Co-creating a Sustainable Healthy Tomorrow. Bush Foundation Project Final Report

Co-creating a Sustainable Healthy Tomorrow Bush Foundation Project Final Report

Co-creating a Sustainable Healthy Tomorrow Bush Foundation Project Final Report Introduction and Background Minnesota has the opportunity to pioneer a model of co-creation that transforms how clinicians, patients/citizens, and communities partner together to address health care costs. We are spending more than ever on health care, and we do not have better health to show for our investment. Our current rising health care costs are unsustainable and seriously reduce the resources available for other important factors that make us healthy such as education, affordable housing and job development. We must be transparent with patients/citizens about the gravity of this public problem. Addressing health care costs in a manner that is understandable and acceptable to patients/citizens and clinicians will be no small task. We believe, however, that empowering citizens to address health systems and health care costs within their own communities will ultimately generate the bold leadership, political will and action required to create a healthy economic future for our communities, our governments and ultimately our children and grandchildren. In health care, a framework that has made addressing health care costs acceptable to clinicians has been the Triple Aim 1 : simultaneously improving population health, improving the experience of care including quality, and improving affordability by reducing per capita costs. The recent Citizen Solutions report (Appendix B) has validated the importance of this framework but also revealed that citizens want more engagement and empowerment in their own health. Within this context, we created the initiative Co-Creating a Sustainable Healthy Tomorrow. This initiative has had an aim of fostering community conversations and actions around the Triple Aim with more engagement and empowerment by bringing clinicians, patients/citizens and community stakeholders together within communities to: 1. Understand rising health care costs, 2. Create goals on the Triple Aim, especially addressing ways to decrease costs by waste reduction in health care, 3. Develop action plans that inspire creative solutions to reach the goals. Minnesota had several building blocks in place for this work as this project began. The Institute for Clinical Systems Improvement (ICSI), Twin Cities Public Television (TPT), Bush Foundation, Citizens League, and the State of Minnesota have been working on various aspects of redesigning health and health care to address costs. The basis for citizen engagement was set by the Citizen Solutions initiative, spearheaded by the Bush Foundation and Citizens League. The timing is also ideal as new health care models emerge, such as Accountable Care Organizations (ACOs) that are responsible for delivering health care to a population with accountability for quality and costs. ACOs will benefit from 1 Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health and Cost, Health Affairs 27, no. 3 (2008): 759 769; 10.1377/hlthaff.27.3.759 1

citizen input into the transformations that are needed to improve the experience, quality and cost of care. In addition, their long-term viability will be influenced by the health of the populations they serve because of ACOs inherent economic incentives for improved population health. In fact, communities need clinicians and citizens to be accountable for health, i.e., Accountable Health Communities. (Appendix C.) The time is ripe for co-creation on health, care and costs. With the collective wisdom of citizens and clinicians, we can address health care costs and create a sustainable tomorrow for our children. Project Goals and Objectives The objective of this project was to support the early growth of the Co-Creating a Sustainable Healthy Tomorrow initiative by engaging in a deliberative planning process. Referred to as Phase 1 of the initiative, these deliberative planning activities were envisioned as an imperative first step prior to subsequent pilots and launching a broader initiative. Implementing Phase 1 activities required a dynamic collaboration and partnership. The partners involved ICSI, Citizens League, and TPT strove to advise and develop activities based on each organization s expertise and the unique aspects of the work. Each brought separate and complementary strengths and expertise to engage and plan with three categories of stakeholders: health care clinicians, individual citizens and leaders in local communities, and a larger public audience. Informed by this partnership, deliverables for this project were: 1) A summary of stakeholder interviews and key lessons on addressing health care costs. 2) A report on the lessons learned from bringing clinicians and citizens together, informed by the Citizens Solutions report. 3) A Reinertsen lecture, workshop and video-documentary. 4) Establishment of an Advisory Committee. 5) A graphic video developed by David Gillette. 6) A summary of the planning elements and recommended next steps. 7) Identified strategies to solicit funding for the proposed community pilots. A summary of these activities follows with documentation of each attached as an appendix and/or available online. Deliverables 1. Stakeholder Interviews about Addressing Costs To learn from past experience engaging citizens and clinicians on health care costs, interviews were conducted with fifteen health leaders in the state representing providers, citizens, health plans, policy makers, the philanthropic community, and nonprofits. Interviewees were asked for their thoughts in three areas: Based on your experience, what have we learned about addressing health care costs in Minnesota? What will be most important in bringing citizens and clinicians together to address costs, particularly since it is a sensitive topic? To set goals on the Triple Aim, especially costs, what advice would you give? 2

