A-4 - Questions Following Morning SessionMeeting Overview and Charge to Participants – Day 1
(activity done in small groups at tables)

Red Team: How do we move forward in this tight budget period of funding?

Green Team: Considering the fact that among the current topic areas, some areas may be left out – specifically HIV and other infectious diseases – how do those fit into this current strategy for moving forward?

Black Team: What are we doing least effectively with respect to partnerships and collaborative efforts, across the various agencies?

Blue Team: What is the most common barrier or constraint related to policy for collaboration and how do we overcome it?

Brown Team: Considering that there are three areas that sustainability needs to consider, not just the interagency work that has been going on, but also the programs that have been in place and the outcomes that have been accomplished, where do you put the focus?

Purple Team: How did you negotiate partnerships outside of your authority without budgets and identifiable policies?

Lime Team: What is the available funding for follow-up projects that we identify here, and what does Dr. Ruffin see has their role in moving the work of this meeting forward?

Mauve Team: What are the indicators of sustainability?

Teal Team: What are the barriers that may exist and how can we better facilitate transfer of funds across or between departments?

Yellow Team: When do you graduate good or successful programs into the next level of competition, looking at both qualitative and quantitative measures as you do that? When do you move them forward?

Orange Team: How can we target our collaborations to the practice agencies or the institutions within agencies that translate the science into policy and practice at the community level (i.e. those institutions that actually have community investments now)?

A-5 - Questions and Answers Following Dr. David Chambers' Presentation

Orange Team

Q: When will the findings from the RFA to states be available?

A: Currently, they have summaries from a meeting where they discussed lessons learned. They are 3-year studies, and they should have final results in about 1 year or so. In the meantime, they are encouraging them to make notes about what they are finding as they go along.

Yellow team

Q: What is team science?

A: Team science is all about going beyond research to the people who will be impacted by the research, including providers, patients, communities, etc.

Q: Can you give an example of an organization that has a successful standard dissemination component, and what does it do?

A: Kaiser and other managed care organizations can provide a potential model for successfully integrating research into standard operating procedures, by designating staff members who have that as their primary responsibility. They have established teams and methods for implementation and they encourage the continuous quality improvement and skill development.

Teal Team

Q: Is there a best practice or strategy for dissemination that should be kept in mind as they consider priorities for research questions?

A: The range of best practices is moving more towards action and activity as opposed to a more passive approach. Think about a more strategic way to get the dialogue out there instead of paper or website that stands alone. The notion is to attempt to engage the people who will be impacted at the beginning of the process, encouraging more involvement at every level of the system instead of developing the research in a vacuum.

Mauve team

Q: Are Indian tribes eligible for the Program Announcement with Review (PAR) dissemination grants?

A: Yes.

An observation: When there are conversations about collaboration, there are drastically different ways of looking at clinical research versus social science research.

A: They are attempting to convene an ongoing forum across HHS agencies to encourage more input about collaboration. Sometimes you get very narrow approaches, depending on who is at the table, and everyone was strongly encouraged to contribute their ideas and concerns.

Lime Team

Q: What vehicles are in place assure that you get the advanced experiences of communities, even if that evidence has not been written up in journals?

A: We are looking at ways to build capacity to capture data and store it and this will help to know what things are working and what things may be improved.

Purple Team

No questions.

Brown team

Q: Before dissemination occurs, you have to agree on research. So, what do you do if you cannot agree about the type of research?

A: One logical starting point for dealing with this challenge is to look at the missions of the different agencies or partners involved. Consider the key questions and relevant outcomes that each partner is focusing on and realize that this question must be asked first because otherwise the assumption is that you already know what they are looking for.

Black Team

Q: When attempting to put the information shared into the context of basic science research versus the science of improvement, where does the paradigm for research that you are describing fit into that context?

A: Although it is certainly true that there are key differences in each approach, and funding is often still allocated by different stages of research, they would like to see some of those begin to break down. The question now is whether the advantage of having a very well-controlled study outweighs the disadvantage of results that are potentially unrealistic in terms of intervention. They would like to see more intervention development and testing within the settings where people will ultimately get care, with the populations who represent those who need care.

Blue Team

Q: What are your thoughts about the department's move toward plain language?

A: It is a good notion to make sure that we can connect what they are disseminating with the people who can benefit from it. The positive aspect is that it orients people to think about connecting with their audience, but the danger is that people may assume that the message has been adequately delivered because their program won a “plain language” award or simply because the message carries that label.

Green Team

Comment: It is good to see the sociology of science in action.

Q: How do you motivate people who are teaching in universities that you not funding to adopt these principles?

A: This is a great question, and one with which several agencies are struggling. One consideration is through licensure and another is to incentive training programs that have the broader picture of evidence-based practice.

Red Team

Comment: Your presentation was excellent. Although your focus was on providers in the clinical practice setting, everything said is also true for community settings, such as evidence-based school interventions that might need dissemination and implementation.

A: This is a great point. In an attempt to streamline the presentation, certain aspects are emphasized, but we definitely want to consider that healthcare is only one component. Service settings are certainly much broader.

Comment: And, it is not only about care, but also prevention and public health approaches.

A: This is absolutely true.

A-6 - Questions and Answers Following Dr. Rochelle Rollins

Comment: One person who was one of the 400 contributors to the PRG program mentioned that one of the 14 recommendations was trans-sectoral leadership around health disparities. She remarked that although it was not one of the original six that were selected to be addressed, this is one of the recommendations that feeds directly into this work and could perhaps be pulled up as a point of reference and motivation for this initiative. She suggested that perhaps it could be put into the preamble.

A: I concur and after I had the committee going for approximately one year, I asked whether I was still limited to the original six recommendations, and was told that perhaps the focus could now be expanded to include others of the 14 recommendations. I will share the document with the group.

Follow-up Q: Wasn't there a council of lay people that were convened on the issue of health disparities?

A: I am unfamiliar with any such group and that if no one in the room is aware of such a council that is a clear indication that a handoff was not handled well.

