Q13: Pathways to Population and Community Health for Health Systems Kevin Barnett, Marie Cleary-Fishman, KellyAnne Johnson, and Soma Stout Monday, December 11, 8:30am 4:00pm #IHIFORUM #100MLives
Objectives 2 After this session, you will be able to: Assess where you are on the journey to population health Identify key levers and opportunities to improve health, well-being, and equity of your patients and communities Develop an action plan for your journey
Faculty 3 Kevin Barnett, PhD Sr. Investigator, Public Health Institute Marie Cleary-Fishman, MS, MBA VP, Clinical Quality Health Research & Educational Trust Trissa Torres, MD, MSPH, FACPM SVP, Institute for Healthcare Improvement KellyAnne Johnson Sr. Project Manager Institute for Healthcare Improvement Disclosure: the faculty in this session have nothing to disclose.
Special Guest Faculty 4 Sara Bader Senior Manager, Upstream Quality Improvement HealthBegins Don Berwick, MD, MPP President Emeritus and Senior Fellow, Institute for Healthcare Improvement
Agenda 5 Topic Welcome and Introductions Understanding the Journey to Population Health Break Assess Yourself World Café: Exploring the Portfolios of Population Health Lunch Developing a Balanced Portfolio and Action Planning Break Pitching your Plans for Expert Feedback Appreciative Reflections and Closing Duration 8:30AM 9:00 AM 9:00AM 10:00 AM 10:00AM 10:15AM 10:15 AM 11:00AM 11:00AM 12:00PM 12:00PM 1:00PM 1:00PM 2:30PM 2:30PM 2:45PM 2:45PM 3:45PM 3:45PM 4:00PM
Where Everybody Knows Your Name 6
Introductions 7 Please share: Your name Your theme song Where you re from (location, organization, role) What questions you are bringing with you today
Working Agreements 8 Share your experience all teach, all learn Practice saying yes, and instead of yes, but Responsible for your learning Show up, choose to stay present
Understanding the Journey to Population Health 9:00-10:00
Meet Gabe 10
The Triple Aim A System design that is one aim with three dimensions: Improving the health of the populations; Improving the patient experience of care Reducing the per capita cost of health care.
Diabetes Management Commonwealth Fund evaluation. NCQA sites = Union Square and Revere
36% Reduction in Hospitalization Rate for Patients with Diabetes
The Context of Our Communities
Cost of Chronic Disease Is Unsustainable 16
The Need for a Life Course View Exposure to toxic stress in early childhood may lead to as much as a 40x increase in rate of chronic disease by the time you re 50.
Interaction Intervention possibility slim Adapted from McGuinnis et al.
Coming to Terms with Health Inequities Unhealthy housing Exposure to array of environmental hazards Limited access to healthy food sources & basic services Unsafe neighborhoods Lack of public space, sites for exercise Limited public transportation options Inflexible and/or poor working conditions Health impacts (e.g., allostatic load) of chronic stress
When the External Becomes Internal: How We Internalize Our Environment Allostatic Load Inadequate Transportation Long Commutes Housing Stress Stress Stress Stress High Demand- Low Control Jobs Lack of access to stores, jobs, services Lack of social capital Stress Stress Crime Source: Anthony Iton, MD, JD, SVP, The California Endowment
Health and Social Inequity are Interconnected and Related to Place 21 2 newborns will have a 25 year gap in life expectancy 2 miles apart based on where they grow up.
Interrelationships People Health, wellbeing and equity Community Systems of Society
Foundational Principles 1. Health and wellbeing develop over a lifetime. 2. Social determinants drive health and wellbeing outcomes throughout the life course. What creates health? 3. Place is a determinant of health, wellbeing and equity. 4. Health system can respond to the key demographic shifts of our time. 5. The health system can embrace new financial models and deploy existing assets for greater value. 6. Health creation requires partnership because health care only holds a part of the puzzle. How can health care respond?
What Does Population Health Mean to You? 24 #100MLives
Two kinds of populations 25 A Defined Population Defined by a common characteristic Patients at a community health center Children with sickle cell disease who live in the Midwest People attending a megachurch Geographic or Place- Based Population Defined by a place Children living in three neighborhoods of Chicago
Two Jobs for Health Care Organizations to Embrace 26 Improve the health and wellbeing of patients Improve the wellbeing of communities Population health, wellbeing, and equity
4 Portfolios of Population Health 27
Portfolio 1 28 Focus on the mental and/or physical health of individuals and of individuals within a defined population. Activities include: Optimizing clinical care and treatment Patient empanelment and care management: Develop a system in which a multidisciplinary care team is responsible for managing an identifiable panel of patients. Access: Ensure that patients have 24/7 access to a care team practitioner as well as electronic access to their medical records.
Portfolio 1 29 Optimizing clinical care and treatment Evidence-based practice: Use a combination of current best evidence, clinical expertise, and patient values to guide decisions around care. Risk stratification: Develop a risk stratification process to segment your patient population based on needs and assets. Provide targeted, proactive, relationship-based care management for patients identified as at increased risk. Use a co-designed plan of care that is routinely assessed and updated by the care team.
Portfolio 1 30 Partnering with patients and families: Create and regularly convene a Patient and Family Advisory Council (PFAC) to surface opportunities for improvement, and encourage patient/family participation in quality improvement efforts whenever possible.
Portfolio 1 31 Engaging in performance improvement Data utilization: Identify and track clinical quality measures at the system, practice, and panel level. Use this data to identify, drive, and sustain performance improvement. Improvement: Identify and act on opportunities for improvement.
