease management in Arizona.















The Arizona Chronic Disease Plan















2)















The AzCD Plan will be used as a vehicle for establishing partnerships with local communities and organizations to develop programs to address the burden of chronic disease.















Service delivery. ADHS believes in delivering







services that are based on best practices and supported by evidence-based strategies.















Cultural responsiveness. ADHS believes all







services and technical assistance should be provided in a manner that is responsive to cultural differences and values the importance of culture in the delivery of services to all segments of the population.















3)















The AzCD Plan will be used to establish funding priorities for a portion of the Arizona Tobacco Tax and Health Care Fund � Health Education Account. The funding priorities will address prevention and early detection of the four leading disease-related causes of death: heart disease, cancer, lung disease (chronic obstructive pulmonary disease or COPD), and stroke.















Reduction in health disparities. ADHS







believes in order to reduce existing health disparities, a culturally responsive system of care should be developed and implemented among all levels of Arizona health care providers, which includes but is















4)















The AzCD Plan provides a framework for leveraging resources and exploring other funding















not limited to: � Organizational self-assessment of cultural















streams.















competence � Integration of cultural and linguistic competence measures into existing quality improvement activities (See Appendix F for Culturally and Linguistically Appropriate Services Standards) � Development/review of comprehensive written policies on cultural responsiveness � Customer satisfaction surveys � Solicitation of customer input relative to















ADHS Approach







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Prevention and health promotion. ADHS







believes in prevention and health promotion as the path to optimal health and wellness for all Arizonans. The 2005�2009 ADHS Strategic Plan includes specif ic strategies and objectives focusing on the prevention of chronic disease in Arizona through an integrated and comprehensive approach: The Department is working with health care providers, employees, and organizations to place greater emphasis on the importance of prevention and health promotion activities. By providing leadership and state-of-the-art health information to professionals and consumers alike, the Department can promote healthier lifestyles and reduce the incidence of chronic and degenerative diseases.2















individual needs, beliefs, and behaviors � Trainings and forums for providers and staff.















III







Introduction







Despite the advances in medical technology impacting the early detection, diagnosis, and treatment of chronic disease, minority groups and other vulnerable populations still experience health care bar riers and significantly higher rates of disease and mortality. Eliminating these disparities has become a priority for the health care system nationally and in Arizona. Current health data on Arizona residents shows marked differences in rates of disease and mortality among specific population groups. The Department is committed to addressing disparities in Arizona by increasing dialogue with communities, improving access to public health information, and working collaboratively on community action specifically targeted to improve health outcomes through prevention. The Department will also work to ensure that all Arizonans receive timely diagnosis and treatment of health conditions through expanded access to primary care.3 In addition to services, technical assistance is a critical need to improve health conditions on the reser vations. Resources are significantly limited and capacity building or "nation building" is a critical need. Tribes prefer technical assistance be made available to them in a manner that allows them to customize the assistance based on the needs of the tribe. Improved working relationships between the tribes and state agencies need to be established so tribes can be involved in future planning activities. Geographic bar riers and efficient and expedient methods of communication present challenges in obtaining tribal input on planning activities at the state level. Soliciting input from Indian Health Service (IHS) or the Bureau of Indian Affairs (BIA) is one way used to obtain the Native American perspective in planning efforts; however, these agencies provide a federal perspective, which is not necessarily the local tribal perspective. While going directly to the tribes on the reservations is the only true source of obtaining tribal input, the Inter Tribal Council of Arizona (ITCA) presents an accessible and viable option for obtaining a tribal perspective.







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Native American population in Arizona. In







addressing issues related to cultural competency and disparity, it is important to recognize that Arizona has one of the largest Native American populations in the country comprising approximately 5% of the state's population.4 There are 21 separate sovereign nations located on















Background







In July of 2002, the ADHS Office of Nutrition Services merged with some of the chronic disease















24 Native American reservations throughout Arizona. This presents some distinct challenges in terms of prevention programs in ADHS to form a new office geographic barriers, history, tradition, communication, titled the Office of Chronic Disease Prevention and and governmental structure. The element of sovereignty is a unique aspect of the Native American population, not shared by other minority groups, requiring additional accommodation to work successfully.















The Arizona Chronic Disease Plan















Nutrition Services (OCDPNS). The chronic disease programs that merged included: � Diabetes Prevention and Control � Arthritis Control � Well Woman Healthcheck Program (Breast and Cervical Cancer Early Detection and Diagnosis) During the next year, funding was secured for planning grants in the areas of: � Cardiovascular Risk Reduction � Nutrition and Physical Activity � Comprehensive Cancer Control With the growing number of chronic disease programs















determined by the Centers for Disease Control and Prevention (CDC) or its successor agency. Initially, the Chronic Disease Fund, which resides within ADHS, will address the following chronic diseases: heart disease, cancer, lung disease (COPD) and stroke. By statute, an external advisory commission (Tobacco Revenue Use Spending and Tracking Commission or TRUST) was established to oversee the Health Education Account. The 15-member, ADHS Director-appointed TRUST Commission serves in an advisory capacity to ADHS in providing oversight to the Tobacco Tax revenues, including the Proposition 303 Tobacco Tax-based chronic disease funds. Through internal and external















in OCDPNS, its chronic disease prevention efforts stakeholder input, the decision was made to allocate expanded and work began on establishing these funds for screening and early detection comprehensive chronic disease programming and programs, promoting healthy lifestyle programs, and planning.







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development of a comprehensive chronic disease An additional motivating factor for the strategic plan. development of the comprehensive chronic disease As the public health agency that administers and plan was the need to establish direction and funding manages the chronic disease funds, the need for a priorities for a portion of the Arizona Tobacco Tax systems-level strategic plan that is both and Health Care Fund � Health Education Account. comprehensive and integrated is paramount. Having Voter approval of Proposition 303 in 2002 increased such a plan will ensure that chronic disease-related the state tax on tobacco products and reenacted the "baselines" are developed, actual needs are addressed, Proposition 204 statute that established the Tobacco and funds are allocated in support of policy change Tax and Health Care Fund � Health Education and programmatic services. Account. As a voter approved initiative, a portion of the tobacco tax revenue (2%) was directed to the prevention and early detection of the four leading disease-related causes of death as periodically















III







Introduction







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III







Introduction







In the fall of 2003, the ADHS OCDPNS submitted a grant proposal to the Partnership for Prevention who had been designated by CDC to provide tailored technical assistance to selected states and metropolitan areas in developing comprehensive and integrated chronic disease prevention efforts. In January of 2004, ADHS was notified that Arizona was one of four sites out of 34 applicants to participate in the CDC project. During the planning process, the consultants facilitated on-site meetings of the Chronic Disease Team and provided direction and follow-up to the OCDPNS Office Chief and the AzCD Plan Manager during each of the on-site visits. In addition to the on-site meetings, the consultants were available for individual phone consultation, conference calls as needed, and review of written materials via email. Network, Social Marketing, Steps to a Healthier Arizona, Bureau of Public Health Statistics, Office of Health Systems Development, the Native American Liaison, and the coordinator from the Health Disparities Conference Committee, were added to the team as the planning process required their expertise. The technical assistance consultants facilitated the monthly CD Team meetings held from August 2004 to May 2005. The CD Team served as a steering committee providing direction and content information for the AzCD Plan. Decisions regarding common messaging, cross-cutting strategies, conflicting objectives, establishing priorities, and identifying gaps in the categorical objectives and strategies were all addressed through the CD Team. The CD Team also served as a review workgroup for all written materials pertaining to the AzCD Plan.







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Chronic Disease Team







A Chronic Disease (CD) Team was established within ADHS to assist in the development and provide input on the AzCD Plan. Initially, the CD Team included the representatives from each of the categorical plans and appropriate administrative staff within OCDPNS and the Office of Tobacco Education and Prevention Program (TEPP). As the planning process progressed, other members were gradually added to the CD Team to broaden the scope of representation and/or provide needed input on relevant topic areas. Representatives from ADHS Nutrition















Definition of Chronic Disease







For the purposes of this document, chronic disease is defined as in the February 2003 revision of the Association of State and Territorial Chronic Disease Program Directors Bylaws:5 Chronic disease is defined as an impairment or deviation from normal health having any of the following characteristics: � related to avoidable behavioral/environmental risk factors � is permanent � leaves residual disability � is caused by irreversible pathological alterations















The Arizona Chronic Disease Plan















� requires special training of the patient for rehabilitation















Case for an Integrated Approach







The intent of integration is to strengthen program effectiveness and improve program impact thereby maximizing available resources. Achieving















� may require a long period of supervision, observation, or care.















Comprehensive Approach







Miriam Webster Online defines the term comprehensive as "covering completely or broadly." 6















integration is a process whereby participants learn by sharing common strategies and goals, they can increase the overall impact and efficiency of their programs.















For the purpose of this plan, a comprehensive An integrated approach to chronic disease approach to chronic disease prevention and prevention provides opportunities for programs to management is defined as addressing: work together to provide services more efficiently and � The leading causes of death: heart disease, cancer, lung disease (COPD), and stroke � Two of the most common and costly conditions: diabetes and asthma � The major risk factors for chronic disease: physical inactivity, poor dietary habits, and use of commercial tobacco products







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effectively, promotes group problem solving and teamwork by collaboratively addressing common problems and issues, and supports a more synergistic style of intervention so the combined impact of all programs is enhanced. Other benefits of addressing chronic disease with an integrated and collaborative approach are: � Improved effectiveness in reaching shared target populations and organizations � Ability to address common risk factors that are the same for many of the prominent chronic diseases: poor nutrition, physical inactivity, and use of commercial tobacco products � Enhanced impact of common, consistent social marketing messages and strategies � Opportunity for mutual problem solving and shared learning � Coordination of similar intervention strategies that allows for improved coordination and effectiveness in developing interventions for common intervention sites such as schools, work sites, and communities















� The issues related to chronic disease management from a statewide perspective including: the general population, high-risk groups, and disparate populations � The issues using a broad spectrum of intergenerational strategies implemented through a variety of intervention domains such as: schools, work sites, family and community, and the health care system.