Q: Thank you for the presentation; it was very helpful and inspiring. Why were diabetes, heart disease and emerging diseases not included as part of the council?

A: Although there has not been a subcommittee on it, that does not mean there were not specific activities regarding those topic areas. Everyone is encouraged to ask their agency representative about the topic that they are interested to find out how the council has or has not addressed that topic.

Q: Will the funding for the activities determined here be coming from the HHS Disparities Council or will there be discussions about how to lobby monies for activities?

A: The funding will come from several places, if we do this correctly. We can engage the HHS Disparities Council, and also look for opportunities to add something new or change something in what is already being planned within our agencies (for example, Healthy People 2010 and 2020). Although no one agency is going to provide all the funding necessary, if we can keep the momentum going, potentially there can be some funding from several sources for these activities.

Q: Is it a challenge to work with outside groups to support your goals and activities?

A: Although I have not worked with all agencies, her experience has been positive with regard to working with other agencies. You get “brownie points” for thinking “outside of the box.” There are several strong partnerships that we may not know about yet, and working outside HHS has and will continue to be a good thing in the future.

A-7 - Questions and Answers Following the NIOSH

Q: What have you learned about ensuring sustainability in collaborative initiatives? Are there strategies that you have used that this group should take into consideration?

A: Dr. Baron: Sustainability comes as a result of commitment support at the highest level of organizations, including setting it as a priority and affording the time and resources to work on the initiative.

Q: In addition to the website link, can you comment on other efforts in NORA to disseminate findings from your studies and how NORA studies have changed the face of some industries as far as how they protect workers?

A: Dr. Fleming: On the website, in addition to the compendium, there are other reports on NORA over time, so there are opportunities to see accomplishments there. Also, all grants are on CRISP (computer retrieval information scientific projects). The success stories include latex gloves in terms of the use of those gloves in hospital and other settings; NIOSH and others worked to come up with an alternative to address the latex allergen problem. There are many examples like that. But, the NORA process was not designed in the late 90s to measure the outcomes. We are engaged in that process now, after the fact, and the information is harder to come by because of that. The emphasis has been on doing the research in the areas of interest and reporting those findings in the usual ways (e.g., literature, symposia).

Q: Could perhaps a case study of lessons learned from NORA be published?

A: Dr. Fleming: There have been a number of efforts made to try to capture that information; we do have information on awards made under the announcements in the RFAs. Regarding the documentation of lessons learned, “the proof's in the pudding.” The fact that the program is continuing now testifies to the fact that their success is ongoing. In terms of continuity, the use of RFAs and PAs has been especially important because it shows everyone that there is a long-term commitment to whatever initiative is to be started.

B-1 - Mental Health Care Breakout Session
Text from Power Point Slides

Breakout I: Recommended Priority

During the first breakout session, participants reviewed a starter list of research questions for the topic area. The goal of this breakout session was to determine priority research questions and ideas for the topic area that would then be developed further during the meeting.

Starter List - Likes: Workgroups were asked to review the starter list of research questions and discuss what they liked about the list.

• Not just one target area
• Effort to document the health impact
• What access questions
• Bullets 4, 5, 6
• Prevalence data
• Lifespan, various levels of intervention
• Comprehensiveness of questions
• Integrating primary care and mental healthcare
• Actually design community interventions
• Reducing barriers (question 3)
• How do you intervene early?
• Inter-related?

Starter List – Concerns: Workgroups were asked to review the starter list of research questions and discuss what they did not like about the list.

• Prevalence data
• Question priorities
• System barriers
• Economic
• Geography
• Setting (access)
• Stigma- cultural acceptance within community
• Global mental health
• Rural prisons
• Infrastructure; capacity
• Question #1 wording
• Effective, efficient community based
• Missing “return on investment”
• Duplication of services - efficient use of resources
• Integration: government to government
• Role of substance abuse disorders (missing-doc)
• Disparities in mental health
• No specification of youths vs. adults
• Move towards the health of mental health rather than the illness- strengths rather than deficits- resilience

Starter List – Additions: Workgroups were asked to review the starter list of research questions and brainstorm additional research questions and ideas for the list.

• What are the social and economic costs of and/or contributors to mental health?
• Question #1: change mental “illness” to “health”
• How do we increase capacity and provide continuity (translate) of care?
• What is the role of mental health institutions in public health?
• What is the effectiveness of the de-institutionalization?
• What are the public health and workforce development needs?
• What is working?

Breakout II: Starter Research Description

During this breakout session, workgroups were asked to discuss and draft a starter research description based on the research questions they felt were most important in their area of focus. The exercise went through several components that would make up a draft research description. This was a brainstorming and discussion session.

Background of the problem: Workgroups were asked to provide background information or references to data and other documents hat may provide helpful information for the background portion of the research description.

• Substance abuse (SA), mental health (MH) co-occurring (World Health Organization data)
• Previous data / Literature on mental health SA (costs, incidence, prevalence, long-term burden of disability for MH)
• More monies are spent on other settings than MH settings
• Co-occurrence of SA and MH Treatment across systems, populations
• MH disorders disguised by self-medication, violence, behavior problems, etc.
• Lifespan issues in multiple settings: Populations with MH and SA disorders in juvenile settings, homeless shelters, prisons, jails
• Multi-generational
• Mental health problems in primary care treatment as a medical problem
• Mental health problems in patient care– typically treated as a medical problem
• We do not train professionals for multi-disciplinary interventions and appropriate referrals; systems are not set up for this either
• Disparate populations have limited access to effective MH and SA Treatment Interventions and training at various levels
• There are effective interventions and systems in place and they should be identified and translated– they should be expanded and enhanced

Purpose of Initiative: Workgroups were asked to describe the purpose of the research.

• Identify innovative approaches that build on existing knowledge to improve outcomes for individuals with MH and SA disorders to eliminate disparities
• Identify and/or develop systems and capacity for implementation and translation to eliminate disparities
• Require new kinds of collaborations
• Adapt existing/Develop innovative methods for implementation and translation
• Identify sustainable approaches

Programmatic Areas of Interest: Workgroups discussed which programmatic areas might benefit most from the proposed research.

