From Blind Side to Upside: Redesigning Our Response to Patients' Social Needs

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JOSINA VINKMRP DEFENSE

APRIL 12, 2013

FROM BLIND SIDE TO UPSIDEREDESIGNING OUR RESPONSE TO PATIENTS’ SOCIAL NEEDS

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THANK YOU.ESPECIALLY TO MY INCREDIBLE ADVISORS KATE, ALLISON AND ROSE.AND TO IRMA FOR COLLABORATING ON THE ILLUSTRATIONS.

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PRESENTATION OVERVIEW

D E F I N I N G T H E P R O B L E M D E F I N I N G O P P O R T U N I T Y

[DIVERGE] [CONVERGE] [DIVERGE] [CONVERGE]

DesignConcept

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There is widespread recognition of the importance of social determinants of health . . .

http://psc28.wordpress.com/2012/09/20/progress-report-on-social-determinants-of-health-presented/

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But little has been done to ensure the health care sector in Canada is responding appropriately . . .

http://www.healthpolicysolutions.org/wp-content/uploads/2011/09/Dr.-Kim-White-examines-a-patient-while-speaking-in-Spanish-to-her-mom.jpg

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“HEALTH CARE’S BLIND SIDE”

[Robert Wood Johnson Foundation, 2011]http://www.rwjf.org/en/research-publications/find-rwjf-research/2011/12/health-care-s-blind-side.html

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THE SOCIO-ECONOMIC GRADIENT IN HEALTH7.6

5.6

4.7

3.4

2.7

0

1

2

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6

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Lowest Income Lowest Middle Middle Income Highest Middle Highest Income

% o

f Can

adia

ns R

epor

ting

Diab

etes

[Statistics Canada, Canadian Community Health Survey, 2005]

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RESEARCH QUESTIONS

1. WHY ARE THE SOCIAL DETERMINANTS OF HEALTH OF LOW INCOME PATIENTS CURRENTLY GOING UNADDRESSED BY RURAL FAMILY PHYSICIANS?

2. WHAT CAN BE DONE TO BETTER ADDRESS THE SOCIAL DETERMINANTS OF HEALTH OF PATIENTS?

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WHY DOES IT MATTER?

50%25%15%10%

Social & Economic Environment

Health Care System

Biology & Genetics

Physical Environment

Health of a Population

[Adapted from Canadian Institute for Advanced Research (2002)]

50%25%15%10%

Social & Economic Environment

Health Care System

Biology & Genetics

Physical Environment

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“The benefits extend beyond im-proved health status and reduced health disparities to foster economic growth, productivity and prosper-ity . . . A lack of action will be very costly in terms of direct health care costs, social costs related to welfare and crime, lost productivity and re-duced quality of life.”

[Canadian Senate Subcommittee on Population Health, 2009]

THE COST OF INACTIONCANADIAN PERSPECTIVE A HEALTHY PRODUCTIVE CANADA

AUSTRALIAN CALCULATIONSCOST OF INACTION ON SDOH

• 500,000 Australians could avoid suffering a chronic illness;

• 170,000 extra Australians could enter the workforce, generating $8 billion in extra earnings;

• Annual savings of $4 billion in welfare support pay-ments could be made;

• 60,000 fewer people would need to be admitted to hos-pital annually, resulting in savings of $2.3 billion in hos-pital expenditure;

• 5.5 million fewer Medicare services would be needed each year, resulting in annual savings of $273 million;

• 5.3 million fewer Pharmaceutical Benefit Scheme scripts would be filled each year, resulting in annual savings of $184.5 million each year.

[National Centre for Social and Economic Modeling, 2012]

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PROCESSME

THOD

S

PROBLEM FRAMING INVESTIGATION SYNTHESIS PROTOTYPING PRESENTATION

? !

Understanding the context and defining the

problem

Researching the opportunity for new

value creation

Combining insights to develop potential

interventions

Making concepts tangible, iterating,

evaluating & testing ideas

Sharing project findings, design ideas and

recommendations• Literature review• Trend & driver

analysis

• Semi-structured interviews

• Observations

• Concept mapping and visualization

• Opportunity analysis

• Design framework• Concept

development

• Prototypes• Co-creation

dialogue • Ongoing feedback• Concept

refinement

• Design description• Strategies for

implementation

• Sharing results

PART

ICIP

ATIO

N

TYPES OF PARTICIPANTS

• 10 health service providers • 9 experts and other key informants• 4 patients

NUMBER OF PARTICIPANTS

• 15 participated in interviews• 2 participated in observations• 11 participated in the co-creation