In reply, this group of health care leaders, some of whom have dedicated their entire careers to health reform, shared a virtually unanimous opinion that community-level conversations and efforts must be part of health reform. However, they also made it clear that addressing health care costs in a manner that is understandable and acceptable to patients/citizens and clinicians will be no small task. Nevertheless, they placed a high value on these conversations, and expressed hope about what they might contribute to achieving the Triple Aim. As one interviewee said, If we don t start, we ll never get there. Themes that emerged include: Past experience has shown the following to be especially challenging in addressing health care costs: o Lack of understanding o Belief systems about the way health care works o Economic structures and incentives o Lack of clear lines of accountability In bringing clinicians and citizens together to address the Triple Aim and health care costs, it will be important to: o Focus on shared responsibility o Have committed leadership o Imagine an alternative future o Provide good information A successful clinician and community process will: o Address the intersections in health care o Involve a broad cross-section of the community o Set clear and realistic expectations o Invest in professional meeting design and facilitation o Be open to community views o Work to build common understandings and priorities These interviews, conducted by Citizens League, resulted in findings that will help inform future work. (Appendix D.) 2. Citizen/Clinician Meetings The aim of citizen/clinician meetings was to further explore how to best engage citizens, community stakeholders and clinicians together to discuss the Triple Aim and what matters to them, with a focus on sharing their respective viewpoints, explicitly including rising health care costs, and considering goal-setting. Planning for this work was informed in part by the Citizen Solutions work conducted in 2012 by Citizens League and funded by the Bush Foundation that established a framework of community inclusion around health reform. This led to the determination that each citizen/clinician meeting must be tailored to the individuality of that community, including the status of the conversations already occurring in that community. For instance, the Fergus Falls local planning partnership chose a focus of developing a rural model for an 3

Accountable Health Community. In the North Minneapolis clinic, the conversation was centered on community values and goals. Thus, questions and format were tailored to each group accordingly. Three communities were chosen for these meetings. The first group was made up of members of ICSI s Board of Directors and members of ICSI s Patient Advisory Council. The other two communities, Fergus Falls and North Minneapolis, were chosen both for the differences in their demographics and focal points of conversations as well as the strength of engagement and interest of their local health care leaders. Written summaries of the meetings were developed, as well as video documentary pieces that will be useful tools in demonstrating to other communities how these conversations can be held. (Appendix E. See video clips of the conversations on the ICSI website.) Community 1: ICSI Board of Directors and Patient Advisory Council Participants of the first two meetings in the spring of 2013 were members of the ICSI Board of Directors (clinicians, employer, payer, providers) and members of ICSI s Patient Advisory Council (PAC) plus additional patients to reflect the diversity in the community. The composition of this group was a good starting point for clinician/citizen conversations and offered a safe environment to test messages and format. The meeting opened with the debut of the Healthy Tomorrow video (see section 5 below), which was well received and helped to generate dialogue; next participants engaged in multiple small group exercises. Through these exercises participants identified areas of health care spending they felt they could influence and gave input on how to hold future conversations on Total Cost of Care. Observing and gaining input from this meeting s participants validated that it is possible to engage clinicians and citizens together in conversations that include cost and goal-setting efforts. It also helped to inform our next steps with other community groups. A Healthy Tomorrow by David Gillette Community 2: Fergus Falls Area Fergus Falls is a rural community with a population of just over 13,000. In this community, there was already a local impetus towards developing a sustainable rural health model through the leadership of Larry Schulz, CEO of Lake Region Health Care, and in partnership with Gina Nolte, Director, PartnerSHIP 4 Health. This partnership helped garner the participation of approximately 70 local community stakeholders, including business leaders, clinicians, public health, policymakers, and other citizens in two meetings. Participants in this group imagined ways that the community could impact health, costs and care, and discussed challenges and responsibilities for each type of stakeholder. They expressed appreciation for the mix of viewpoints among participants, saying that it promoted productive, thoughtful conversations. One community participant said, It was good to hear the doctor s viewpoint at our table, and it was good for him to hear ours. 4