• Career development training initiatives
• Better integration of MH and SA in multiple sectors or systems
• Primary care, schools
• Rural, frontier, remote, military and incarcerated populations
• Indian Tribes and Organizations
• Emergency or disaster response
• Standardized MH and SA outreach
• Uses of new media (World Wide Web/social networks)
• Documentation and dissemination of practice-based evidence models
• Maximize the fit between evidence-based practices and specific populations and systems
• Use of research findings to develop personalized care plans

Potential Starter Objectives: Workgroups drafted potential objectives, based on the purpose of the research and the key research questions and areas of focus identified.

• Improve how professionals/providers are equipped to handle mental health / resilience issues
• General workforce and career development through development and training
• Build knowledge around practice-based evidence
• Identify and develop strategies to build capacity and generate research to understand and develop research capacity in Tribal Communities
• Encourage development & evaluation of Tribal based research / grass-root approaches
• Evaluate the impact of policies (e.g., de-institutionalization) on mental health and substance abuse care
• Develop strategies that increase representation of diverse populations in the behavioral health research enterprise, both as researchers and participants in the research studies

• Identify and develop effective strategies for reducing barriers to mental health care for populations who traditionally do not seek treatment and for engaging and motivating these populations to seek care
• Identify or develop and evaluate strategies to remove the impact of stigma as a major barrier to accessing behavioral health care in diverse communities
• Identify the impact of stress and trauma including determinants of neurological basis of MH and SA in disparate populations
• Develop innovative approaches for measuring the social and economic costs of MH and SA in disparate populations

Potential Eligible Applicants: Workgroups identified potential eligible applicants for potential future initiatives and funding opportunity announcements.

• Non-Profit
• For Profit
• Tribal Organizations
• Professional Associations
• Require collaborations: engage target audience for the research; representatives of the different systems

Breakout III: Implementation and Funding Possibilities

During this breakout session, workgroups continued discussion of the draft research description in terms of collaboration and implementation.

Potential Collaborating Organizations: Workgroups identified organizations that may be potential collaborator for the research identified.

• Health and Human Services
• Centers for Disease Control and Prevention, Centers for Medicaid and Medicare Services, Health Resources and Services Administration, Indian Health Service, National Institutes of Health, Office of Minority Health, Substance Abuse and Mental Health Services Administration, etc.
• Department of Justice
• Office of Justice Programs, National Institute of Corrections
• Department of Labor
• Department of Education
• Housing and Urban Development
• Department of Defense
• Department of the Interior
• Homeland Security
• Professional Organizations
• American Medical Association, etc.
• Foundations
• Insurers
• Employee Unions
• Service Employees International
• Veterans Administration

Potential Type of funding Mechanism Suitable for Initiative, including Existing Funding Opportunity Announcements (FOAs): Workgroups identified potential funding mechanisms that may be used to support the research identified.

• Memorandum of Understanding (MOU)
• Interagency Agreements (IAA) [flexible, rigid]
• Parallel Announcements
• Veterans Administration Medical Dollars
• Grants
• Cooperative Agreements

B-2 - Obesity Breakout Session
Text from Power Point Slides

Breakout I: Recommended Priority

During the first breakout session, participants reviewed a starter list of research questions for the topic area. The goal of this breakout session was to determine priority research questions and ideas for the topic area that would then be developed further during the meeting.

Recommended Priority Research Questions

What are individual, societal, and environmental determinants of unhealthful and healthful diet and physical activity behaviors that lead to differential rates of obesity?

And what are cost-effective sustainable approaches to address these factors that will decrease obesity in disadvantaged groups?

Group members decided to beak themselves up into two groups.

Breakout II: Starter Research Description (Group 1)

During this breakout session, workgroups were asked to discuss and draft a starter research description based on the research questions they felt were most important in their area of focus. The exercise went through several components that would make up a draft research description. This was a brainstorming and discussion session.

Background of the problem: Workgroups were asked to provide background information or references to data and other documents hat may provide helpful information for the background portion of the research description.

• Obesity epidemic in America (2/3 adults overweight/obese, overweight increasing in children/youth), higher in minorities
• Obesity leads to chronic diseases, especially in vulnerable populations
• Obesity-related chronic disease results in
• High morbidity and mortality
• Reduced quality of life
• Increased healthcare costs
• Paucity of interventions proven effective, especially in underserved populations
• Need to test tailored and community-based interventions in groups with disparities
• Need to test interventions based on social-ecological model (multi-level)
• Need a community-based participatory research approach with both high internal validity and generalizability (external validity)

Purpose of Initiative: Workgroups were asked to describe the purpose of the research.

• Identify effective intervention approaches to reduce obesity in vulnerable and underserved population groups by addressing determinants of unhealthful diet and physical activity behaviors.
  • Approaches should be potentially cost-effective, disseminatible, adoptable, sustainable, and tailored to populations experiencing disproportionate burden of preventable diseases related to obesity.

Examples of Research

• School Health (children)
• Food policy
• Physical Education classes
• After-school programs
• Address geographic areas with high minorities
• Broader translation of effective programs
• Young adults
• Transition life phases
• Worksite setting
• University setting
• Community research
• Group counseling and referral to healthcare in urban underserved subpopulations
• Lay workers promoting/counseling for diet and physical activity in Latino population
• Diet and physical activity behavior-change self-management in African-Americans
• Multi-level interventions in diverse communities
• Relationship of obesity reduction to disease burden in minority population groups

Programmatic Areas of Interest: Workgroups discussed which programmatic areas might benefit most from the proposed research.

• Lifestyle; nutrition, physical activity
• Behavioral research
• Life stage
• Policy
• Environmental
• Chronic diseases
• Economic factors
• Research in:
• Prevention
• Translation
• Effectiveness
• Dissemination
• Communication
• Social marketing

Potential Starter Objectives: Workgroups drafted potential objectives, based on the purpose of the research and the key research questions and areas of focus identified.