dialogue

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FUTURE THINKING

THE FUTURE OFRURAL MEDICINE

THE CULTUREOF MEDICINE

TECHNOLOGICALADOPTION IN

MEDICINENEW ENTRANTSIN HEALTHCARE

FINANCIALCONSTRAINTS OF

THE SYSTEM

URBANIZATION

COMMUNITYSUSTAINABILITY

weary workers. a new name for everything. youthless towns. the rise of aboriginals. doc in a box. there is an app for that. pill pushing. virtual connection. pay for performance. snip. snip. the growing gap. cheaper. faster. better. golocal. water war. smart streets. integrate or die. cut off. the doctor is out. pulling out the rug from under us. prove it. ipatient. do gooders.

TRENDS DRIVERS

Having a deep understanding of critical forces that may play out in the future contributes to more strategic and relevant design.

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WHY DOES IT CONTINUE TO EXIST?

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ORIGINAL PROBLEM

GETTING HEALTHY FOOD

MANIFESTS PHYSICALLY

FINDING A JOB

MOLD IN THE HOUSE

CARING FOR KIDS

SDOH FACTORS

GIVEN A BAND-AID SOLUTION

Family physicians recognized the need to deal with social needs, but found themselves avoiding social complexities in medical visits.

“SDOH are a hornets’ nest that must be avoided to stay on schedule.” – Rural Family Physician, Ontario

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HUMAN EXPERIENCE“When I go to my family doctor, I expect them to deal with prescriptions and test results.” – Patient, Ontario

Both physicians and patients felt uncomfortable with the interaction and there was a lack of connection between individuals.

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CULTURE

CLASS DIFFERENCE

STIGMA

INCOMEKNOWLEDGE

POWER

“There is certainly a stigma around poverty that contributes to it being ignored.”– Family Physician and SDOH Expert, Toronto

There is a cultural divide between physician and patient driven by a significant class difference and the stigma associated with poverty.

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STRUCTURE

EARLY LIFE MEDICAL SCHOOL RESIDENCY PRACTICE

LACK OF EXPOSURE PRESSURES OF THE CURRENT SYSTEMKNOWLEDGE / EXPERIENCE GAP

CLASS DIFFERENCE

THIRD YEAR EROSION OF EMPATHY

“Our system rewards quick and easy visits not spending time going through a patient`s complex non-medical issues.”– Rural Family Physician, British Columbia

There are critical system barriers that influence physicians, reinforce classism, and limit their engagement with social complexity.

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STRUCTURE“The propagation of wealth has implications.”– Family Physician and SDOH Expert, Toronto

The disease management system involves a reinforcement loop that contributes to poor health and acts as a self-preserving mechanism.

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PURPOSE

MEDICAL MODEL SDOH CONCEPT

At the core, there is a significant disconnect between the purpose of medicine and the social determinants of health approach.

“In the medical model of health, the body is seen as a machine that is either running well or in need of repair.”- Raphael, Social Determinants of Health: Canadian Perspectives (2008)

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MEDICINE CURRENTLY IS NOT WELL ALIGNED WITH THIS WORK DUE TO DEEP SYSTEMIC BARRIERS AND THE ORIENTATION OF THE PROFESSION TOWARD THE TREATMENT OF DISEASE.

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GOVERNMENTPOLICY MAKERS

PUBLICHEALTH

PHYSICIANASSOCIATIONS

SYSTEMADMINISTRATORS

HEALTH RELATEDBUSINESSES

COMMUNITYLEADERS

MEDICALSCHOOLS

PHYSICIANSSOCIAL

SERVICES

OTHER HEALTHPROFESSIONALS

OPERATIONALSUPPORT STAFF

PATIENTS

KEY LEVERAGE POINT

Physicians are a critical connection and leverage point within the system.

“Not only are family physicians treating these patients, they are leading physician associations, influencing government, heading up health care teams, teaching in medical schools and are respected voices in communities.”

- Family Physician and SDOH Expert, Toronto

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THE INSTITUTIONAL ASSUMPTIONRather than start with a question of institutional change, start with the condition. If we do that we will almost always recognize that the primary working area is community life.”

- McKnight (2012)

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BRIDGING THE CLINIC & COMMUNITY

There is an important opportunity space between the community (where health is defined) and the clinic (where patients are treated).