III







Introduction







� Pooling of resources that maximize the eff iciency and effectiveness of programs and allows for improved allocation of limited funding The initial cycle of the AzCD Plan will cover from � Enhanced data sharing � Improved capacity for identifying and resolving gaps in service delivery when those issues are viewed from a multifaceted perspective � Sharing of standards and best practices to eliminate duplication of effort and insuring consistency in standards of care � Enhanced coordination with external partners that results in better communication across programs � Coordination of provider education efforts � Development of training tools for providers that facilitate the process for all concerned and avoids duplication of efforts � Expanded impact of policy and environmental changes � Clearly defined roles and responsibilities � Overall greater impact and effectiveness of programs. 2005 through 2008. The projected timeframes for the categorical plans range from three years to five years as follows: � Cardiovascular Disease Prevention Plan, 2005 � 2010 � Arizona Comprehensive Cancer Control Plan, 2005 � 2010 � Chronic Lung Disease Plan for the State of Arizona, 2005 � 2008 � Diabetes Prevention and Control Program Plan, 2005 � 2008 � Arizona Nutrition and Physical Activity Plan, 2005 � 2010 � Tobacco Education and Prevention Program Plan, 2005 � 2008 Given that strategies and priorities for the AzCD Plan were derived from the categorical plans, the CD Team decided that the overall timeframe for the AzCD Plan should be within the parameters of the categorical plans. The three-year timeframe for the AzCD Plan does not mean all objectives will be met within that period, rather the plan will be monitored, reassessed, and revised after the three years as needed.







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Timeframe for The Arizona Chronic Disease Plan















The Arizona Chronic Disease Plan















IV







The Plan















The Plan







The Burden of Chronic Disease in Arizona The 20th century saw major improvements in the quality of life for citizens in this country. The infant mortality rate dropped signif icantly and life expectancy increased by 30 years. The deaths were due to heart disease (24.9%) and 2,356 focus of public health also were due to stroke (5.5%). shifted dramatically from the � Cancer is the second leading cause of death in communicable diseases that Arizona, second only to heart disease. There were







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plagued the early part of this century to chronic disease as the primary causes of death and disability to our citizens. Today, diseases such as heart disease, cancer,







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9,451 deaths attributed to cancer in 2003 (22.1%).1 � Chronic Lower Respiratory Disease or Chronic Obstructive Pulmonary Disease (COPD) was the third leading cause of death in Arizona for 2003, accounting for 5.9% of deaths.1 � It was estimated that about 262,686 Arizonans had diabetes in 2002. The rate of diabetes-related hospital discharges increased from 133 per 100,000 population in 2000, to 147 per 100,000 population in 2002.9 � Asthma is one of the nation's most common and costly diseases, affecting 17 million Americans, including almost five million children. The prevalence for asthma among Arizona adults (persons 18 years of age or older) was approximately 13.9 % in 2002.10 � "In 2002, more than half of the deaths in Arizona (54.8%) were from diseases for which overweight and obesity are known to increase risk, including















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lung disease, and stroke are among the most common, costly and preventable causes of mortality and morbidity.8 The aging of the baby-boomer generation, and the popularity of Arizona as a retirement state, place additional responsibilities on public health and the health care system to aggressively address chronic disease from a prevention perspective and utilize screening and early detection to reduce the burden of chronic disease. Chronic disease accounts for seven out of the 10 leading causes of death in the state of Arizona.1 They are the most prevalent, costly, and preventable of all health problems. � In Arizona, heart disease and stroke were the first and fourth leading cause of death in 2003; 10,649















The Arizona Chronic Disease Plan















diseases of the heart (25.9%), malignant neoplasms (22.4%), and cerebrovascular disease (6.5%)."







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discuss the issues related to chronic disease and minority populations throughout the state. Participants represented urban and rural communities, Asian, African American, Hispanic, Native American, White, and gay/lesbian/ bisexual/transsexual populations.18 Also, between November 2004 and March 2005, over 40 focus groups representing Arizonans 65 years of age and over were held by the Governor's Council on Aging to provide input for the Aging 2020 Plan. Many common themes surfaced during the focus groups. The commonalities often identified the broader elements of the system of care and how responsive or unresponsive that system was to the needs of the individual groups. Common issues such as the need for a greater focus on prevention and early detection of chronic disease, culturally responsive health care and health education, strategies to address uninsured/underinsured, and access to care (primary and specialty) surfaced across the groups. The results of the touch point comparison of the disease entities as well as the results of the focus groups indicate a clear need for addressing these common elements through a coordinated, comprehensive, and















� "An estimated 65% of adults in the United States are overweight or obese."







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� In Arizona, 57.1% of adults are overweight or o b e s e . 11 � "The obesity rate among Arizona adults increased by 80% from 1990 to 2002."







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� "More than 60% of American adults do not get enough physical activity to provide health benefits and 26% are not active at all." 13 � In 2003, prevalence data indicated that 21.2% of Arizonans did not engage in any physical activity.14 � "An estimated 45.8 million adults in the United States smoke cigarettes even though this single behavior will result in death or disability for half of all regular smokers." 15 � Each year, approximately 440,000 people die due to tobacco-related diseases, which calculates to







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approximately 20% of all deaths in the United States.16 � "If current smoking patterns continue, 6.4 million people currently younger than 18 will die prematurely from a tobacco-related disease."







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integrated plan.















� The 2002 prevalence rate for Arizona adults who smoke was 20%.17















Health Disparities







There are distinct differences in the rates of mortality and morbidity for certain populations and racial and ethnic groups. While there are a number of common themes within the health-related issues for these groups, the solutions for these common issues may be different due to the varied needs, cultural diversity, and geographic locations relevant to the specific group(s). There may also be targeted issues that pertain only to certain populations. In addition to the common issues, the chart to the right depicts examples of specific issues as identified by each group.















The Need for an Arizona Chronic Disease Plan







Reviewing the objectives and strategies among the disease-specif ic entities, it becomes evident that there are many commonalities that overlap the disease categories such as common risk factors, service delivery methodologies, intervention sites, target populations, and need for common messages. Between September 2004 and April 2005, seven focus groups were held in conjunction with the Chronic Disease Disparities in Arizona Conference (April 13�15, 2005) to















IV







The Plan















African American Community (Phoenix, AZ) � Critical health issues: hypertension, diabetes, high cholesterol, prostate and breast cancer � Sickness viewed as a sign of weakness � Credibility is increased when information comes from person of same race and gender � Males tend to not seek medical attention � Wellness programs are well-received when connected to churches















H i s p a n i c C o m m u n i t i e s ( Y u m a a n d S o u t h Tu c s o n , A Z ) � Critical health issues: heart disease, diabetes, stroke, and hypertension � Language barriers; lack of translation services in hospitals � Immigrant status � legal v.s. non-legal � In border communities, prefer to cross border to Mexico for health care � Males tend to not seek health care � Need for more lay health workers/promotoras







21















Rural Communities (Cottonwood area) � Critical health issues: cardiovascular disease and cancer � Geographic isolation; lack of transportation to providers � Socio-economic disparities � includes very wealthy and very low income � Underserved and high rate of uninsured � Limited health resources Native American Population (Native American Community Health Center (NACHC), Indian Health Service) � Critical health issues: diabetes and obesity � Native American provider for Native American clients is very important � Cultural differences, language barriers � Distance and transportation are challenges in access to services � Cultural belief that discussing disease puts them at risk for transmission















The Arizona Chronic Disease Plan















Asian Community (Metro Phoenix, AZ) � Critical health issues: hepatitis B/liver cancer, cardiovascular disease (hypertension, stroke, diabetes), cervical cancer, and tobacco � Lack of general preventive health information � Unaware that risk for breast cancer significantly increases for Asian women who have been in U.S. for 10 years or more � Language barriers � Medical interpreters needed � Demographically dispersed � Potential contradictions between Western medicine and Eastern medicine (homeopathic, acupuncture, etc.)















A g e 6 5 Ye a r s a n d O v e r, A g i n g 2 0 2 0 F o r u m















22















� Critical health issues: heart disease, cancer, cerebrovascular disease, chronic respiratory disease, and Alzheimer's disease � Need for a single point of access to information and services � Identify and disseminate models to learn about healthy aging � A focus on prevention will require public education campaigns for lifelong education and healthy lifestyle education, active lifestyle programs, health information � Increase use of computer and Internet based information (make programs less intimidating to older adults) � Prioritize and educate about chronic diseases as they relate to high-risk populations















G a y / L e s b i a n / B i s e x u a l / Tr a n s s e x u a l ( G L B T ) ( W i n g s p a n � Tu c s o n , A Z )















� Critical health issues: no cancer screening; health programs tied to HIV/STD screening � Health movement does not exist unless focused on HIV � Data is not collected specific to GLBT � Lack of provider education about lesbian health � Healthcare is the number one problem for transsexual community















IV







The Plan







Significant disparities exist between the health of the Native American and the general U.S. population. "Health gains among Indians have slowed or ceased altogether in recent years as disease patterns have changed. Injuries, chronic disease, and behavior-related diseases have emerged as new challenges. The new disease patterns are associated with consequences from poverty and � Explore available options for expanding cultural dislocation. Inadequate education, high rates of unemployment, and discrimination all contribute to unhealthy lifestyles and disparities in access to care."







19















� Share information, resources, and technical assistance among all stakeholders � Provide information and training to tribes regarding the available telemedicine options � Encourage the design and implementation of prog rams that address access to care issues such as transportation, insurance applications procedures, and alternative medicine resources















traditional medicine programs � Find innovative ways to address the health care provider workforce challenges.















Native Americans born today have















a life expectancy of 72.9 years as compared with the life expectancy of 76.5 for all races in the U.S., an almost four year difference.







20















The Cost of Not Taking Action







Americans are living longer due to advances in science and medical technology and improvements in living conditions. Life expectancy has increased from 59 years of age in 1950, to 77 years of age today. The percentage of the population over age 65 years has significantly increased and will continue to rise. Since 1900, the number of people in America age 65 years or older has increased from three million to nearly 35 million and this number is expected to double to 70 million in the next 30 years. Because health care needs of older adults are usually greater than younger adults, medical costs can be expected to increase with the growing numbers of adults over age 65 years.23 The growing number of adults over the age of 65 years, the cost of improvements in medical technology, and inflation have all contributed to the







23















In Arizona, the















disparity in life expectancy between Native Americans and all Arizonans is even more striking. In 2003, the average age at death from all causes in Arizona was 71.2 for all Arizonans compared with 54.7 for Native Americans, more than a 16 year difference.