• Physical activity
• Diet
• Overweight/obesity rates
• Reduction in gaps

Potential Eligible Applicants: Workgroups identified potential eligible applicants for potential future initiatives and funding opportunity announcements.

• Standard list plus:
  • Historically Black Colleges and Universities
• Indian Health Service
• Faith-based Organizations
• Community Based Organizations
• Networks and consortia given high priority, especially community collaborations

Breakout II: Starter Research Description (Group 2)

Background of the problem: Workgroups were asked to provide background information or references to data and other documents hat may provide helpful information for the background portion of the research description.

• Obesity affects everyone –all groups- but there is an increased burden in certain populations
• A multi system approach is necessary for addressing obesity health disparities

Purpose of Initiative: Workgroups were asked to describe the purpose of the research.

• To conduct basic, clinical, behavioral, or translational research which addresses modifiable determinants of obesity in populations disproportionately affected across the lifespan

Programmatic Areas of Interest: Workgroups discussed which programmatic areas might benefit most from the proposed research.

• Behavior
• Policy
• Metabolic
• Social
• Built Environment
• Economic

Potential Starter Objectives: Workgroups drafted potential objectives, based on the purpose of the research and the key research questions and areas of focus identified.

• To determine drivers of behavior (e.g., income, social norms, attitudes about physical activity and diet) among different populations
• To determine the impact of policy on nutrition and physical activity among different populations (e.g., transportation, urban development, access to healthy food)
• To determine the differences in health disparities among different subpopulations

Potential Eligible Applicants: Workgroups identified potential eligible applicants for potential future initiatives and funding opportunity announcements.

• Standard Federal Funding Opportunity Announcement (FOA) Statement

• Include non-Federally recognized Tribal Communities

Additional Notes Group 2 Potential First-Wins

• Capitalize on existing programs and mechanisms already in place to help determine evidence-based strategies for reducing obesity in subpopulations
• Develop interagency taskforce to maintain information sharing, formalizing networking, dissemination of funded research of findings

Breakout III: Implementation and Funding Possibilities

During this breakout session, workgroups continued discussion of the draft research description in terms of collaboration and implementation.

Potential Collaborating Organizations: Workgroups identified organizations that may be potential collaborator for the research identified.

• Federal Government
• National Associations
• Foundations
• Professional Organizations
• Others

Potential Type of funding Mechanism Suitable for Initiative, including Existing Funding Opportunity Announcements (FOAs): Workgroups identified potential funding mechanisms that may be used to support the research identified.

• Types of Announcements: Request for Applications (RFA), Request for Proposals (RFP), Program Announcement (PA), Broad Agency Announcement (BAA), Program Announcement with Review (PAR), Program Announcement with Set-aside Funds (PAS)
• Funding Mechanisms: R01, R21, R18, Cooperative agreements, contracts, R24, P01, P20, P60
• Training Awards (develop new investigators)
• Cooperative Agreements
• Inter-agency Agreements
• RO1
• All types –including Memorandum of Understanding (MOU)
• Contracts

B-3 - Co-Morbidities Breakout Session
Text from Power Point Slides

Breakout I: Recommended Priority

During the first breakout session, participants reviewed a starter list of research questions for the topic area. The goal of this breakout session was to determine priority research questions and ideas for the topic area that would then be developed further during the meeting.

Starter List - Additions: Workgroups were asked to review the starter list of research questions and brainstorm additional research questions and ideas for the list.

1. What are the effective prevention strategies for individual communities in improving health?
2. Use one of (National Health Care Disparities Report) measures
3. What are effective models for improving access (individual, community)
4. How can we get translational research to communities and practitioners to utilize and improve health?
5. Does one stop shopping work?
6. How does intervention research on social determinants of health affect the pattern observed of multiple morbidities?
7. How do we integrate function/disability as an outcome of multiple morbidities?
8. What is/are the main reasons for health disparities; access, SES, race, environment?
9. What is the relationship of mental health and co-morbidities?
10. Different ways of organizing clinical care and impacting multiple morbidities
11. What are the priorities, priority areas?
12. What is the timing of interventions at different life stages and their relationships with co-morbidities?
13. What is the impact of policy changes on multiple chronic health conditions at different life stages?
14. How do race/ethnicity/sex/gender issues influence health?
15. How does technology influence quality of care
16. How can technology be better used to address multiple chronic conditions in disadvantaged individuals across the life course?
17. What are parallel measures of cultural sensitivities that need to occur to accomplish the prevention of co-morbidities?
18. What is the consumer and community research needed to support the co-morbid management approach?
19. What are the national surveillance systems we need to identify monitor and better understand co-morbidities and their genesis?

Starter List - Likes: Workgroups were asked to review the starter list of research questions and discuss what they liked about the list.

• Questions address quality
• Question #3 gets to the issue of co-morbidities
• Like #6 -need to get to fundamental research
• Ditto- it is fundamental
• #4 Need efficiencies
• #3 and 4 most important
• Like emphasis on multiple morbidities and ditto #6
• #5 focuses on better ways of measuring the right thing
• Like #1 because it is foundational, need to have evidence for co-morbidities and what to measure.
• Like #2 and #5. If we develop the measures will they have an impact Interaction between multiple health issues/indicators
• #2 because of multiple co-morbidities
• Real life applications of the relationships
• Co-morbidities is a complex issue

Starter List - Concerns: Workgroups were asked to review the starter list of research questions and discuss what they did not like about the list.

