From the Robert Wood Johnson Foundation's Aligning Forces for Quality project:
Inequities in health care continue to exist in our system and influence whether a patient receives the procedures and treatment they need. Disparities in care can result in shortened lives, increased illness, and higher health care costs. Improving health care equality begins with identifying areas where inequality exists, understanding patients’ cultural backgrounds and knowing how to address them.
Aligning Forces for Quality community alliances are closing the racial and ethnic disparities gap by sharing data, encouraging collaboration and engaging patients. This package of materials includes an issue brief, interview, case studies, videos and other resources that outline efforts to level the playing field, improve health care quality and create a national culture of health.
These resources are part of AF4Q’s “Quality Field Notes” series highlighting lessons learned by clinicians, patients, and payers to transform health care locally. They can be found at www.rwjf.org/equity.
From the Robert Wood Johnson Foundation's Aligning Forces for Quality Program:
Patients in Western New York hospitals are having less fraught transitions from the hospital to home thanks to a community initiative. Under the leadership of the P2 Collaborative, 10 hospitals and eight community-based organizations have banded together to reduce avoidable hospital readmissions. Contracted by the Centers for Medicare and Medicaid Services through the Community-based Care Transitions Program (CCTP), the coalition provides coaching services to Medicare Fee-for-Service patients who are at risk for readmission to the hospital after an acute care episode. Patients are eligible for CCTP only if they are insured under Medicare Fee-for-Service.
The goal of the Western NY CCTP is to strengthen the self-management skills of patients moving from the hospital to home while providing support by a trained coach and increasing referrals to community programs and resources. The goal of the program is to reduce readmissions by 20 percent over two years. Ultimately, the intended outcome is a significant cost savings to both Medicare and the community while affording patients the best possible experience.
Core components of the coaching model include medication self-management, creating a patient-centered record, primary care and/or specialist follow up after hospital discharge, and helping the patient to understand “red flags” about their condition.
During the first year of the program, the Care Transitions of Western New York coalition provided coaching services to more than 280 Medicare Fee-for-Service beneficiaries across seven participating counties (Allegany, Cattaraugus, Chautauqua, Genesee, Niagara, Orleans, and Wyoming). At only nine months into year two, the coalition already has exceeded year one’s numbers, having served more than 420 patients to date.
Initially, the launch of the CCTP program was problematic. Shrinking hospital financial resources and ever-increasing demands on hospital staff time limited the time and attention it received. The number of eligible patients declined as more patients chose Medicare Advantage plans over Medicare Fee-for-Service. A continuous difficulty has been the problem of patient volume. “The economies of scale just aren’t there without the volume,” said Megan MacDavey, manager of care transitions for P2.
Dana Corwin RN, nurse coordinator with Chautauqua County Office for the Aging, described the initial difficulties her agency faced in offering CCTP to local hospitals. “We had some communication and some relationship, but it really was kind of a tough sell to the hospitals. They were afraid that we were going to interfere with their discharge plans.” The Office for the Aging had to introduce itself anew and explain its perspective as a single point of entry for long-term services for older adults. Even then, the hospitals flagged some appropriate cases for the program— but not all the cases. “It was a very slow ramp up,” said Corwin.
Once an area hospital had a change in its administration, the Chautauqua County Office for the Aging re-approached the hospital and was approved to have a case manager join rounds three times per week on a nursing unit, and twice a week on primary care disposition
rounds. Once the case manager joined rounds, brainstorming about client care and discharge plans became all the easier with hospital staff. “Once that started, referrals to the program doubled!” said Corwin. “Now the staff are really seeing a value.”
“The coach joining rounds is pretty unique. The coach represents a lot of services given by the office of aging and also can serve as a resource for patients that aren’t eligible for CCTP by referring to other services, such as meals on wheels,” said MacDavey.
Other small changes have increased CCTP’s uptake. “It’s simple things, like multidisciplinary staff discussing the program each time when visiting the patient, if they are eligible, and explaining the benefits,” said Joan Breese, RN, CCM director of case management with Upper Allegheny Health System. Other hospitals have found success by requiring eligible patients to opt out, rather than securing permission to opt in.
As the coalition, hospitals, and care managers work together to grow the program, more and more patients in Western New York will thrive after an acute hospital episode.
From the Robert Wood Johnson Foundation's Aligning Forces for Quality Program:
More than 80 participants gathered in Dallas September 19-20 to discuss bridging the gap between health care and population health. Representatives from each Alliance and outside guests, community partners involved in population health projects, joined staff from the National Program Office and the Robert Wood Johnson Foundation to share experiences—both successes and frustrations—as they move toward addressing population health issues as they continue their work with Aligning Forces for Quality—and beyond.