At the conclusion of the second meeting, participants were asked to leave their name if they were interested in follow-up. More than 35 individuals expressed an interest in continuing involvement in this work in their community. Community 3: North Minneapolis The final citizen/clinician meeting was held in an urban setting, with local leadership by Stella Whitney-West, CEO of NorthPoint Health and Wellness Center of Minneapolis. A community health center, NorthPoint wanted to support more conversations with the community to improve health outcomes. The co-creating partnership wanted to better understand issues in an urban, more diverse setting, and learn how conversations around heath and costs might differ. Participation consisted of NorthPoint patients and a number of clinicians. In small group exercises, participants explored possible goals and action steps they could set in their community around improving health and reducing costs. Participants in this group particularly stressed challenges of affordability and awareness of resources. Citizens and clinicians were highly satisfied with the event and most reported that the mix of perspectives at the table helped them think through the issues. Comments also acknowledged the complexity of the issues and need for more time and effort to be able to thoughtfully cocreate solutions and build healthier communities. We began changing our approach from just treating sick people to disease prevention and wellness we had to go beyond our medical group and involve other community leaders to achieve better health in our region. Community leaders came together to define what we wanted our community to be in the future. - Larry Schultz, CEO of Lake Region Health 3. ICSI Reinertsen Lecture and ReThink Workshop The annual ICSI Reinertsen lecture in October 2012 was used to lay the groundwork for the cocreating work and Accountable Health Communities (AHCos). Entitled Moving from ACOs to Accountable Health Communities: Delivering on Population Health in the Triple Aim, with two leading national experts (Drs. David Kindig and Bobby Milstein), the lecture discussed stewardship of health care costs to avoid robbing the other social determinants of health. Dr. Milstein also talked about the unique ReThink Health Dynamic simulation model designed to facilitate conversations on health investments. Following the lecture, ICSI hosted a workshop that provided an opportunity for 50+ Minnesota health and health care stakeholders to explore these concepts more in-depth. We envisioned that together, this lecture and workshop could expand the co-creating conversation. These events were indeed a catalyst for further energy around local solutions to meet this challenge, galvanizing leaders in Fergus Falls who then became part of the co-creating initiative. Further, in the spring of 2013, ICSI again partnered with ReThink Health to sponsor ReThinking Health: Leadership Essentials in a Changing System, an online course which involved more than 60 Minnesota health care professionals. Participants learned how to best assess their community s challenges, assets and progress in moving toward an accountable, sustainable health system. 5