• Working with technology will cross cut the translational issues.
• Do not have clinical interventions that are crosscutting/need interventions across morbidities
• Focus across life course/transitions
• Do not need measures
• Cultural competence is important, mistrust, poverty, misinformation, physician bias, practice
• Lots of commonality between chronic diseases, treatment
• Racial and ethnic groups or across all groups
• Do we look at root causes, fundamental causes of diseases
• What are effective ways of addressing social determinants at the systems level
• Outreach component is very important, advancing practical application
• Community-oriented primary care, research on system and organizing clinical care
• Flip question #6
• May need to focus on access
• Consider calling indicators quality measures
• Treat one disease may create problem for another
• Not enough focus on causation and prevention-moving people from the edge of the cliff/not enough focus on common causes
• Focus on transition of care (acute/home care), must be inclusive of all groups, those for whom we have data and those we don't have data
• Only looking at chronic? Need to look also at infectious disease
• How big or small? Sex and gender are also issues
• Do not have the full spectrum of research, biological and social, and primary secondary and tertiary. There are links from infectious and chronic disease/go from basic science to translational research. Think of research across the silos, multiple lifestage, working with multiple morbidity Include multiple lifestage approach
• Lots of commonality between chronic diseases, treatment
• Racial and ethnic groups or across all groups

Breakout II: Starter Research Description

During this breakout session, workgroups were asked to discuss and draft a starter research description based on the research questions they felt were most important in their area of focus. The exercise went through several components that would make up a draft research description. This was a brainstorming and discussion session.

Background / Preamble: Workgroups were asked to provide background information or references to data and other documents hat may provide helpful information for the background portion of the research description.

• Rising rates of obesity, heart disease, diabetes, among others, along with sexually transmitted diseases and the HIV epidemic, are among the realities that are increasing the numbers of persons suffering from co-morbidities and multiple morbidities
• In this developing phenomenon, there are unacceptable health disparities with people of color, women, and poor people suffering disproportionately
• There is a social-economic divide that coincides with racial/ethnic status
• Neglect, discrimination, and racism have together created a situation in which we observe this syndemic, which urgently needs to be addressed through research and intervention
• Among the co-morbidities/multiple morbidities that require immediate attention include: depression, cardiovascular health, diabetes, hepatitis, HIV/TB/HCV, obesity, cancer
• This growing trend shows no sign of abating
• We will not be able to address effectively these issues without a comprehensive approach
• To effectively address co-morbidities/multiple morbidities, a multi-faceted approach is required which extends beyond the healthcare and broader health sectors to include a wide range of sectors that impact health including: education, housing, justice, private enterprise, labor, agriculture, transportation, etc.
• This approach must address all aspects of the unfolding realities: from data collection to community intervention, from policy to clinical practice
• We envision a multi-faceted and multi-sector process and invite other federal agencies to join with us in this innovative and creative approach by offering their energy, ideas and resources

Note: This workgroup approached the discussion of research ideas and directions differently and thus the format of the notes to follow does not parallel those of the other workgroups.

Research Themes

1. Quality and outcome measures
2. Organization of delivery systems
3. Health information technology
4. Determinants of health
5. Data
6. Vulnerable populations
7. Effective prevention strategies
8. Access to health care
9. Translation, dissemination, implementation
10. Life stage approach
11. Policy
12. Cultural and linguistic competence
13. Community involvement

1. Quality and outcome measures
   • What are the quality indicators for identifying effective and efficient treatment guidelines for persons with multiple chronic health conditions and for managing their co-morbidities?
   • What are the effects of adopting quality-of-care indicators for managing and monitoring multiple co-morbidities?
   • How will new quality indicators for multiple co-morbidities improve the health of different social and ethnic groups with known health disparities?
   • How can health care quality measures support change and improvement in care across multiple conditions?
   • How can we capture function as an outcome measure when addressing co-morbidities/multiple morbidities?
2. Organization of delivery systems
   • What is the impact of integrating disparate services on prevention or treatment of co-morbidities (i.e., one-stop shopping)?
   • How can community resources be effectively integrated in delivery of prevention and care for persons with co-morbidities?
   • Evaluate COPOC as a mechanism for prevention and/or improving treatment
   • Are categorical or population specific health care settings (e.g. sexually transmitted disease clinics, school based clinics, correctional health care) offering unique opportunities to address health disparities for multiple morbidities as compared to community health centers and other primary care settings?
3. Health information technology
   • How can technology be used to better address multiple health conditions in disadvantaged individuals across the life course?
   • How can technology be used to increase portability and provide greater consistency and communications across systems?
   • Study models that exist and communicate the lessons learned (e.g., Veterans Administration and emergency preparedness efforts).
   • Study how HIT systems can be used for disease management for people with multiple morbidities.
5. Data
   • What surveillance systems that already exist can be augmented to inform co-morbidities and multiple morbidities research and applications (e.g., National Cancer Institute, Surveillance Epidemiology and End Results [SEER])?
7. Effective prevention strategies
   • What are parallel measures of cultural sensitivities that need to occur to accomplish the prevention of co-morbidities?
   • What is the consumer and community research needed to support the co-morbidity management approach?
   • What are the effective prevention strategies for individual communities in improving health?
   • How do we empower the patient to accomplish the prevention of co-morbidities?
   • How do we use community empowerment to accomplish the prevention of co-morbidities?
   • How do we identify and utilize community assets and advance community experience to accomplish the prevention of co-morbidities?
8. Access to health care
   • Are there effective models for improving access to health care?
   • What is the impact of inclusion of special populations in clinical trials?
   • What is the impact of single payer systems on co-morbidities and multiple morbidities?
   • What is the interaction between access and health care behavior?

Co Morbidities Breakout III: Implementation and Funding Possibilities

During this breakout session, workgroups continued discussion of the draft research description in terms of collaboration and implementation.

Note: This workgroup approached the discussion of research ideas and directions differently and thus the format of the notes to follow does not parallel those of the other workgroups.