21















In April 2003, ADHS published a Report of the Arizona Native American Primary Care Resources Workshop/Forum Series, which was a summary of







22















work conducted during the summer of 2002 regarding the primary care resource needs of the Native American population in Arizona. Some of the key recommendations from that report are: � Support and expand data sharing agreements and encourage collaboration among data holders to prevent fragmentation and improve data validity � Encourage and support inter-tribal partnerships and collaboration















The Arizona Chronic Disease Plan















rising costs of health care. If current trends continue, by 2011, we can expect to be spending over 2.8 trillion dollars nationally on health care. With a public health focus that emphasizes prevention as a priority, we can become a healthier society and enjoy five to seven additional years of healthy life if we improve access to quality health care, emphasize healthy lifestyles, and focus on reaching the greatest number of people at the lowest cost through effective policies and strategies.24 Chronic disease is not an inevitable result of the aging process. In many cases, chronic disease is the result of preventable, behavioral practices that, over time, significantly increase an individual's risk for any one of a number of chronic diseases. Evidence indicates that individuals will take control of their behavior and their health when presented with







24















� "In 2000, the total cost of obesity in the United States was estimated to be $117 billion, of which $61 billion was for direct medical costs and $56 billion was for indirect costs."







26















� "Each year, over $33 billion in medical costs and $9 billion in lost productivity due to heart disease, cancer, stroke, and diabetes are attributed to diet."







26















Estimated cost of physical inactivity.







� Blue Cross Blue Shield of Minnesota did a study calculating the dollars required to treat the results of inactivity for its members. "Using a `cost of illness' approach to medical expenses for particular diseases, the study found that heart disease was the most expensive result of a sedentary lifestyle, costing $35.3 million in 2000. In that year, nearly 12% of depression and anxiety and 31% of colon cancer, heart disease, osteoporosis and stroke cases were due to physical inactivity. This translates to $83.6 million, or $56 per member." 27 � "In 2000, health care costs associated with















education and support.25 While it is difficult to predict the cost of Arizona's not taking action, there is ample national and state-specific evidence regarding the cost and impact of the primary risk factors for chronic disease (i.e., poor dietary habits, physical inactivity, and use of commercial tobacco products).















physical inactivity were more than $76 billion." 26















Estimated cost of commercial tobacco use.







� "Direct medical expenditures attributed to smoking total more than $75 billion per year. In addition, smoking costs an estimated $80 billion per year in lost productivity."







28















Estimated cost of poor dietary habits.







� "Among children and adolescents, annual hospital costs related to obesity were $127 million during 1997�1999 ...up from $35 million during 1979�1981."







26















� "About 14% of all Medicaid expenditures are for smoking-related illnesses." 7 � "Even if current tobacco use stopped, the residual burden of use among past users would cause disease for decades to come."







29















IV







The Plan







By making healthier choices, individuals can reduce their risk for chronic disease. CDC estimates that with as little as a 10% weight loss, an overweight person can reduce their lifetime medical costs by as much as $2,200 � $5,300, and if 10% of adults would begin a walking program, $5.6 billion dollars in heart disease costs could be saved. 26 Additionally, smokers who stop smoking reduce the potential medical costs associated with cardiovascular disease by approximately $47 the first year and $853 during the following seven years.16 Each categorical plan presents a statewide guideline for reducing the impact of chronic disease in Arizona from a disease-specific and/or risk factor perspective and will continue to function in that capacity. The goal of the AzCD Plan is to enhance the impact of these categorical plans by identifying common, cross-cutting objectives and strategies. The intent in identifying these overlapping areas is to maximize the effectiveness of implementing cross-cutting strategies to achieve a synergistic effect. In other words, by working together, the effectiveness of each plan is enhanced and the overall results are potentially greater than what each plan is able to accomplish individually. The elements of systems coordination, collaboration, and integ ration are critical to the success of this new approach to chronic disease management and prevention. The overall planning process for the AzCD Plan was unique in that it did not follow the typical strategic planning format of needs assessment, inter nal/exter nal review, SWOT analysis, establishment of goals and objectives. These aspects of a typical planning process were accomplished in the development of the individual categorical plans. The goal of the AzCD Plan was to effectively merge the many elements of the categorical plans into a coordinated, cohesive, and integrated model of the proposed system of care for the prevention and management of chronic disease in Arizona.







25















How This Plan is Different







This plan is different from many other planning documents. The scope of the plan is very broad, encompassing several distinct disease categories: hear t disease, cancer, lung disease (COPD), stroke, and diabetes, and the risk factor categories of poor nutrition, physical inactivity, and use of commercial tobacco products. Each of the disease-specific entities has developed a comprehensive and integ rated planning document that outlines evidenced-based objectives and strategies particular to the disease category. The risk factor categories of poor nutrition, physical inactivity, and commercial tobacco use have likewise developed planning documents that identify the key strategies for improving healthy lifestyle behaviors and reducing risk for chronic disease. The categorical plans were developed by bringing together appropriate agency and community partners, utilizing best practice standards and guidelines, and conducting assessment of state and community needs.















The Arizona Chronic Disease Plan















In the development of the AzCD Plan, a number of matrices were used to visually represent those commonalities across the categorical plans. Common areas were identified in service delivery methodologies, risk factors, target populations, common messages, and intervention sites. (See Appendix A.) These matrices were also useful in identifying contradicting areas and/or gaps in strategies. An important aspect of this analysis was to ensure that the common messages were consistent and that overlapping strategies were not in conflict. We recognize that the AzCD Plan does not include all chronic diseases. However, it does address the current four leading causes of mortality: hear t disease, cancer, lung disease, and stroke, and diabetes and asthma, which are among the most common and costly chronic diseases. Diabetes, in







26















advances in science and technology, and changes in the needs of the population. This plan represents ADHS' effor ts to approach chronic disease from a more comprehensive and integrated perspective. It is an innovative approach that is reflected in national public health programs. The plan is an initial phase in the Department's long-term commitment to reducing the impact of chronic disease in Arizona. It is meant to be a guide for encouraging collaboration among state agencies and community stakeholders in working together to combat the most common disease-related causes of mortality and morbidity in Arizona.















Purpose of the Plan







Create a paradigm shift. The AzCD Plan shifts







the focus of chronic disease management and control from the more traditional disease-specific emphasis to a more comprehensive and integrated risk factor approach. It reflects a paradigm shift in how we think about chronic disease and what methodologies are used in reducing the overall impact of these diseases in our society.















addition to being a disease category, is also a signif icant risk factor for cardiovascular disease. In addition to the disease-specific categories mentioned above, the plan also includes the primary risk factors of commercial tobacco use, poor nutrition, and physical inactivity that impact the above disease categories and many other chronic diseases. Promoting a healthy lifestyle that includes good nutrition, physical activity and no commercial tobacco use will also positively impact many chronic diseases not specifically addressed in the plan. It is anticipated that additional disease categories will be added to the AzCD Plan over time and that priorities will be revised to reflect current trends,















Provide direction. The plan provides a clear







direction for addressing the issues of chronic disease prevention and early detection in Arizona. Key cross-cutting strategies will be identified in the primar y risk factor areas and in the disease-specific priority areas.















IV







The Plan







27















28















IV







The Plan







Set funding priorities. The plan identifies







initial funding priorities, specifically for the Proposition 303 Tobacco Tax chronic disease fund. The plan provides direction for the allocation of these funds over the next three-year period. Per Arizona Revised Statutes, these funds are to be used "for the prevention and early detection of the four leading disease-related causes of death in this state, as periodically determined by the Centers for Disease Control and Prevention, or its successor agency. Initially, these are cancer, heart disease, stroke and pulmonar y disease." (Statutory reference � Appendix B.) 3. Lung Disease Plan for the State of Arizona 4. Diabetes Prevention and Control Program Plan 5. Arizona Nutrition and Physical Activity Plan 6. Tobacco Education and Prevention Program Plan Each prog ram has developed a plan using widely accepted national standards and evidenced-based strategies. The categorical plans were developed using a variety of methodologies and formats due to many factors such as availability of resources and timeframes, and requirements of specific g rants and funding streams. A conscious decision The objectives and strategies in the AzCD Plan was made not to require any specific structure or are not meant to be mandates, but rather a guide to for mat in the development of the individual plans, assist communities and organizations in implementing strategies locally. Examples of cur rent projects and community initiatives are described. Suggestions and opportunities are provided for communities and organizations to become involved in systems change at the local level to the extent that is feasible based on their current resources. Communities are encouraged to select but rather allow the workgroups and subcommittees to develop the individual plans based on identified needs.







29















small projects or segments of larger projects to implement.















Description of Categorical Plans







There are six programs plans involved in the development of the AzCD Plan: 1. Arizona Cardiovascular Disease Prevention Plan 2. The Arizona Comprehensive Cancer Control Plan















Ensure ongoing assessment and evaluation.







The plan provides a consistent vehicle for ongoing assessment of chronic disease programs and a system for evaluating the effectiveness of strategies designed to reduce the burden of chronic disease. It includes a plan for periodic review that consists of evaluation and revision of established priorities, timeframes, and strategies.















How to Use This Document















Arizona Cardiovascular Disease Prevention Plan. The goal of the Arizona Cardiovascular







Disease (CVD) Prevention Plan is to create an















The Arizona Chronic Disease Plan















integrated and comprehensive state action plan to increase the cardiovascular health of all Arizonans and decrease the burden of heart disease and cerebrovascular disease. The CVD Prevention Plan will establish a community partnership in order to share existing data and ideas. Through this par tnership it will be possible to assess the status of CVD in Arizona in relation to health education, health status and policy. The plan focuses on secondar y prevention for those individuals who have been diagnosed with some form of CVD. The prevention and education strategies are aimed at decreasing the risk of a second CVD event such as a stroke or a heart attack. It also focuses on reducing the disability associated with CVD. The emphasis of the CVD Prevention Plan is secondar y prevention. Categories for the







30















coordinated approach to reduce the incidence, morbidity, and mortality of cancer through prevention, early detection, treatment, rehabilitation, and palliation."







29















CCC is a process















achieved through a partnership of public and private stakeholders who hold the common mission of reducing the overall burden of cancer. ADHS, in conjunction with partners, has developed a statewide comprehensive cancer control plan. Par tners include: American Cancer Society, the University of Arizona's Arizona Cancer Center and College of Public Health, Arizona Health Care Cost Containment System, American College of Surgeons, Arizona Oncology Nursing Society, Phoenix Indian Medical Center, Translational Genomics Research Institute (TGen), and many more organizations.















secondar y prevention objectives and strategies are primarily intervention targets and/or sites such as: individual interventions, community, education, health care system (hospitals, providers, first responders), work site, policy and environmental changes, health marketing, disparities, and s u r ve i l l a n c e .