The meeting kicked off with a dinner featuring keynote speaker T.R. Reid, noted journalist and author. “Building models for national reform is an ingenious idea, and it’s working,” he told the group. “Where AF4Q is working, it’s really making a difference.”
Reid touched on different models for health care—the Beveridge, Bismarck, Douglas, and “Out-of-Pocket” models (such as that used in the United States)—with some examples of where these models are being used and what the big picture for health care quality is in those areas.
The common thread? In every country, the poor have a higher rate of illness and a lower rate of recovery from illness. They die younger, even in places like Great Britain that provide health care to everyone for free. This, suggested Reid, is where attention to population health steps in.
The following day four panels discussed on how to connect health care and population health. In “Pulling the Correct Levers to successfully Connect Health Care and Population Health,” panelists hit the ground running by defining the two. “Public health has the mission, but health care has the money,” said Patrick Remington, associate dean for public health at the University of Wisconsin School of Medicine and Public Health. “Align the money with the mission.” The panelists also discussed how the differences between the two might allow for synergy.
Jim Hester, former director of the Population Health Models Group, Center for Medicare & Medicaid Innovation, said that developing a community health system that gets at the root of illness is critical. “Start with the determinants of health model and work at all levels,” he said. He also stressed the importance of finding a sustainable payment model. “Get away from dependence on grants,” he advised.
“The financial payment model is a key lever in this work,” he said. “Payment models have been a barrier to population health. We need a portfolio of interventions to improve pop health, not just one mechanism. How can we tap into different sources of funding and use that support for new interventions?”
Peter Briss, medical director at the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, stressed the importance of convening stakeholders when attempting to improve population health. Doing so can help identify and spread what really works and enable partnering organizations to address the most important drivers, such as payment, data infrastructure, and measurement such as the County Health Rankings. It’s important to identify those drivers and any areas of need and then match dollars to those needs. “It’s easier to bring stakeholders together if you have standing,” he said, “but you can still accomplish something through coalition building, even though it’s hard, slow, hand-to-hand combat.”
ACA and Population Health
Many aspects of the Affordable Care Act (ACA) are pushing and will continue to push health care stakeholders to work more closely with population health-focused organizations in their communities to keep people health. This momentum will open up opportunities, but it obviously creates challenges as well.
“Expanded community health needs assessment and community benefit requirements for non-profit hospitals are an opening for not just public health stakeholders to partner with hospitals, but also community-based groups not traditionally associated with health care,” said Jessica Curtis, director of the Hospital Accountability Project, Community Catalyst. But she warned of an information gap in the communities—a gap Alliances are poised to fill by communicating clearly how these new requirements can work in their communities to create new partnerships to promote health.
Nalini Pande, principal policy director at American Institutes for Research, agreed communication is key, but added that a boots-on-the-ground approach, like the one taken by the P2 Collaborative of Western New York, is out in the community measuring and focusing on social determinants, is a key in bridging the gap. Nevertheless, she said, “Alliances need to think through the reality of your community and what is feasible. Success might be incremental.”
Despite the potential for better partnerships and more effective communication that would come about with ACA implementation, concerns remain. Offering a government agency perspective, Princess Jackson, director of the Dallas region for the Health Resources & Services Administration (HRSA), told the gathering that HRSA is looking at helping organizations provide resources to anyone regardless of their ability to pay. They’re concerned about the number of patients who will still be uninsured after ACA implementation. Jackson said AF4Q and HRSA should work together on these issues and there are many HRSA grantees that, while working to sign up people for insurance, are doing great work in their communities to connect patients with community resources.
This session about patients who comprise a small percentage of the population but who account for a huge percentage of health care costs offered some excellent examples of groups that have made a big difference in their communities by addressing this issue connecting high-utilizers of health care with community resources to keep them healthy.
In Doug Eby’s Anchorage community, Nuka, an Alaska Native-owned and -run health safety net system organization built their organization with a customer-owned and customer-designed approach that helped them see, in Eby’s words, “we need to quit doing things topeople. We need to connect with their hopes and aspirations.” Nuka’s outcomes have been impressive, accomplished through an integrated care team, an approach mirrored by the communities of the other panelists. Both the Community Medicaid Collaborative (CMC) in Niagara Falls and the Austen BioInnovation Institute in Akron use similar community-based approaches. CMC uses care coordinators and community health workers in primary care settings, empowering neighborhoods and working for culture change at all levels. The Austen BioInnovation Institute focused on community health from a perspective of building the community by returning some cost savings to the accountable care community—so named because it connects with nontraditional stakeholders like parks and transportation—and investing some in new initiatives. Janine Janosky, vice president of medical services at Austen, stressed that collaboration is a process with collective impact as the outcome—system redesign hinges on knowing when an implemented program is not meeting objectives.