1. Infrastructure and Follow-up
   • Develop or vehicle for continuing (a)(1)
   • Charge us as a loose work group (a)(1)
   • Identify a single rep at each of the agencies/dept (here today) who would agree to meet each month.(a)(1)
   • Define how the mechanisms for working across agencies would be developed e.g. work plans how funding is distributed, avoiding competing among programs. (a)(1)
   • Hold follow-up meeting.(a)(2)
   • Have dedicated staff whose sole job is to do it; make sure someone from agencies is on call, make sure processes and accountability is there. (a)(1)
   • Establish a list serve (a)(2)
2. Communication and outreach
   • Publish a summary of meeting so we can say what we did at this meeting. (b)(2,3)
   • Present as a concept to our colleagues (the barriers and things to do). (b)(3)
   • Make report widely available.(b)(2)
   • Publish an article on this process in the Health Disparities Journal, also op ed articles.(b)(1,2,3)
   • Better integrate across the four areas. (b)(2,3)
   • Provide opportunities for breakout group's review of work after it has been cleaned up. (b)(2,3
3. Building buy-in, will and alliances
   • Identify a specific high level recipient of this work(c)(1)
   • Contact American Public Health Association (APHA) –Georges Benjamin and give report to build on APHA call to action (alliance)(c)(2)
   • CDC armed with executive summary and implementation plan, contact higher levels in participating agencies with response required(c)(1)
   • Interact with National Action Agenda (Office of Minority Health) to get recommendations into the agenda. Send announcement to all members.(c)(6)
4. Building the case and background
   • Pull our recommendation from Trans-HHS Cancer Health Disparities Progress Review Group that relate to the meeting.(d)(2)
   • Build strong business case for this proposal (cost analysis), and quality of care. (d)(5)
   • Get buy-in at highest level decide how to move it down through their agencies, (providing energy, time , ideas, and funds).(d)(1,4)
   • Bring in groups like the Institute Of Medicine to push this, also look into documents that they already have in this area.(d)(1,2)
   • What others have done in health disparity research collaboration, (American Public Health Association, World Health Organization, Institute Of Medicine, World Bank) research on co-morbidities(d)(6)
5. Accountability
   • Identify a national Czar to eliminate health disparities and for two-way accountability (e)(1)'
   • Communicate current Government Performance Results Act (GPRA), healthy people accountability for health disparities (e)(6,7)
   • Get agreement for HHS Assistant Secretary of Health to undertake this work and provide resources (e)(8)

Potential Collaborating Organizations: Workgroups identified organizations that may be potential collaborator for the research identified.

• Health Resources and Services Administration
• Centers for Disease Control and Prevention
• National Institutes of Health
• Indian Health Service
• Agency for Healthcare Research and Quality
• Centers for Medicaid and Medicare Services
• United States Department of Agriculture
• Food and Drug Administration
• Department of Transportation
• Office on Women's Health
• Census Bureau
• Department of Justice
• Robert Wood Johnson Foundation
• Kaiser Foundations
• Social Security Administration
• Office of Civil Rights
• Office of Personnel Management
• Department of Defense
• Department of Justice Bureau of Prisons
• National Association of Black Journalists/Media
• National minority health organizations
• National Association of County and City Health Officials
• Association of State and Territorial Health Officials
• Legislative organizations and associations
• Pan American Health Organization
• World Health Organization
• Women's organizations

Potential Type of funding Mechanism Suitable for Initiative, including Existing Funding Opportunity Announcements (FOAs): Workgroups identified potential funding mechanisms that may be used to support the research identified.

• Thinking innovatively and involve philanthropic community (Gates Foundation, Robert Wood Johnson Foundation, Kaiser Family Foundation, Kellogg Foundation) perhaps vis-a-vis CDC foundation
• Involve private industry (McDonalds, others)
• New congressional appropriation
• Pool and leverage existing funds from collaborating agencies
• Start with agencies' research snapshot of ongoing projects in our four focus areas

Implementation Activities for Proposed Research and Collaboration

• Develop or vehicle for continuing (a)(1)
• Charge us as a loose work group (a)(1)
• Publish a summary of meeting so we can say what we did at this meeting (b)(2,3)
• Present as a concept to our colleagues (the barriers and things to do) (b)(3)
• Identify a specific high level recipient of this work (c)(1)
• Identify a single rep at each of the agencies/dept (here today) who would agree to meet each month (a)(1)
• Pull our recommendation from Trans Cancer Progress Review Group that relate to the meeting (d)(2)
• Contact American Public Health Association (APHA) –Georges Benjamin and give report to build on APHA call to action (c)(2)
• Define how the mechanisms for working across agencies would be developed e.g. work plans how funding is distributed, avoiding competing among programs (a)(1)
• CDC armed with exec summary and implementation plan, contact level in participating agencies with response required. CDC strong in pushing/not highest like may document (c)(1)
• Make report widely available (b)(2)
• Build strong business case for this proposal (cost analysis), and quality of care (d)(5)
• Hold follow-up meeting (a)(2)
• Publish an article on this process in the Health Disparities Journal, also op ed articles (b)(1,2,3)
• Better integrate across the four areas (b)(2,3)
• Get buy-in at highest level decide how to move it down through their agencies, (providing energy, time , ideas, and funds) (d)(1,4)
• Bring in groups like the IOM to push this, also look into documents that they already have in this area (d)(1,2)
• What others have done in health disparity research collaboration, (American Public Health Association, World Health Organization, Institute Of Medicine, World Bank) research on co-morbidities (d)(6)
• Interact with National Action Agenda (OMH) to get recommendations into the agenda. Send announcement to all members (c)(6)
• Identify a national Czar to eliminate health disparities and for two-way accountability (e)(1)
• Have dedicated staff whose sole job is to do it; make sure someone from agencies is on call, make sure processes and accountability is there (a)(1)
• Communicate current GPRA, healthy people accountability for health disparities (e)(6,7)
• Establish a list serve (a)(2)
• Provide opportunities for breakout group's review of work after it has been cleaned up (b)(2,3)
• Get agreement for HHS Assistant Secretary of Health to undertake this work and provide resources (e)(8)

B-4 - Built Environment Breakout Session
Text from Power Point Slides

Breakout I: Recommended Priority

During the first breakout session, participants reviewed a starter list of research questions for the topic area. The goal of this breakout session was to determine priority research questions and ideas for the topic area that would then be developed further during the meeting.

Starter List - Likes: Workgroups were asked to review the starter list of research questions and discuss what they liked about the list.