Chronic Lung Disease Plan for the State of Arizona. The Chronic Lung Disease Plan for







the State of Arizona has two components: a plan addressing chronic obstructive pulmonary disease (COPD) and a plan addressing asthma. The overall goals of the COPD Plan are to reduce the propor tion of adults in Arizona whose activity is limited due to chronic lung disease and reduce deaths from COPD among Arizona adults. The primary goals for the Asthma Plan are to reduce asthma deaths in Arizona, asthma-related hospitalizations and emergency department visits,















Arizona Comprehensive Cancer Control Plan. The goal of the Arizona Comprehensive







Cancer Control (CCC) Plan is to reduce the overall burden of cancer through the prevention, early detection, and effective treatment of cancer, and improving the quality of life of those living with cancer through a statewide system of care. According to the CDC, CCC is "an integrated and















IV







The Plan







and the number of asthma-related missed school and workdays. ADHS initiated the development of these plans with the intent of setting priorities by formulating objectives and suggesting strategies to address chronic obstructive pulmonary disease and asthma as serious public health issues in Arizona. The Chronic Lung Disease Plan for the State of Arizona (both COPD and Asthma) used a combination of disease specific and system inter vention strategies. The COPD categories for the objectives and strategies included: epidemiology and research, treatment and management, consumer education and quality of life, prevention, disparity, collaborative efforts, advocacy, and public awareness. Asthma incor porated most of the above categories as well, except that prevention was changed to secondary prevention and school childcare issues was added to the list of objectives. prevention, the most recent standards of care and best practices, health systems improvements through on-site chart audits, staff training and evaluation, and training of community health workers in diabetes self-management skills. The population they serve is culturally diverse and usually lacks access to care. The plan targets at-risk populations, persons living with diabetes, and their families. The Diabetes Prevention and Control Program Plan components include: identifying and reducing health disparities in the Hispanic and Native American populations, establishing linkages to promote wellness and physical activity, as well as measurement procedures to track program success, reducing the number of new cases and end-stage renal disease related to diabetes, and decreasing the number of persons with diabetes that receive lower extremity amputations. The Diabetes Prevention and Control Program Plan used the Ten Essential Public Health Services as the framework for developing strategies. There were three subcommittees who worked on developing the strategies: Surveillance, Education, and Advocacy. Each of the strategies were then linked to the appropriate Essential Public Health Ser vice.







31















Diabetes Prevention and Control Program Plan. The goal of the Diabetes Prevention and







Control Program Plan is to reduce the burden of diabetes in the state of Arizona. Much of this burden can be prevented with early detection, improved delivery of care, and better education on diabetes self-management. The program is committed to providing communities statewide with technical assistance and support resources to address the quality of life for people living with diabetes. The Diabetes Program provides continuing education to health care professionals and lay health workers on primary and secondary















Arizona Nutrition and Physical Activity Plan. The goals of the Arizona Nutrition and







Physical Activity (NUPA) Plan are to reduce the burden of chronic disease and obesity in Arizona















The Arizona Chronic Disease Plan















through nutrition and physical activity efforts. The pur pose of the plan is to provide guidelines for schools, health care providers, communities, and work sites to address overweight and obesity in Arizona. It also represents an opportunity to develop policies and modify our environments in ways that will ultimately help Arizona residents lead healthier lives. The plan provides Arizona with a wide range of public health opportunities with objectives and strategies for action. The development of this plan demonstrates that working together to address the burden of chronic disease and obesity are the first steps towards combating this problem in Arizona. The Arizona Nutrition and Physical Activity Plan, developed by the NUPA Program, used inter vention sites as the focus for their workgroups.







32















promoting quitting among young people and adults, specif ically those identified who have high prevalence of commercial tobacco use; eliminating nonsmokers' exposure to environmental tobacco smoke; identifying and eliminating the disparities related to commercial tobacco use and its effects among different population groups.29 The core elements of the plan, as found in most comprehensive tobacco control programs, include preventing the initiation of tobacco use among youth and young adults, promoting smoking cessation, and reducing exposure to secondhand s m o ke . The TEPP Plan was developed primarily as an inter nal operational plan. Objectives and strategies focused on intervention sites and/or types of inter vention necessary to reduce the burden of commercial tobacco use, i.e., community programs, chronic disease programs, health care, school, enforcement, statewide programs, countermarketing, cessation programs, surveillance and evaluation, and administration and management. Although the plan was developed primarily by inter nal staff, an external advisory committee provided input and feedback in the development of the objectives and strategies.















Originally there were seven workgroups consisting of Family and Community, Schools, Physical Environment, Health Care, Special Needs and Work Site. In the final version of the plan, health care was incorporated into the family and community section and the special needs objectives, strategies, and action steps were incorporated into all of the above sections of the plan.















Tobacco Education and Prevention Program Plan. The goal of the Tobacco







Education and Prevention Program (TEPP) Plan is to reduce disease, disability, and death related to tobacco use by: preventing the initiation of commercial tobacco use among young people;















IV







The Plan







33















V







Integration















Integration







Healthy Lifestyles "Tobacco use is the single most preventable cause of death and disease in our society." 30 The role of tobacco prevention and cessation programs is critical in the management of chronic disease. BMI can also be calculated by multiplying weight The burden of overweight and (in pounds) by 705, then dividing by height (in obesity manifests itself in inches) twice." "premature death and disability, Healthy weight for adults is defined as:







33















in health care costs, in lost productivity, and in social stigmatization." 31 If allowed to continue, overweight and obesity may cause as much disease and death as tobacco use.32 This AzCD Plan supports the promotion of healthy lifestyles as primary prevention strategies in combating the key risk factors for chronic disease, i.e., poor nutrition, physical inactivity, and use of commercial tobacco products. A healthy lifestyle includes: maintaining healthy weight, following healthy eating guidelines, engaging in regular physical activity, and no use of commercial tobacco products.















BMI >18.5 < 24.9. � BMI standard for "overweight" is defined as BMI > 25.0 � 29.9. � BMI standard for "obese" is defined as a BMI  30.0. 14















35















Healthy weight for children is defined as a BMI







for age from the 5th percentile to the 85th percentile. � "Underweight" is defined as BMI-for-age < 5th percentile. � "At risk/overweight" is BMI for age between the 85th � 95th percentile. � "Obese" is defined as BMI-for-age > 95th percentile. 34















Healthy weight. Body Mass Index (BMI) is used







to determine whether or not a person is overweight. It is calculated by "dividing a person's weight (in kilograms) by his or her height (in meters, squared).















Healthy eating. Healthy eating is defined as







(complete definition in Appendix C.): � Making smart choices from every food group















The Arizona Chronic Disease Plan















� Finding your balance between food and physical activity � Getting the most nutrition out of your calories. A healthy eating plan is one that: � Emphasizes fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products � Includes lean meats, poultry, fish, beans, eggs, and nuts � Is low in saturated fats, transfats, cholesterol, salt (sodium), and added sugars � Promotes indigenous foods grown as close to the consumer as possible.















� Catalyst for change � Cross-cutting strategies, integrated approach � Reach/impact; return on investment � Evidenced-based, standards, guidelines � Resources: financial, human resources, community assets, stakeholder engagement. The matrix in Appendix D lists all of the priorities submitted by the categorical plans. These priorities were later re-configured within the context of the framework established by the CD Team as described on the following page.















Physical activity. Physical activity is defined as: 35







� 30 to 60 minutes of moderate activity most days of the week for the average adult � 60 minutes of moderate to vigorous activity most days of the week for children.







36















Priorities







Once the priorities were identified from the categorical plans, they were placed under the appropriate intervention level of the framework (Individual choice, Health care provider responsibility, Systems support) and divided into integrated and disease-specif ic priorities. Some of the diseasespecif ic priorities appear in more than one intervention level as appropriate. The designation of integrated and disease-specif ic perspectives acknowledges both the common areas of overlap as well as the unique aspects of each disease category.















Tobacco-free.







� Do not use commercial tobacco products of any kind. � If you use commercial tobacco products, stop as soon as possible.















Priorities for Chronic Disease Prevention







Selection of priorities. In the selection of







priorities for the AzCD Plan, the categorical plans were asked to identify 5�10 priorities. Criteria for establishing plan priorities included: � Ability to make a difference � Needs, gaps, health disparities � Feasibility Community action







S















I. Individual Priorities







(Consumer Education)







A. Promote healthy lifestyles as primary prevention for chronic disease. Integrated:







� Saturate communities with consistent, culturally sensitive and intergenerational messages regarding healthy lifestyles















tate action















� Systems change, provides sustainability � Measurable, outcome driven















V







Integration















Framework







The CD Team reviewed the selected priorities from the categorical plans. The integrated priorities for the plan were identified as the common overlapping areas from the categorical plans in three functional areas:















1. Individual choice (consumer education) 2. Health care provider responsibility (provider education and training) 3. System support















System Support







� Capacity building � Technical assistance � Data / Surveillance � Policy / Environmental change � Resources / Workforce � Access to care















37















Individual Choices







� Make healthy choices � Be aware � benefits of screening & early detection � Take responsibility for requesting screening services















Education Training















Provider Responsibility







� Knowledge re: screening protocols & guidelines � Order tests according to accepted guidelines � Make referrals and/or follow accepted treatment standards















The Arizona Chronic Disease Plan















The AzCD Plan Envisions... AN INDIVIDUAL WHO...







� Eats a healthy diet � Maintains a healthy weight � Engages in regular physical activity � Abstains from or quits using commercial tobacco products of any kind � Participates in chronic disease early detection and screening � Actively requests referral for appropriate screening procedures from health care provider � Complies with recommended treatment and follow-up to screening procedures � Takes responsibility for partnering with the health care provider in making decisions about personal health screening, diagnosis, treatment, and follow-up.















A HEALTH CARE PROVIDER WHO...







� Counsels patients regarding healthy lifestyle behaviors � Orders appropriate screening tests based on standards of care for chronic disease







38















� Utilizes current advances in screening technology and screening protocols � Provides information on all appropriate options for treatment and/or follow-up for patient consideration � Makes appropriate arrangements for treatment and/or follow-up � Monitors patient compliance with recommended treatment and/or follow-up.















A SUPPORTIVE SYSTEM THAT...







� Creates a process for collecting accurate and timely data for surveillance and evaluation purposes � Promotes policy and environmental changes to support individual healthy lifestyle choices and provider involvement in the prevention and early detection of chronic disease � Provides technical assistance to facilitate "capacity building" and sustainability in local communities � Provides access to affordable, quality health care for all residents � Promotes collaboration of advocacy groups for resolution of common cross-cutting issues � Strives to eliminate disparities in mortality and morbidity due to chronic disease.