(Recordings of the Reinertsen lecture can be accessed on the ICSI website and information on the ReThink Health course can be found at www.rippelfoundation.org.) 4. Advisory Committee An Advisory Committee was established to help shape the path for future community collaborations and provide important connections to other innovative health and health care model initiatives across Minnesota [e.g., accountable care organizations, State Health Improvement Programs (SHIP), etc.] The advisory committee was charged with making specific recommendations on areas critical to the development of an Accountable Health Community (AHCo) model, including framework, design, implementation, and anticipated outcomes; how to involve multiple populations and address disparities; how goal-setting might be accomplished; and how to align with other innovative health and health care initiatives. They were asked to share innovations and lessons learned from their respective organization, position, and/or community to enhance our collaboration and further inform the development of AHCos and co-creating efforts. The committee defined important attributes and parameters of community that would pertain to an AHCo, from geographic location and an association of data and budget, to a community s commitment to the issue and its capacity for interventions. Anticipated outcomes included increasing the capacity for interventions and defining specific parameters around improving health, reduced costs, and care. The group recommended requirements for community-level goal setting in the Triple Aim, and ways to create a reinforcing loop for investment. (Appendix F.) 5. Graphic Video from David Gillette In the past, clinicians and citizens have often been shielded or asked not to consider costs in their discussions about health care, so a tool was needed to help quickly articulate to clinicians and citizens why their involvement is valuable and necessary in cost discussions. We envisioned that this graphic video could be used in multiple ways, including interactions with funders. Thus, the Healthy Tomorrow video was commissioned by the co-creating partnership through TPT and created by David Gillette. This two-minute video was shown at the start of each citizen/clinician meeting and was extremely well received. It has also been used in various health and health care presentations in Minnesota and beyond, including a recent showing at the national Institute for Healthcare Improvement (IHI) forum, and is available on the ICSI website. 6. Planning Elements Partners ICSI, TPT and Citizens League met twice monthly to accomplish initiative activities, incorporate lessons learned, manage the budget, align with local and national work, and consider strategies for future expanded initiative work (section 7 below). We sought input from Grassroots Solutions on specific questions related to engagement, particularly with regard to public and private collaboration. 7. Alignment, Strategies for Future Funding and Next Steps Several opportunities exist to advance this work either in alignment with existing projects or in response to interest expressed by other parties. During the course of our development and 6

implementation, the State of Minnesota applied to the federal government for a State Innovation Model that included the concept of Accountable Health Communities called Accountable Communities for Health (ACHs). In 2013, the state received more than $40 million for a multi-pronged initiative that will include 15 ACHs. Recently, the Robert Wood Johnson Foundation (RWJF) has funded Total Cost of Care projects in five states. Minnesota is one of those states, and we have had conversations with MN Community Measurement, the Network for Regional Healthcare Improvement and RWJF about how to use this coming data transparency to spur conversations with citizens and clinicians. Further, RWJF invited representatives from the partnership to meet with them in December 2013 about our co-creating work. We continue to have follow-up conversations with them to consider our common goals and opportunities for future endeavors, potentially in conjunction with their work with ReThink Health. Meanwhile, RWJF has awarded ICSI a grant that funds the development of communication materials directed to a health care audience to promote greater interrelatedness of health care with public health and other community health resources. This work will include a communication about how to get boards on board with the Triple Aim and community involvement. (More information available on the ICSI website.) In addition, ICSI successfully applied to the ABIM Foundation for a Choosing Wisely grant in partnership with the Minnesota Health Action Group and the Minnesota Medical Association. This two-year $50,000 grant enables us to engage clinicians and citizens in awareness of overuse that contributes to rising health care costs. (More information available on the ICSI website.) Finally, in December 2013 we were asked to speak at the IHI National Forum to share the strategies piloted here. The workshop was well attended, and many of the 125 participants stayed afterward to ask questions and continue the discussion. (Appendix G.) Lessons Learned This project taught us some valuable lessons as well as provided some validation for the direction of co-creating. For instance, an unanticipated finding was how readily, in a safe setting, clinicians and citizens could discuss all aspects of the Triple Aim and deepen their understanding of the issues. This validated the belief that lower cost could be part of a conversation (and an initiative) when approached simultaneously with issues of better health and better care (i.e., the Triple Aim). Lessons learned from each citizen/clinician meeting instructed the development of the next. In the beginning some planners had discomfort with conversations that included cost; this became easier as experience showed it could be done and would even be welcomed. Leadership was key to focusing on the sensitive issue of costs while simultaneously addressing health and care. In Fergus Falls, a key takeaway was that their community members believe that a community can make a meaningful difference when it comes to health, costs, and care, and they want to participate in doing so. We learned they were eager for information, especially regarding health status and costs: when they had that information, they used it to set priorities and make choices. In North Minneapolis, one theme noted was trust. It was articulated in multiple ways that when health care stakeholders build trust, citizens can feel comfortable with information given and in working towards a common goal. 7