Portfolio 1 32 Focus on the mental and/or physical health of individuals and of individuals within a defined population. Activities include: Effective patient-centered medical home transformation Team-based care Proactive planned care Health coaching in the clinic or in the community Integration of behavioral health into primary care
Portfolio 1 Example: Intermountain Healthcare 33 Intermountain Healthcare 22 hospitals, 1400 physicians High functioning primary care, behavioral health integration into primary care, telemedicine; functioning as an ACO Saved $500 million in medical expense alone Returning savings to employers and patients as reduced premiums
Portfolio 2 34 Address social and spiritual drivers of health and wellbeing. Activities include: Screening for and addressing the social and spiritual drivers of health (social connectedness, sense of purpose of agency) Partner with local social service agencies, faith communities, housing organizations, and other community-based organizations
Portfolio 2 Example: Pathways Community Hub Model 35 Pathways Community Hub Model
Addressable Risk Reduction Engagement of at risk client Initial Checklist Captures Comprehensive Risk Issues Assign Pathways Initiation Step Track/Measure Results (Connections to Care) By: Care Coordinator Agency Region Name Medical Pregnancy Social Home Service CHW A 5 2 10 CHW B 1 3 4 CHW C 9 15 18 Yes No Question Do you need a primary medical provider? Do you need health Insurance? Do you smoke cigarettes Do you need food or clothing? Action Step Action Step Completion Step Site Medical Home Pregnancy Social Service Agency A 50 25 22 Agency B 64 17 35 Agency C 40 32 19
Percent Low Birth Weight Published Study on Results 37 18 16 14 12 10 8 6 6.1 13.0 Cost Savings: $3.36 for 1 st year of life; $5.59 long-term for every $1 spent 4 2 0 Pathway intervention over 4 years
Portfolio 3 38 Improve community health and wellbeing in a focused, place-based way. Collaboratively performing a community health needs assessment Being part of the community team to improve place-based health, wellbeing, and equity Ability to share data across partners Example: Support community wide medication cleanout drives organized by a peer recovery group
Portfolio 3 Example: Childhood Asthma Outcomes at Cambridge Health Alliance Childhood Asthma: % Patients with Asthma Admissions Pilot Sites (PEDO & SOPED) Rest of CHA 12% School Home % Patient Count 10% 8% 6% 4% 2% 0% Goal <=0.5% Jan-2002 Jan-2003 (N-Pilot = 125) (N-Pilot =369) (N-Rest = 18) (N-Rest = 30) Jan-2004 (N-Pilot = 479) (N-Rest = 209) Jan-2005 (N-Pilot =596) (N-Rest = 643) Jan-2006 (N-Pilot = 926) (N-Rest = 880) Jan-2007 (N-Pilot = 1097) (N-Rest = 889) Jan-08 Jan-09 Pediatrician
Portfolio 4: Communities of Solution 40 Co-investment in a comprehensive community revitalization strategy to address the symptoms of poor health and mobilize assets to address the drivers. Combine services and action on the ground with leadership development, capacity building, and policy development to build sustainable solutions.
Portfolio 4 Examples 41 University Health System (Cleveland) Engage local firms, local purchasing in poorest 7 zip codes surrounding the hospital. 5200 jobs created, $500 million infused into communities with worst life expectancy. Dignity Health, Bon Secours, Trinity Health Deploy investment portfolio as complement to CB spending Investments yield affordable housing, healthy food financing, child care centers, and small business development.
Trinity Health Transforming Communities Initiative 42 Seven sites for design of comprehensive revitalization strategies. Diverse community coalitions serve as intermediaries for planning, implementation, and monitoring. Combination of local assets, CB, and investments
Loyola School of Medicine and Proviso Partners for Health 43 Eliminate food deserts Community and youth leadership Economic development as a core strategy Training site
Break Be back by 10:15
Assess Yourself 10:15 11:00
A Moment of Reflection 46 Assess where you are in terms of systems change. What activities do you currently have in the 4 portfolios of population health? Are they balanced?
World Café: Exploring Portfolios of Population Health 11:00-12:00
World Café Questions What examples have you seen in this Portfolio? What do you think contributed to success?
Lunch The fun resumes at 1:00
Action Planning 1:00 2:30
Key Levers Care provider) Employer Restauranteur Purchaser Investor Advocate / Policymaker Environmental Steward Insurer Needs assessor Funder Community partner Placemaker Systems change agent Trusted advisor Others?
Action Planning 52 Individual Reflection Sharing in teams of 3 Designing a strategy to advance the journey to population health Practice your pitch!
Create Your3 Min Pitch! 53 Include: Portfolio(s) Key elements of the strategy Key partners / levers Anticipated barriers you ll need to address?
Break Be back at 2:45
Pitching Your Plans to Don Berwick 2:45 3:45
Moving Forward and Invitation 3:45 4:00
100 Million Healthier Lives Identity: An unprecedented collaboration of change agents pursuing an unprecedented result: 100 million people living healthier lives by 2020 Vision: to fundamentally transform the way we think and act to improve health, wellbeing, and equity. Equity is the price of admission. > 1000 members, partners and communities globally who reach more than 100 million people in the US alone
What We Do 58 Catalyze a movement of change leaders based on unprecedented collaboration, innovative improvement and system transformation Develop capability in communities and anchor institutions within communities to achieve measurable improvements in health, wellbeing and equity Innovate to solve complex and common problems Spread and scale bright spots and evidence-based practice Make the job of creating change easier for the change agents
Improve Population Health with Us 59 Download Pathways to Population Health: An Invitation for Health Care Change Agents (and provide feedback) Foundational concepts and a common language for understanding the journey to population health (the WHY) Portfolios of population health (the WHAT) Levers for implementation to accelerate progress across portfolios (the HOW) Contribute tools, resources, and stories to share with others on the journey. Join other HCOs around the country to learn, act, and improve on the journey to population health (more information coming March 2018) Visit www.pathways2pophealth.org
Appreciative Reflections