V







Integration







Disease-Specific:







Cardiovascular � Increase the number of those diagnosed with heart and cerebrovascular disease who participate in cardiac rehabilitation and other formal, multidisciplinary approaches to secondary prevention of the heart and cerebrovascular disease Cancer � Reduce the risks for developing cancer among all Arizonans by promoting and engaging in healthy behaviors Lung � Promote healthy living practices that provide the most effective method of preventing COPD (tobacco abstinence, periodic health checks, and avoidance of unhealthy work environments) Lung � Improve self-management knowledge and behavior in people with COPD, their families and other caregivers � Promote, increase, and optimize the appropriate utilization of high-quality cancer screening and follow-up services Cancer � Increase the proportion of women aged 40 and over who have received a mammogram and clinical breast exam within the past year to 70% by 2010 Cancer � For adults aged 50 and over, increase the proportion of the population who has been screened for colorectal cancer using colonoscopy, sigmoidoscopy, or fecal occult blood test to 50% by 2010 Lung � Improve early detection and diagnosis of COPD







39















Cardiovascular � Increase the number of people who are aware and can recognize the signs and symptoms of a heart attack or myocardial infarction Cardiovascular � Increase the number of women who are aware of the symptoms of a heart attack, which are very different from the signs of a heart attack for men Cancer















B. Inform, educate, and empower consumers regarding benefits of early detection and the availability of screening resources. Integrated:







� Implement health marketing campaigns regarding the benefits of and options for early detection of chronic disease � Develop and implement a health marketing campaign to encourage consumers to become actively involved as partners with their health care provider in initiating referrals for screening services















C. Link people to needed personal health services by developing and disseminating a comprehensive list of resources regarding screening, early detection and treatment services. Integrated:







� Develop database of screening/early detection resources















Disease-Specific:







Cardiovascular � Increase the number of people who are aware and can recognize the signs and symptoms of a stroke and know the next step that needs to be taken















The Arizona Chronic Disease Plan















� Provide multi-media access for screening/early detection resource database















Cancer � For adults aged 50 and over, increase the proportion of the population who have been screened for colorectal cancer using colonoscopy, sigmoidoscopy, or fecal occult blood test to 50% by 2010 Lungs � Improve early detection and diagnosis of COPD















Disease-Specific:







Cancer � By 2008, increase access to quality information and patient navigation sites across the state and identify barriers to access Cancer � Educate the public regarding the importance and relevance of participating in clinical trials Lung � Improve self-management knowledge and behavior in people with COPD, their families and other caregivers















B. Assure competent public and personal health care by educating providers regarding benefits of screening and screening benchmarks. Integrated:







� Train physicians on appropriate screening and referral protocols for chronic disease















II. Health Care Provider Priorities







(Provider Training)







A. Promote screening for chronic disease according to established guidelines.







40















� Encourage public health systems to develop effective health communication and education strategies for providers � Increase number of health care systems that incorporate basic skills intervention trainings as professional development for staff and service providers � Increase provider education and training offered to medical students regarding disparities















Integrated:







� Develop and disseminate adult early, periodic, screening, diagnosis, and treatment guidelines for chronic disease















Disease-Specific:







Cancer � Promote, increase, and optimize the appropriate utilization of high-quality cancer screening and follow-up services Cancer � Increase the proportion of women aged 40 and over who have received a mammogram and clinical breast exam within the past year to 70% by 2010 Cancer � Increase the proportion of women aged 40 and over who have received a mammogram and clinical breast exam within the past year to 70% by 2010















Disease-Specific:







Cancer � Promote, increase, and optimize the appropriate utilization of high-quality cancer screening and follow-up services















V







Integration







41















42















V







Integration







Cancer � For adults aged 50 and over, increase the proportion of the population who has been screened for colorectal cancer using colonoscopy, sigmoidoscopy, or fecal occult blood test to 50% by 2010 Lung � Improve early detection and diagnosis of COPD Lung � Increase awareness of the medical community, public health officials and the general public that COPD is a serious public health problem in Arizona Cancer � Promote, increase, and optimize the appropriate utilization of high-quality cancer screening and follow-up services Lung � Educate health care providers to manage patients with COPD to increase longevity and quality of life and reduce exacerbation of the disease Lung � Promote better care for patients with COPD in Arizona according to established guidelines















C. Educate providers regarding appropriate referrals based on screening outcomes. Integrated:







� Train physicians on appropriate referral protocols for chronic disease















III. System Support Priorities







A. Improve data and surveillance systems. Integrated:







� Expand existing data collection to include more specif ic ethnicity, socioeconomic, geographic, and linguistic information � Ensure adequate resources to develop and maintain surveillance data systems







43















Disease-Specific:







Cardiovascular � Increase the number of people that are being referred to the appropriate professionals to receive medical nutrition therapy and a formal exercise prescription to treat high cholesterol and high blood pressure Cardiovascular � Increase the number of those diagnosed with heart and cerebrovascular disease who participate in cardiac rehabilitation and other formal, multidisciplinary approaches to secondary prevention of the heart and cerebrovascular disease Cancer � Educate the public regarding the importance and relevance of participating in clinical trials















Disease-Specific:







Cardiovascular � Increase the number of hospitals participating in the American Heart Association's program "Get With The Guidelines" Cancer � Create database inventory or clearinghouse for cancer researchers in the state Lung � Establish a surveillance system to accurately track the mortality and morbidity of COPD in Arizona and also measure the impact on the economy of the state















The Arizona Chronic Disease Plan















B. Develop policies and environmental changes to support community and individual health efforts. Integrated:







� Work with policymakers to encourage screening and diagnostic services as benefits in existing health plans � Partner with governmental regulatory agencies to manage environmental and occupational risk factors















C. Support plans and actions that support the development of community infrastructure. Integrated:







� Encourage planners, developers, and policymakers to design healthy communities � Work with architect and engineer educators regarding the inclusion of healthy environmental design in curriculum � Provide technical assistance to communities in terms of capacity building � Create multiple mechanisms for community health care agencies to exchange information to solidify a universal message/program















Disease-Specific:







Cardiovascular � Implement protocols whereby a paramedic/EMT unit may bypass a hospital in order to transport a stroke victim to a primary stroke center, thereby increasing their chance for survival Cancer � Increase access to appropriate and effective cancer diagnosis and treatment services







44















D. Promote access to quality personal and population-based health services. Integrated:







� Promote access to and provide economic support for convenient health care, prevention, and early detection services















Cancer � Increase support for health care providers and payers in directing those affected by cancer to quality of life services Lung � Advocate and support policies to reduce the prevalence of commercial tobacco use and secondhand smoke exposure among Arizonans Lung � Support research into COPD etiology and clinical management, as well as health care policies and outcomes particularly as the activities relate to state issues







I I















mprove access to screening services for the















four leading causes of death: heart disease, cancer, lung disease (COPD), and stroke







P















rovide financial support for screening















services (four leading causes of death) ncrease access to telemedicine sites around















Arizona � Improve provider accessibility and availability � Set measurable clinical standards based on scientif ically valid guidelines















Disease-Specific:







Cardiovascular � Increase the number of hospitals participating in the American Heart Associations program "Get With The Guidelines"















V







Integration







Cardiovascular � Increase the number of primary stroke centers in AZ from six to 15 Cardiovascular � Increase the number of automated external def ibrillators in the public, beginning where people congregate in large numbers and where EMS availability may be delayed Cardiovascular � Increase the number of people that are being referred to the appropriate professionals to receive medical nutrition therapy and a formal exercise prescription to treat high cholesterol and high blood pressure Cancer � Increase access to appropriate and effective cancer diagnosis and treatment services Cancer � Increase the proportion of women aged 40 and over who have received a mammogram and clinical breast exam within the past year to 70% by 2010 Cancer � For adults aged 50 and over, increase the proportion of the population who has been screened for colorectal cancer using colonoscopy, sigmoidoscopy, or fecal occult blood test to 50% by 2010 Cancer � Educate the public regarding the importance and relevance of participating in clinical trials Cancer � Increase access to the comprehensive management of acute, chronic, and delayed effects of cancer and its treatments Cancer � Increase support for health care providers and payers in directing those affected by cancer to quality of life services Cancer � Promote participation in cancer clinical trials in Arizona, specifically among underserved populations Lung � Increase awareness of the medical community, public health officials and the general public that COPD is a serious public health problem in Arizona Lung � Improve access to pulmonary rehab programs for Arizonans with COPD to prevent premature morbidity and mortality







45















Cancer � By 2007, utilize telemedicine to increase access to state of the art diagnosis and treatment techniques and expertise as well as second opinions and resources















E. Mobilize community partnerships and promote collaboration of advocacy groups. Integrated:







� Encourage advocates for chronic disease entities to work together � Create multiple mechanisms for community health care agencies to exchange information to solidify a universal message/program















Disease-Specific:







Cardiovascular � Support a capacity building conference, promoting collaboration among existing agencies in order to disseminate information about current and developing screening methods and tools by 2010















The Arizona Chronic Disease Plan















F.















Monitor health status to identify and strive to reduce disparities. Integrated:







� Ensure that all Arizonans receive quality screening, diagnostic, and treatment services















These funds give Arizona a unique opportunity to design a funding stream which not only supports the prevention and early detection of the four leading causes of death, but does it in an innovative manner which simultaneously promotes the integration of resources where commonalities exist and disease specif ic initiatives where they are most needed. The unique aspects of this funding allows the TRUST to design a system to reduce the impact of chronic disease and, as such, is a major strength of this funding source. Example A, below, shows a more traditional model where funding streams have tended to be very targeted, which has limited the ability to















Disease-Specific:







Cancer � Reduce cancer disparities among Arizonans Cancer � By Fall 2005, create a health disparities work group that will research and identify current barriers to care as well as draft strategies to reduce inequalities in cancer care















Funding Priorities







One of the motivating reasons for developing the AzCD Plan was to provide direction and set funding priorities for the Proposition 303 Tobacco Tax funds.







46















integrate program efforts. Example B, also below, demonstrates an integrated model for customizing a system of care to address multiple priorities through combined funding streams.