All panelists agreed that using community health workers usually works and that the next step is to expand their use.
“Deep personal relationships formed between patients and community health workers is how you make interventions work in the community,” Eby said.
What Could Work?
The final panel explored examples of communities that are successfully bridging the gap between population health and health care. At Hennepin Health, they’re redesigning care through an ACO focused on Medicaid patients. In one year, the ACO in Hennepin County reduced health care costs for participating patients by 30 percent, according to Nancy Garret, director of the Analytics Center of Excellence at Hennepin Health. They’ve created a data warehouse so they can get the whole picture of the patient from multiple sources inside and outside the health care system. They are also bringing dental care into medical settings to make it easier to treat the whole person.
Cambridge Health Alliance has achieved success by using evidence-based practices, identifying roles and responsibilities, reviewing data, determining shared priorities with community partners, and monitoring progress. “Incremental strategies are a great way of getting people started and have a better chance of sustainability,” said Karen Hacker, formerly of the Camden Health Alliance and currently head of the Allegheny Health Department. Through this approach, Camden improved childhood asthma rates so much they closed down their unit.
“You need people in your organization who are bridge builders,” said Hacker.
For Healthy Livable Communities Consortium of Cattaraugus County in New York, the bridge builder was the P² Collaborative, AF4Q’s Alliance in Western New York. The Alliance plays the part of the community integrator. “In all of our worlds, we lean one way or another, and we know we need objectivity—P² Collaborative provided that for us,” said Cattaraugus’s Public Health Educator Debra Nichols.
From the Robert Wood Johnson Foundation's Aligning Forces for Quality Program:
More than a year ago, the P² Collaborative of Western New York began a unique new working relationship with the New York State Department of Health on its agenda for public health. The state of New York requires every county to complete a community health assessment every three years to evaluate local strengths and weaknesses in public health. Based on the assessment, counties then create a community health improvement plan—this is how a county will address the problems identified during the assessment phase. Both components are essential to improving public health.
This year, the state has been asking counties and hospitals to work together and collaborate on these plans and, for the first time, to set measurable goals. As a neutral convener, P² has been instrumental in connecting public health county officials and medical providers in seven counties in western New York. “Whenever we can strengthen the partnerships between the health departments and the hospitals, that’s extremely beneficial. And even the hospitals among themselves—oftentimes they are in competition,” said Daniel Stapleton, public health director of the Niagara County Department of Health. “If we all work together, we can have a greater, measurable impact on the health of the communities we serve.”
This approach was brand new to many in local public health communities. “For people who’ve never done a health assessment, this can be a scary task. P² has taken the lead in organizing,” said Dennis J. McCarthy of the Upper Allegheny Health System. P² was able both to connect health leaders and help facilitate setting measurable goals for each county. P² has helped counties gather input from area residents through meetings and surveys, compile data, run focus groups, and train people to continue these types of conversations beyond the immediate task at hand.
Many local health agencies gathered interested residents to talk about health concerns and needs in a facilitated conversation known as a community conversation. Each local health agency hosting a community conversation devised a strategy to best reach area residents, with the assistance of P². Community conversations were advertised through multiple media to reach the most diverse cross-section of residents possible. Strategies ranged from low-tech—flyers at libraries and grocery stores—to outreach through email and mailing lists.
To expand the reach of community conversations, P² used a train-the-trainer model, equipping local representatives with the skills to manage open conversations about health needs. In Niagara County, the local health department and county hospitals all conducted individual focus groups to identify the health needs of their various stakeholder groups. In Genesee, Orleans, and Wyoming counties, local health department representatives conducted more than 10 rural community conversations. In Cattaraugus County, P² again trained local health department staff and other health care agency representatives to facilitate the conversations. In a unique effort in Chautauqua County, P² partnered with local hospitals to co-host a community conversation in each hospital service area. In August, P² hosted a webinar to explain further the types of support available to local health agencies.
P² worked with representatives from the local health departments to develop a survey to help the counties assess community needs. The survey was distributed via email; paper copies were available as well. The survey also was available in Spanish. All told, 6,500 western New York residents responded to a county-specific survey about their health needs. In addition, P2 crunched the data on behalf of local health departments. Said McCarthy, “Without P², it would have been much more of a struggle, and less collaborative. They have the knowledge and skills, and they pulled us all together.”
Aligning Forces for Quality (AF4Q) is the Robert Wood Johnson Foundation’s signature effort to lift the overall quality of health care in targeted communities, reduce racial and ethnic disparities and provide models for national reform.