• Much wider vision
• Produce benefit of health disparities
• Role the environment of particularly of people with disability
• Focus on individual and systems level
• Opening statement that includes workplace
• Last bullet
• That built environment is listed as a key theme
• Nature of the questions provide tremendous opportunity
• Emphasis on systems approach, focus areas and cross disciplinary aspects
• Economic determinant and impact is valuable
• Addresses the full range of issues of upstream and down stream issues as it relates to build environment
• Discussion of planning and zoning that allows for housing choice and recognize disparities
• Extremely comprehensive and includes injury
• Systems approach and value of green-space in health
• Emphasis on social determinants of health and upstream factors

Starter List - Concerns: Workgroups were asked to review the starter list of research questions and discuss what they did not like about the list.

• Intergenerational scope; history of how the environment took place; look at wide range of affect including health; too narrow focus.
• Collaboration in research focus on the elimination of health disparities, which doesn't address concern number one; health is spiritual, environmental, and social
• Upside is that it is possible for everyone to see themselves here; who are we talking about and how are we defining that? Possibility of disconnect if we do not define our mission; concerned that the target population is not clear
• Built environment is made up of a lot of things. Who is pushing the interaction of those components of built environment? It also is interaction between components - push the interaction more
• Consensus and definition of vulnerable populations; vulnerable populations are not clearly defined
• Lack and importance of health care facilities; in disability area, all does not include health care facilities
• Lack of consensus on methodology issues; How can you study consequence? Lack of methodology; needs to be an emphasis on understanding the casual nature of built environment; more research on causal relationships is needed.
• Interaction of built environment and poverty and how they influence health
• What do we already know? How do we determine what we need in order to prioritize the list? Not clear what is already known
• What's the paradigm of health disparities in terms of persons and environments?
• Intergenerational affect; does not look at children, elderly
• Nutrition and physical activity are part of the built environment
• How can a built environment support health? Deals with obesity; It's general but can be specific; tangible, factional areas that are cross cutting, issues such as walkability. Not enough emphasis on cross cutting issues and actions that impact these issues; key decision points of planning, and zoning investment
• Last bullet needs to be broader; people of vulnerable populations, people with disability
• More emphasis on barriers and facilitators; It's the lifespan prospective as well.
• Populations flow; how our choices today differ from those back then; Intergenerational and across the lifespan
• List is too short and not enough examples

Starter List - Additions: Workgroups were asked to review the starter list of research questions and brainstorm additional research questions and ideas for the list.

• Development and validation of subjective and objective measures of built environment in multiple domains
• Impact of mobility/migration on all research realms. Looking at movement from high and low income areas - the impact on health education
• What are people doing to bring about regional benefit? Micro benefits that would bring about environmental and social changes. What micro and land use activities that can bring about micro goals? Look at interface between environment and health
• Define threshold for action or inaction
• How do all changes of the built environment influence nutrition and physical activity across the lifespan?
• What is the optimum mix of change (i.e., laws, economic, regulations, etc.) to achieve the desired outcome?
• Need to develop methodology to give valued measures of health impact.
• Need research questions that engage the community we are talking about. How do we involve communities of concerns in addressing the built environment?
• Make sure communities are represented

Breakout II: Starter Research Description

During this breakout session, workgroups were asked to discuss and draft a starter research description based on the research questions they felt were most important in their area of focus. The exercise went through several components that would make up a draft research description. This was a brainstorming and discussion session. For some portions of this breakout session participants divided themselves into two smaller groups.

Background Group 1: Workgroups were asked to provide background information or references to data and other documents hat may provide helpful information for the background portion of the research description.

• Health and well being is broadly influenced by the physical and socio-economic environment in which people live, work and play. Land use and community design influence rates of obesity, injury, heart diseases and conditions. Certain populations may be at greater risk of health disparities based on certain aspects of the built environment in which they live. Thus, research aimed at examining the relationship between the built environment and the health of vulnerable populations allows for an innovative approach to reducing health disparities. Solutions to these complex problems require research and a systems approach.

Purpose of Initiative Group 1: Workgroups were asked to describe the purpose of the research.

• What tools are needed to understand the dynamics of the built environment and their influences on health and health disparities?
• What are the impacts of the built environment on health outcomes of vulnerable populations leading to health disparities?
• What is the best application of public and social policies in reducing health disparities as related to the built environment and the health of vulnerable populations?

Background Group 2: Workgroups were asked to provide background information or references to data and other documents hat may provide helpful information for the background portion of the research description.

• What tools are needed to understand the dynamics of the built environment and their influences on health and health disparities?
• Built environments influence health and health inequities
• Built environments are complex and changing
• There is substantial room to develop and improve methods, models, and analytical tools to explore opportunities to modify the built environment for improving health and health equities
• The built environment may influence health via its effects on health behavior, psychological status, or exposure to toxins; Think carefully about how to measure and model these different processes in vulnerable populations
• What are the impacts of the built environment on health outcomes of vulnerable populations leading to health disparities?
• Refer to introduction paragraph
• Built environment includes institutions, and community such as, but not limited to, healthcare settings, homes, neighborhoods, commercial settings and systems that impact community participation
• How the different elements of the built environment integrate together to impact quality of life
• Health outcomes includes mental and physical health, risk behaviors, and quality of life
• Vulnerable populations includes SES, rural, and urban disabled persons, minorities
• What is the best application of public and social policies in reducing health disparities as related to the built environment and the health of vulnerable populations?
• The built environment and health outcomes are a function of government subsides, laws, and practices which influence the arrangement of physical infrastructure and residential and commercial development. Just as public and social policies affected inequitable outcomes of past, future policies can help reverse negative outcomes. Pilot programs that promote walkable communities and parks, greenways, safety and even other choices (transportation, housing and other innovative strategies)

Purpose of Initiative Group 2: Workgroups were asked to describe the purpose of the research.