EXAMPLE















A















Community Resources Traditional Model Targeted Resources















EXAMPLE















B















Community Resources Integrated Model Transcends Targeted Resources















Tobacco Tax $$















Procured Resources Foundations/ Grants















ac ob T















c o Ta x $$















Community's Own Grant's Foundation State Federal $$















Community's Own Resources















State & Federal $$$















V







Integration







47















Implementing an Integrated Approach







For the purposes of this plan, an integrated approach to the management of chronic disease requires, at a minimum, addressing one integration priority in each of the three areas (Individual, Health Care Provider, and System) across at least two or more disease/risk factor related categories. This can be accomplished by initiating two or more new categorical areas simultaneously or by adding a new categorical area to existing services or resources. In other words... 1) Program chooses one or more integration priorities in each of the three areas: � Individual � Health Care Provider � System







48















intervention modalities to more than one disease/risk factor specific categorical area. It combines the integrated perspective with the targeted approach to achieve a more comprehensive and coordinated model. As pictured on the next page, to implement an integrated model, programs would select one integration priority from each outer circle and link those to two or more of the inner circle disease and/or risk factor specific categories.















State Level Action







ADHS has many health care initiatives currently in operation including: programs involving border health, children with special health care needs, minority health and disparities, medically underserved areas, tobacco education and prevention, chronic disease, older adults, linkages with local health departments, and primary care. For a list of related ADHS programs and services, see Appendix E.















2) For each of the integration priorities, the program must cut across two or more categorical areas, i.e., disease/risk factor related.















Community Level Action







There are also a number of communities who have developed model integrated systems for promoting the















Add a new categorical interest area to existing services / resources OR Promote two or more new categorical areas simultaneously















"healthy community" concept. The following are examples of some of those programs:















Steps to a Healthier Arizona







The Steps to a Healthier US five-year cooperative agreement program funds states, cities, and tribal entities to implement chronic disease prevention efforts focused on reducing the burden of diabetes, overweight, obesity, and asthma and addressing three















This approach is based on addressing chronic related risk factors: physical inactivity, poor nutrition, disease issues from multiple levels of integration and commercial tobacco use. interventions including the individual, the provider, and f inally the system of care, and linking those















V







Integration















Integration Wheel







Line up selected disease, risk factor and strategy for each level of intervention (individual, provider, system) with the arrow. Use the resulting framework to develop an operational plan with specific action steps, timelines and responsible individuals.















49















The Arizona Chronic Disease Plan















50















V







Integration







There are several border communities in Arizona � Cochise County, Santa Cruz County, Yuma County, and the Tohono O'odham Nation � participating in this model of reducing chronic disease disparities. Special action groups in each community, consisting of providers, families, community organizations, and schools, form partnerships to address chronic disease issues in their communities. For more information on the Steps program, see http://www.healthierus.gov of input. An evaluation survey form will be included in the document. Users of the plan will be asked to complete the form and submit their comments and feedback regarding the priorities, strategies, and integrated model proposed in the plan.















Quarterly meetings of the CD Team. The CD







Team will meet at a minimum on a quarterly basis to: � Present updates on the status of the implementation of the categorical plans � Document new integrated community initiatives � Track data from categorical plans � Provide ongoing CD Team assessment and feedback of the AzCD Plan















Healthy Avondale







Healthy Avondale is based on the statewide Healthy Arizona 2010 initiative. The Healthy Avondale program has been in existence since October 2003 and is a partnership with ADHS, local businesses, schools, health care providers, community and faith-based organizations, and others. The program promotes participation in four primary areas: healthy lifestyle choices, healthy eating, physical activity, and early detection and screening. The intent of the program is to involve the entire community and build a place where all residents can live a healthier life. For more information on the Healthy Avondale program, see http://www.avondale.org















Contract performance measures and deliverables. Contracts issued under the Proposition







303 funding will be monitored to track outcomes, performance measures and deliverables.







51















State level integration initiatives. New







integrated chronic disease organizational initiatives within ADHS will be documented.















Summary







This plan represents ADHS' ongoing commitment to reducing the mortality and morbidity of chronic disease through collaboration among all stakeholders. It is hoped that the AzCD Plan will encourage the development of partnerships among state agencies, policy and decision makers, communities, organizations, health care providers, and consumers to promote a comprehensive and integrated approach to improving the health of all Arizonans.















Evaluation







Ongoing assessment and revision of the AzCD Plan







Over the next three years, the AzCD Plan will be monitored on an ongoing basis through various methods with revisions made as needed. Outlined below are some of the assessment strategies that will be implemented.















Annual review. There will be a review of the







AzCD Plan on an annual basis based on several sources















The Arizona Chronic Disease Plan















VI







Appendix A















Appendix A:







Sample Matrices







PROGRAM CATEGORY







HEART







STROKE CANCER LUNG DIABETES NUTRITION/ PHYSICAL ACTIVITY TOBACCO















SCREENING & DETECTION SECONDARY PREVENTION DIAGNOSIS & TREATMENT MASS MEDIA / HEALTH MARKETING POLICY / ENVIRONMENTAL CHANGE















X















X X X X X X X X X X















X X X X X X X X X X X















X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X















X X X X X X X X X X X X X X X







53















X







X X X X X X X X















SERVICE DELIVERY















ADVOCACY HEALTH EDUCATION (CONSUMER) PROVIDER EDUCATION INFRASTRUCTURE / DATA SURVEILLANCE ACCESS TO CARE RESEARCH FINANCIAL / INSURANCE ISSUES QUALITY OF CARE COLLABORATION FUNDING / GRANTS TOBACCO CONTROL CULTURAL COMPETENCY / SENSITIVITY















X X X X















X X X X















X X X X















PROGRAM CATEGORY INTERVENTION SITES







HEART STROKE CANCER LUNG DIABETES NUTRITION/ PHYSICAL ACTIVITY TOBACCO















SCHOOLS WORK SITES COMMUNITY & FAMILY HEALTH CARE SYSTEM















X X X X X X X X X X















X X X X X X















X X X X















X X X X















The Arizona Chronic Disease Plan















P R O G R A M CATEGORY







HEART STROKE CANCER















PREVENTION & EARLY DETECTION















� Cholesterol screening � BP screening � Work site health screenings















� Cholesterol screening � BP screening � Work site health screenings�Stroke Check















� Sun protection � Colon cancer screening � Breast cancer screening � Cervical cancer screening � Prostate cancer screening















� 5 A Day















� 5 A Day � AZ Nutrition Network � BMI















� 5 A Day � Fiber � Kilocalories � Low-fat















NUTRITION















� AZ Nutrition Network � BMI















MESSAGES















� P.L.A.Y.















� P.L.A.Y. � W.E.L.L. � Work site programs � Physical education in schools � Moderate activity: 30 � 60 minute/day 5 days per week















54















PHYSICAL ACTIVITY















� W.E.L.L. � Work site programs � Physical education in schools















ALCOHOL















� Abstain or moderate intake















� Smoking cessation















� Smoking cessation � Smoke-free environments















TOBACCO















� Smoke-free environments















� Smoking prevention, cessation, & secondhand smoke � "Quit line" for AZ















VI







Appendix A







P R O G R A M CATEGORY







LUNG DIABETES NUTRITION / PHYSICAL ACTIVITY TOBACCO















� ABCs of Diabetes � Periodic health checks � Avoid unhealthy work environments � Decrease: Hb-A-1C level BP Cholesterol � Foot exams � Eye exams















� Culturally sensitive & intergenerational media messages re: preventive screening, healthy weight & physical activity















� Healthy eating; healthy lifestyles � Achieve & maintain healthy weight � Encourage work site breast-feeding policy � BMI � 5 A Day � Portion Control � BMI















� P.L.A.Y.















� Physical activity; healthy lifestyles















55















� Abstain















� "Go Cold Turkey" � Cessation for Diabetics � "Inhale Life"; "Be Tobacco Free" � Tobacco abstinence � Reduce / abstain � Native American "Breathe Tradition, Respect Tobacco" � Spanish language� "Respire Vive" � African & Asian � "Ashes to Ashes � be tobacco free"















The Arizona Chronic Disease Plan















A N A LY S I S OF CATEGORICAL PLAN OBJECTIVES (sample)







CARDIOVASCULAR CANCER LUNG (COPD)















� Increase numbers of Arizonans who know their cholesterol numbers � Increase numbers of Arizonans who know their BP numbers � Increase numbers of physicians who follow guidelines for cholesterol screening & treatment















� Routine oral cancer screening � Skin self exams � Increase numbers of Arizonans who use effective sun protection � Promote use of American Cancer Society guidelines � Develop consistent screening guidelines for colon cancer � Consistent standards for all populations � Screening tool for lung cancer � Increase to 70% women 40 yrs+ who had breast exam & mammogram within past year � Prostate cancer screening for high-risk groups � Adults 50+, increase colorectal screening to 50% � Women 18yrs+, increase pap test to 95% � Total body screening for skin cancer















� Reduce exposure to environmental and occupational risk factors � Improve early detection & diagnosis of COPD � Promote healthy living practices � Reduce exposure to environmental & occupational risk factors � Develop practical & feasible list of indicators for spirometry � Encourage PCPs to perform office spirometry for all patients who report smoking or have symptoms of COPD � Develop consensus for severity assessment criteria















A N A LY S I S OF OBJECTIVES (sample)















PREVENTION & EARLY DETECTION















� Increase numbers of physicians who follow guidelines for BP screening & treatment � Increase numbers of physicians & EMTs who follow triage guidelines for stroke � Follow "Barbershop Hypertension Screening Program" re: identifying hypertension in African Americans















56















VI







Appendix A







A N A LY S I S OF CATEGORICAL PLAN OBJECTIVES (sample)







DIABETES NUTRITION / PHYSICAL ACTIVITY TOBACCO















� The Diabetes Prevention and Control Program is mandated to lead diabetes-related secondary and tertiary prevention















� Saturate communities with culturally sensitive & intergenerational messages re: preventive screening, healthy weight & physical activity � Streamline and focus obesity prevention efforts in AZ















� Fund early detection screenings of COPD, � Increase number of health care professionals who provide intervention messages and encourage cessation to clients � Promote Public Health Cessation Standards through health care provider trainings















57















The Arizona Chronic Disease Plan















58















Courtesy of Heard Museum















VI







Appendix B















Appendix B:







Arizona Revised Statutes Title 36 Public Health and Safety Chapter 6 Public Health Control A r t i c l e 8 To b a c c o Ta x F u n d s







36-770. Tobacco products tax fund







(Caution: 1998 Prop. 105 applies) A. The tobacco products tax fund is established consisting of revenues deposited in the fund pursuant to section 42-3251.01 and interest earned on those monies. The Arizona health care cost containment system administration shall administer the fund. B. Forty-two cents of each dollar in the fund shall be deposited in the proposition 204 protection account established by section 36-778. C. Five cents of each dollar in the fund shall be deposited in the health research fund established by section 36-275. D. Twenty-seven cents of each dollar in the fund shall be deposited in the medically needy account established by section 36-774. E. Twenty cents of each dollar in the fund shall be deposited in the emergency health services account established by section 36-776. F. Four cents of each dollar in the fund shall be deposited in the health care adjustment account established by section 36-777. G. Two cents of each dollar in the fund shall be deposited in the health education account established by section 36-772. H. Except as provided in section 36-776, monies in the fund: 1. Are continuously appropriated. 2. Do not revert to the state general fund. D. Monies in the fund and its accounts: 1. Do not revert to the state general fund under any circumstances. 2. Are exempt from the provisions of section 35-190 relating to lapsing of appropriations. E. Monies in the fund: 1. Shall be spent only for purposes that are authorized by this article. 3. Are exempt from the provisions of section 35-190 relating to lapsing of appropriations.