Small group exercises with citizens and clinicians generated significant conversations, and included: 1. Choosing a clinic based on costs and quality 2. Improving a clinic in your community what would you and other citizens do to improve the quality and cost 3. Prioritizing goals 4. Setting a goal on Total Cost of Care It was absolutely critical to have a neutral, trusted facilitator such as Citizens League who made it safe for community members to talk among themselves during these exercises. The facilitator also was sensitive to the issues and dynamics of each group and was able to keep participants from shying away from difficult topics. We learned they were hungry for information, especially regarding health status and costs. When they had that information they used it to set priorities and make choices. During the conversations, we ensured a mix of citizens and clinicians at each table for richer small group discussions with a broad representation of viewpoints. Our experience taught us that this needed to be scripted carefully; otherwise, clinicians sit with clinicians and citizens sit with citizens. These interactions gave people a chance to experience meeting face-to-face to discuss hard issues, bridging differences of background and experience, and seeing the different perspectives as an asset rather than a liability. Including citizens, clinicians, and other community stakeholders in not only the conversations but in the planning allowed the best outcomes. Details like sending personal invitations helped gain participation, and choosing a neutral location when possible was helpful. Having food at the event even if only healthy snacks provided a way for participants to socialize and begin talking before the formal conversations began. It was important to include all aspects of the Triple Aim in the discussion, while being explicit about costs. Attention to language was important because often the separate and unique features of each part of the Triple Aim could be confused. For example, people thought the population health aim was individual health versus the health of the community. Costs were not just the price of an individual item, but it was the combination of how much we used and how much things cost. Using local data such as the county-based health rankings information (www.countyhealthrankings.org), Medicare costs, health care measures (e.g., MN Community Measurement), demographic data, etc. was critical to engagement. To engage people in the data and stimulate conversations, we used an audience response system to poll participants and display the groups results in real time for all to review and discuss. Having a video to open the meeting, such as A Healthy Tomorrow, was a quick way to frame a very challenging topic of health care costs and the social determinants of health. We have had multiple requests for use of the video, and showed A Healthy Tomorrow twice in Fergus Falls. For taping of the events, attendees were comfortable being recorded when we explained that the video would be used to show others how to have these conversations, and we offered people an opt-out process. Overall, we validated that constructive clinician/citizen meetings are possible - bringing citizens, clinicians, and community stakeholder together in co-creating efforts to review data, consider goals 8

and consider actions around the Triple Aim, including cost. Further, as supported by key stakeholder interviews and the thoughtful consideration of an Advisory Committee, we have explored how stakeholders can build Accountable Health Communities. Summary While Minnesota is working to accelerate accountability in the health care system, we are creating Accountable Health Communities communities accountable for the Triple Aim of better health, better costs and better care. Addressing health care costs in a manner that is understandable and acceptable to patients/citizens and clinicians will be no small task, and their engagement is crucial for accountability. Empowering stakeholders to address health, costs and care within their own communities will ultimately generate the bold leadership, political will and action required to create a healthy economic future for communities, governments and future generations. Appendix A. Financial Report B. Citizens Solutions Report C. Achieving Accountability for Health and Health Care White Paper D. Interview Summary E. Clinician/Citizen Meeting Materials F. Advisory Committee Summary G. IHI Presentation 9