• Develop and improve methods, models, and analytical tools to explore opportunities to modify the built environment for improving health and health equities
• Disseminate advances in methods
• Raise awareness and build capacity to use appropriate methods
• Integrate improved methods into policy, planning, and evaluation
• Examine the association (impact) of characteristics of the built environment with reduction/elimination of health disparities
• Access economic and health impact of modifications on the built environment
• Enhancing collaborations focusing on decreasing health disparities caused by the built environment
• Examine impact of successful policies in decreasing health disparities and translating those to built environment
• Enhance built environment policies which are proven (shown) to be effective in health disparities
• Increase the participation of the affected stakeholders in policy development which have potential impact on their health
• Increase knowledge on the dynamics of the built environment and its influence on health disparities
• Increase knowledge on the characteristics of communities positively impacted by social/public policies
• Understand the policy intervention which impacted health conditions of individuals and communities (e.g., health outcomes)

Programmatic Areas of Interest: Workgroups discussed which programmatic areas might benefit most from the proposed research.

• Research on how the built environment promotes healthy behaviors (nutrition, increased physical activity, reduction of substance abuse), and reduces injury, disease and disability.
• Impact of the built environment accessibility on health outcomes of people with disabilities
• Location, design, and accessibility of workplaces within communities influence both individual and community health
• Impact of transportation systems on environmental population and impact on health
• Changes in the built environment on violence and injury
• Multi-disciplinary collaborations including research, community based and health organizations or institutions
• To access community benefits of commercial agreements
• Directed towards improving equity health conditions and decreasing health disparities
• To identify the impact of population density on the health of individuals and communities
• Explore and assess policy interventions that positively affect health conditions in affected communities and among vulnerable populations
• Describe positive characteristics of healthy communities
• Environmental health (e.g., lead, radon, and asthma)
• Chronic disease, (e.g., heart disease and cancer)
• Injury prevention (e.g., carbon monoxide poisoning, fire and violence)
• Mental health (e.g., depression, stress, and substance abuse)
• Place-based settings (e.g., schools, worksites, and healthcare settings)
• Transportation and land use planning

Potential Starter Objectives: Workgroups drafted potential objectives, based on the purpose of the research and the key research questions and areas of focus identified.

• Accessibility, green space and other recreational areas on improvement of physical activity
• Access to healthful food and nutrition sources (e.g., farmers market, community garden, zoning of fast foods). Modifications to cafeterias, food offerings, schools, worksites, etc.
• Improve access of healthcare facilities, buildings, equipment and communications
• Include substance abuse
• Workplace commute times and environmental pollution issues
• Develop clearer statements of causal hypothesis; use modeling to establish and refine theories about built environment and health
• Develop and improve tools to understand and measure the dynamics of the built environment over time and space
• Develop and improve tools to characterize the consequences of different policies, both prospectively and retrospectively
• Develop and improve culturally appropriate instruments to measure subjective and objective features of the built environment
• Develop and improve study designs for causal inference where random clinical trials are impossible to conduct

Potential Eligible Applicants: Workgroups identified potential eligible applicants for potential future initiatives and funding opportunity announcements.

• Non-profit organizations
• For-profit organizations
• Public or private institutions, such as universities, colleges, hospitals, and laboratories
• State and local health departments and government, including U.S. territories
• Tribal organizations
• Community-based organizations
• Faith-based organizations
• Any individual or organization with the necessary skills, knowledge and resources to carryout the proposed research will be eligible
• Multi-disciplinary teams will often be required and should be encouraged

Potential Collaborating Organizations – Federal

• Department of Health and Human Services
• Office of Minority Health
• Office on Disability
• Centers for Disease Control and Prevention
• National Center for Environmental Health/Agency for Toxic Substances and Disease Registry
• National Center for Injury Prevention and Control
• National Center for Birth Defects and Developmental Disabilities
• National Institute for Occupational Safety and Health
• National Center for Chronic Disease Prevention and Health Promotion
• National Institutes for Health
• National Eye Institute
• National Heart Lung and Blood Institute
• National Institute for Child Health and Human Development
• National Center for Research Resources
• National Institute of Environmental Health Sciences
• National Cancer Institute
• National Institute of Diabetes and Digestive and Kidney Diseases
• National Institute of Allergy and Infectious Diseases
• Food and Drug Administration
• Indian Health Service
• Department of Housing and Urban Development
• National Institute on Disability Rehabilitation Research
• Environmental Protection Agency
• Children's Health Office
• Office of Smart Growth
• Office of Toxics (CARE)
• Environmental Justice
• Office of Research and Development (Sustainability Program)
• Tribal Science Program
• Department of Justice
• Department of Commerce
• National Council on Disability
• Veterans Administration
• Department of Agriculture
• Department of Defense
• Department of Labor
• Occupational Safety and Health Administration
• Department of Interior
• Bureau of Indian Affairs
• National Park Service
• Bureau of Land Management
• Department of Energy
• National Science Foundation
• Department of Education
• Department of Transportation
• Robert Wood Johnson Foundation
• Ford Foundation Sustainability Group
• American Diabetes Association
• Fannie Mae Foundation
• Rockefeller Foundation
• MacArthur Foundation
• Casey Foundation
• Sierra Club
• Professional associations (e.g., medical, engineering, architectural, Rehabilitation Engineering and Assistive Technology Society of North America, American Psychological Association)
• Environmental Defense
• Audubon Society
• Natural Resources Defense Council
• American Planning Association
• American Public Health Association (Built Environment Initiative)

Potential Type of funding Mechanism Suitable for Initiative, including Existing Funding Opportunity Announcements (FOAs): Workgroups identified potential funding mechanisms that may be used to support the research identified.

• Program announcement
• Request for applications
• Request for proposals
• Program announcement with review

Additional Notes: Sustaining Activities

• Smaller group discussion
• Disability (Interagency Committee on Disability Research)
• Centers for Disease Control and Prevention
• Write Initiative
• Memorandum of Understanding
• Collaborative Model
• Consortiums
• Academic partners, community based organizations, local health departments
• Intramural research activities
• Go back to HHS Disparities Council (Office of Public Health Research, CDC)
• Review HHS Council (HHS and National Institutes for Biomedical Research)
• Agencies contribute on a panel (i.e., Institute of Medicine , National Academy of Science)
• Get feedback from various networks (internal and external) on built environments
• Develop intra-agency implementation plans
• Partner with private practice groups or settings
• Development of a consortium of agencies to write the action to address health disparities in the built environment