36-771. Tobacco tax and health care fund







A. The tobacco tax and health care fund is established. The fund consists of all revenues deposited in the fund pursuant to sections 42-3252 and 42-3302 and interest earned on those monies. On notice from the department, the state treasurer shall invest and divest monies in the fund and in all accounts in the fund as provided by section 35-313, and monies earned from investment shall be credited to the fund. B. The fund shall be deposited in four separate accounts and shall be administered pursuant to the provisions of and for the purposes prescribed by this article. C. Except as provided by subsection F of this section, the fund and its accounts are not subject to appropriation. Expenditures from each account are not subject to additional approval, notwithstanding any statutory provision to the contrary.







59















The Arizona Chronic Disease Plan















2. Shall not be used for expenditures on capital construction projects, lobbying activities involving elected officials or political campaigns for individuals or any ballot proposal. F. Notwithstanding any other provision of this section, the legislature may appropriate monies from the fund to the department of revenue for the reasonable administration and enforcement costs of the department in administering the levy of taxes that are dedicated to the fund pursuant to section 42-3252. The appropriation shall be applied before monies are deposited in the fund accounts. Any unused monies at the end of the fiscal year revert to the fund.















(a) Contracts with county health departments, qualifying community health centers as defined in section 36-2907.06, Indian tribes, accredited schools, nonprofit organizations, community colleges and universities for education programs related to preventing and reducing tobacco use. (b) Administrative expenditures related to implementing and operating a program developed pursuant to subdivision (a) to award and oversee contracts for education programs including obtaining expert services to assist in evaluating requests for proposals and responses to those requests. (c) Department of health services expenditures for















36-772. Health education account; audit; reports







(Caution: 1998 Prop. 105 applies) A. In addition to the monies deposited pursuant to section 36-770, twenty-three cents of each dollar in the tobacco tax and health care fund shall be deposited in







60















developing and delivering education programs that are designed to prevent or reduce tobacco use including radio, television or print media costs. When contracting for the development and production of original advertising materials, the department shall require advertising, production and editorial firms to use their best efforts to employ or contract with residents of this state to manage, produce and edit the original advertising. The department shall report annually by December 1 to the governor, the president of the senate and the speaker of the house of representatives regarding instances when the department did not employ or contract with residents of this state, including the reasons for failing to do so. (d) The evaluations required by subsection F of this section. D. The department of health services shall use monies deposited in the account pursuant to section 36-770 for the prevention and early detection of the four leading disease related causes of death in this state, as periodically determined by the centers for disease control and prevention, or its successor agency. Initially, these are cancer, heart disease, stroke and pulmonary disease. The monies shall only be used to supplement monies that are appropriated by the















the health education account for programs for the prevention and reduction of tobacco use, through public health education programs, including community based education, cessation, evaluation and other programs to discourage tobacco use among the general population as well as minors and culturally diverse populations. B. The department of health services shall administer the account. C. Except as provided in subsection D of this section, monies that are deposited in the health education account: 1. Shall be used to supplement monies that are appropriated by the legislature for health education purposes and shall not be used to supplant those appropriated monies. 2. Shall be spent for the following purposes:















VI







Appendix B







legislature and shall not be used to supplant those appropriated monies. E. Monies from the health education account shall not be spent for lobbying activities involving elected off icials or political campaigns for individuals or any ballot measure. F. The department of health services shall evaluate the programs established pursuant to subsection C, paragraph 2 of this section and shall biennially submit a written report of its findings to the governor, the president of the senate and the speaker of the house of representatives. The department of health services shall provide a copy of each report to the secretary of state and the director of the Arizona state library, archives and public records. The department of health services shall submit its first report on or before November 15, 2004. The first report shall include data beginning in f iscal year 2001-2002 needy account to provide health care services to persons who are determined to be eligible for services pursuant to section 36-2901.01 or 36-2901.04 as provided by the Arizona health care cost containment system pursuant to chapter 29, article 1 of this title or any expansion of that program or any substantially equivalent or expanded successor program established by the legislature providing health care services to persons who cannot afford those services and for whom there would otherwise be no coverage. These services shall include preventive care and the treatment of catastrophic illness or injury, as provided by the Arizona health care cost containment system. B. The Arizona health care cost containment system administration or any successor shall administer the account. C. Monies that are deposited in the medically needy account: 1. Shall only be used to supplement monies that are















36-773. Health research account







A. Five cents of each dollar in the tobacco tax and health care fund shall be deposited in the health research account for research on preventing and treating tobacco-related disease and addiction. B. The Arizona disease control research commission shall administer the account. C. Monies that are deposited in the health research account shall only be used to supplement monies that are appropriated by the legislature for health research purposes and shall not be used to supplant those appropriated monies.















appropriated by the legislature for the purpose of providing levels of service that are established pursuant to chapter 29, article 1 of this title to eligible persons as defined in section 36-2901 or any expansion of those levels of service, or for any successor program established by the legislature providing levels of service that are substantially equivalent to, or expanding, those provided pursuant to chapter 29, article 1 of this title to eligible persons. 2. Shall not be used to supplant monies that are appropriated by the legislature for the purpose of providing levels of service established pursuant to chapter 29, article 1 of this title.







61















36-774. Medically needy account; definition







A. Seventy cents of each dollar in the tobacco tax and health care fund shall be deposited in the medically















D. For purposes of this section, "levels of service" means the provider payment methodology, eligibility criteria and covered services established pursuant to chapter 29, article 1 of this title in effect on July 1, 1993.















The Arizona Chronic Disease Plan















36-775. Adjustment account







A. Two cents of each dollar in the tobacco tax and health care fund shall be deposited in the adjustment account for transfer of appropriate amounts to the corrections fund established by section 41-1641 to compensate for decreases in the corrections fund resulting from lower tobacco tax revenues available under section 42-3104 as a result of the levy of luxury taxes that are dedicated to the tobacco tax and health care fund pursuant to section 42-3252. Any monies in the adjustment account in excess of the amount needed for the adjustment revert to the tobacco tax and health care fund for distribution in equal proportions to the accounts described under sections 36-772, 36-773 and 36-774. B. The department of revenue shall administer the adjustment account.















770. The department of revenue shall administer the account. B. The department of revenue shall transfer appropriate amounts of account monies to the health education account established by section 36-772, the health research account established by section 36-773 and the medically needy account established by section 36-774 to compensate for decreases in these accounts due to lower tobacco tax revenues available under section 36771 as a result of the levy of luxury taxes that are dedicated to the tobacco products tax fund pursuant to section 42-3251.01. C. Any monies in the account in excess of the amount needed for the adjustments prescribed in this section revert to the tobacco products tax fund for distribution in equal amounts to the accounts described in section 36-770, subsections B, C, D and E.















36-776. Emergency health services account







62















36-778. Proposition 204 protection account







(Caution: 1998 Prop. 105 applies) A. The proposition 204 protection account is established consisting of monies deposited pursuant to section 36-770. The Arizona health care cost containment system administration shall administer the account. B. The administration shall use account monies to implement and fund programs and services required as a result of the expanded definition of an eligible person prescribed in section 36-2901.01. C. The administration shall spend the balance of monies in the account before it spends monies from the Arizona tobacco litigation settlement fund established by section 36-2901.02.















(Caution: 1998 Prop. 105 applies) A. The emergency health services account is established consisting of monies deposited pursuant to section 36-770. The Arizona health care cost containment system administration shall administer the account. The administration shall use account monies solely for the reimbursement of uncompensated care, primary care services and trauma center readiness costs. B. Monies in the account are subject to legislative appropriation. Any monies remaining unexpended and unencumbered on June 30 of each year in the account revert to the proposition 204 protection account established by section 36-778.















36-777. Health care adjustment account







(Caution: 1998 Prop. 105 applies) A. The health care adjustment account is established consisting of monies deposited pursuant to section 36-















VI







Appendix B







63















64















VI







Appendix C















Appendix C:







Arizona Department of Health Services Healthy Eating Guidelines







The purpose of these guidelines is to ensure uniform healthy eating messages are utilized in programs, services, and materials provided by the Arizona Department of Health Services. Healthy eating messages and materials should: � Be based on the U.S. Dietary Guidelines, 6th edition, and U.S. Food Guide. � Be tailored to meet the specific nutrient needs of target populations such as children and adolescents, pregnant women, breastfeeding women, and older adults. Please refer to the Arizona Department of Health Services, Office of Chronic Disease Prevention and Nutrition Services, Nutrition Standards for guidance. � Recommend exclusive breastfeeding for all infants unless a specific contraindication exists. � Reflect a 2,000 calorie per day reference intake for sample menus, examples, and recipes unless the materials are specifically for a target population with differing needs (such as teen age or the older adult). � Utilize terminology consistent with the Food Facts Label and the U.S. Dietary Guidelines. � Include foods, recipes, and cooking methods that reflect the culture of the target audience. � Promote indigenous foods grown as close to consumers as possible. � Meet recommended intakes within energy needs by adopting a balanced eating pattern, such as the USDA Food Guide or the DASH Eating Plan. � Be developed utilizing social marketing approaches, including with formative research of the target audience. When formative research for a specific audience cannot be conducted, messages should be selected from nationally developed campaigns including: Healthy Lifestyles from the U.S. Department of Health and Human Services; 5 A Day from the National Cancer Institute; Eat Smart, Play Hard from the U.S. Department of Agriculture; Verb from the Centers for Disease Control and Prevention; Milk Matters from the U.S. Department of Agriculture; and Small Steps, Big Rewards from the National Diabetes Education Program. Programs, services, and materials for the general public should reflect the following key recommendations.















65















Adequate Nutrients Within Calorie Needs







Key Recommendations: � Consume a variety of nutrient-dense foods and beverages within and among the basic food groups while choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol.















The Arizona Chronic Disease Plan















Weight Management







Key Recommendations: � To maintain body weight in a healthy range, balance calories from foods and beverages with calories expended. � To prevent gradual weight gain over time, make small decreases in food and beverage calories and increase physical activity.















Fats







Key Recommendations: � Consume less than 10% of calories from saturated fatty acids and less than 300 mg/day of cholesterol, and keep trans fatty acid consumption as low as possible. � Keep total fat intake between 20 to 35% of calories, with most fats coming from sources of polyunsaturated and monounsaturated fatty acids,















Food Groups to Encourage







Key Recommendations: � Consume a sufficient amount of fruits and vegetables while staying within energy needs. Two cups of fruit and 2 1/2 cups of vegetables per day are recommended for a reference 2,000 calorie intake, with higher or lower amounts depending on the calorie level.







66















such as fish, nuts, and vegetable oils. � When selecting and preparing meat, poultry, dry beans, and milk or milk products, make choices that are lean, low-fat, or fat-free. � Limit intake of fats and oils high in saturated and/or trans fatty acids, and choose products low in such fats and oils.















� Choose a variety of fruits and vegetables each day. In particular, select from all five vegetable subgroups (dark green, orange, legumes, starchy vegetables, and other vegetables) several times a week. � Consume 3 or more ounce-equivalents of wholegrain products per day, with the rest of the recommended grains coming from enriched or whole-grain products. In general, at least half the grains should come from whole grains.















Carbohydrates







Key Recommendations: � Choose fiber-rich fruits, vegetables, and whole grains often. � Choose and prepare foods and beverages with little added sugars or caloric sweeteners, such as amounts suggested by the USDA Food Guide and the DASH Eating Plan. � Reduce the incidence of dental caries by practicing















� Consume 3 cups per day of fat-free or low-fat milk or equivalent milk products. � All women capable of becoming pregnant should consume 400 micrograms of synthetic folic acid daily, from fortified foods or supplements, or a combination of the two, in addition to folate in foods from a varied diet.















good oral hygiene and consuming sugar- and starchcontaining foods and beverages less frequently.















VI







Appendix C















Sodium and Potassium







Key Recommendations: � Consume less than 2,300 mg (approximately 1 tsp of salt) of sodium per day. � Choose and prepare foods with little salt. At the same time, consume potassium-rich foods, such as fruits and vegetables.















C















hill (refrigerate) perishable food promptly and















defrost foods properly.







A















void raw (unpasteurized) milk or any products















made from unpasteurized milk, raw or partially cooked eggs or foods containing raw eggs, raw or undercooked meat and poultry, unpasteurized juices, and raw sprouts.















Alcoholic Beverages







Key Recommendations: � Those who choose to drink alcoholic beverages should do so sensibly and in moderation--defined as the consumption of up to one drink per day for women and up to two drinks per day for men. � Alcoholic beverages should not be consumed by some individuals, including those who cannot restrict their alcohol intake, women of childbearing age who may become pregnant, pregnant and lactating women, children and adolescents, individuals taking medications that can interact with alcohol, and those with specific medical conditions. � Alcoholic beverages should be avoided by individuals engaging in activities that require attention, skill, or coordination, such as driving or operating machinery.















Messages and materials for consumers should include these key points:







� Make smart choices from every food group. � Find your balance between food and physical activity. � Get the most nutrition out of your calories. A healthy eating plan is one that: � Emphasizes fruits, vegetables, whole grains, and fatfree or low-fat milk and milk products. � Includes lean meats, poultry, fish, beans, eggs, and nuts. � Is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars. Some general recommendations include:







67















Focus on fruits. Eat a variety of fruits. Choose fresh,















Food Safety







Key Recommendations: � To avoid microbial food borne illness:







C















frozen, canned, or dried fruit. Go easy on fruit juice.















Vary your vegetables. Eat more dark green







vegetables like broccoli, spinach, and other dark leafy greens. Eat more orange vegetables like carrots, sweet potatoes, and winter squash. Eat more dry beans and peas, such as pinto beans, kidney beans, and lentils.















lean hands, food contact surfaces, and fruits and















vegetables.







S















eparate raw, cooked, and ready-to-eat foods















while shopping, preparing, or storing foods.







C















ook foods to a safe temperature to kill















microorganisms.















The Arizona Chronic Disease Plan















Make half your grains whole. Eat at least 3 ounces







of whole-grain cereals, breads, crackers, rice, or pasta every day. One ounce is about 1 slice of bread, 1 cup of breakfast cereal, or 1/2 cup of cooked rice or pasta. Look to see that grains such as wheat, rice, oats, or corn are referred to as "whole" in the list of ingredients.















f irst few ingredients. Some names for added sugars (caloric sweeteners) include sucrose, glucose, high fructose corn syrup, corn syrup, maple syrup, and fructose.















Know your fats. Look for foods low in saturated fats,







trans fats, and cholesterol to help reduce the risk of heart disease (5% DV or less is low, 20% DV or more is high). Most of the fats you eat should be polyunsaturated and monounsaturated fats. Keep total fat intake between 20% to 35% of calories.















Go lean with protein. Choose lean meats and







poultry. Bake it, broil it, or grill it. Vary your protein choices with more fish, beans, peas, nuts, and seeds.















Get your calcium-rich foods. Get 3 cups of low-fat







or fat-free milk--or an equivalent amount of low-fat yogurt and/or low-fat cheese (1 1/2 ounces of cheese equals 1 cup of milk)--every day. If you don't or can't consume milk, choose lactose-free milk products and/or calcium-fortified foods and beverages.















Reduce sodium (salt), increase potassium.







Research shows that eating less than 2,300 mg of sodium (about 1 tsp of salt) per day may reduce the risk of high blood pressure. Most of the sodium people eat comes from processed foods, not from the salt shaker. Also look for foods high in potassium, which counteracts some of sodium's effects on blood pressure.















Check servings and calories. Look at the serving







size and how many servings you are actually







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Play it safe with food. Know how to prepare, handle,







and store food safely to keep you and your family safe: � Clean hands, food-contact surfaces, fruits, and vegetables. � Separate raw, cooked, and ready-to-eat foods while shopping, preparing, or storing. � Cook meat, poultry, and fish to safe internal temperatures to kill microorganisms. � Chill perishable foods promptly and thaw foods properly.















consuming. If you double the servings you eat, you double the calories and nutrients, including the % Daily Values (DV).















Make your calories count. Look at the calories on







the label and compare them with what nutrients you are also getting to decide whether the food is worth eating. When one serving of a single food item has over 400 calories per serving, it is high in calories.















Don't sugarcoat it. Since sugars contribute calories







with few, if any, nutrients, look for foods and beverages low in added sugars. Water would be a good substitute for sugar-containing beverages. Read the ingredient list and make sure that added sugars are not one of the















About alcohol. If you choose to drink alcohol, do so







in moderation. Moderate drinking means up to 1 drink a day for women and up to 2 drinks for men. Remember that alcoholic beverages have calories but are low in nutritional value.















VI







Appendix C Description of DASH Diet







Two major studies have shown that blood pressure can be lowered by following a particular eating plan, the Dietary Approaches to Stop Hypertension (DASH) Diet Eating Plan, and reducing the sodium in one's diet. The eating plan alone lowers blood pressure, but the combination of the eating plan and reduced sodium intake gives the biggest benefits and may help prevent the development of high blood pressure.







1, 2















A reference page to the DASH Eating Plan at 1,600-, 2,000-, 2,600-, and 3,100- Calorie Levels is also part of the 6th edition of the Dietary Guidelines available at www.health.gov/dietaryguidelines/dga2005/document/h tml/appendixA.htm. 1. Appel LJ, Moore TJ, Obarzanek E, Vollmer WM, Svetkey LP, Sacks FM, et al. A clinical trial of the effects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med. 1997; 336:1117-1124. 2. Vollmer WM, Sacks FM, Ard J, Appel LJ, Bray GA Simons-Morton, DG, Conlin PR, Svetkey LP, Erlinger TP, Moore TJ and Karanja N. Effects of Diet and Sodium Intake on Blood Pressure: Subgroup Analysis of the DASH-Sodium Trial. DASH Collaborative Research Group. Ann Intern Med. 2001; 135:10191028.















The DASH Diet Eating Plan emphasizes fruits, vegetables and low-fat dairy products. It is moderate in total fat and low in saturated fat and cholesterol. It includes whole grains, poultry, beans, fish and nuts. The following publication includes a week's worth of sample menus, recipes for heart healthy dishes and a summary of the findings from the "Dietary Approaches to Stop Hypertension" clinical study. It has a form to track food habits before starting the plan and a chart to help with meal planning and grocery shopping. Facts About the DASH Eating Plan, 24 pages, NIH Publication No. 03-4082 is available online and single orders are free. See www.nhlbi.nih.gov/health/public/heart/hbp/dash or NHLBI Health Information Center P.O. Box 30105 Bethesda, MD 20824-0105 Phone: 301-629-3255















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The Arizona Chronic Disease Plan















Appendix D:







To p P r i o r i t i e s F r o m C a t e g o r i c a l P l a n s







T O P PRIORITIES FROM CATEGORICAL PLANS







CARDIOVASCULAR PREVENTION







� Increase the number of hospitals participating in the American Heart Association program "Get With The Guidelines."















CANCER







� To reduce the risks for developing cancer among all Arizonans by promoting and engaging in healthy behaviors.















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EARLY DETECTION















� Increase the number of people who are aware and can recognize the signs and symptoms of a stroke and know the next step that needs to be taken. � Increase the number of people who are aware and can recognize the signs and symptoms of a heart attack or myocardial infarction. � Increase the number of women who are aware of the symptoms of a heart attack, which are very different from the signs of a heart attack for men.















� To promote, increase, and optimize the appropriate utilization of high-quality cancer screening & followup services � Increase the proportion of women aged 40 and over who have received a mammogram and clinical breast exam within the past year to 70% by 2010 � For adults aged 50 and over, increase the proportion of the population who has been screened for colorectal cancer using colonoscopy, sigmoidoscopy, or fecal occult blood test to 50% by 2010















VI







Appendix D















T O P PRIORITIES FROM CATEGORICAL PLANS







LUNG (COPD)







� Increase awareness of the medical community, public health officials and the general public that COPD is a