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DESIGN FRAMEWORKVALUES• Health• Community• Equity

PURPOSETo support transformation toward community health.

DESIGN PRINCIPLES1. Take a systems approach 2. Seek large-scale transformation3. Start small4. Leverage physicians 5. Empower patients6. Enable community ownership 7. Build on what works8. Embrace multi-disciplinary teams 9. Impact health

CONSTRAINTS• Time – Take action in two years• Resources – Leverage available resources• Money - Require minimal funds• Scope – Implementable by a small team • Scale – Initiate at the community and/or

clinic level

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COMMUNITY HEALTH ACCELERATOR (CHA)

A CHA is a catalyst of connections and conversations to address SDOH. It leverages primary care and empowers the community to animate health.

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THREE-PRONGED APPROACH

HEALTH INQUIRYDIALOGUES

ANIMATEHEALTH TOOL BOX

COMMUNITY HUB OR POP-UP STUDIO

These three components essentially reorganize existing assets to support health in a new way by shifting the focus from illness to community.

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HEALTH INQUIRY DIALOGUES

These dialogues are monthly collaborative conversations that engage students in a immersive and reflective exploration of social health issues in community.

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ANIMATEHEALTH TOOLBOX

It is a box filled with conversation, assessment, and referral tools to support primary care professionals or volunteers in a primary care setting with SDOH.

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COMMUNITY HUB

The hub is a pharmacy with people instead of pills, where community members utilize their strengths and relationships to address social health needs.

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Student Volunteers

Shared Community Network

Exposure and Skill Development of Students

Aware Graduates with Need for Clinical Tools

Health Professionals to Share Experiences

Support in Addressing Health Needs

Prescriptions and Subscriptions

Identification of Community Health Patterns

COMMUNITY HUB

HEALTH INQUIRYDIALOGUES

TOOL BOX

COMMUNITYHEALTH

A SYSTEMS INNOVATION

These interdependent interventions create a system innovation that strengthens the benefits of each component and amplifies the impact.

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BACK STAGECOMMUNITY HUB

SUPPORTING INFRASTRUCTURE GUIDING COLLABORATIVE

COMMUNITY ANIMATORS FACILITATOR

HEALTH INQUIRYDIALOGUES

TOOL BOX

Mapping & Faciliation

Topics & Participants

Health Expertise Patterns & Referrals

Resources & Support

Interests & Assets

In addition to the connections between components, there are a number of back-end roles and systems that link and enable the front line components.

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DIFFERENT JOURNEYSPA

TIEN

TST

UDEN

TPR

OVID

ERCO

MMUN

ITY

MEMB

ER

Stakeholders link into and engage in the system in a variety of ways, all collectively working at improving community health.

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IMPACT

IMPROVED HEALTH OUTCOMES

REDUCED HEALTH CARE COSTS

INCREASED RESILIENCE

STRONGER COORDINATION

GREATER HEALTH EQUITY

SHIFTED HEALTH CARE SYSTEM

ENHANCED QUALITY OF LIFE HEIGHTENED PROSPERITY

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KEY PARTNERS

COST STRUCTURE REVENUE STREAMS

KEY ACTIVIES VALUE PROPOSITIONS CUSTOMER RELATIONSHIPS

KEY RESOURCES CHANNELS

CUSTOMER SEGMENTS

BUSINESS MODEL

The innovation is financially viable while at the same time modeling a collaborative, innovative structure within the health care industry.

ImpatientsPrimary care clinics/providersProfessional Health SchoolsLocal Health Integration Network

Primary care clinics Health care students Community leaders Social servicesInpatients Tech. partner(s) Colleges or universities LHINs

Animation, tool dev., hub maintenance, technology dev., training, reporting, & communication

Animators, relationships, community leaders, space, & information

Support for health improvements Assistance meeting patient needsStudent development and community investmentCost reductions & population health

Personal assistance & connection to community

Hub, clinics, web, schools, and partner channels

Free service to impatients, sales of tool kit and subscription from primary care, lump sum investment from schools, and funding proportional to health outcomes

Community facilitator salary, tech. development and maintenance, hub space, tools, training, and admin.

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MOVING FORWARD

Experiments Begin

Business Plan

Pilot Begins

500 People Reached

Initial Evaluation

Full Implementation inOne Community

2,500 People Involved

2013 2014 2015

To move the CHA concept forward, a lot more work will need to be done on development, planning and implementation.

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THE HOPE IS THAT WITH FURTHER EXPERIMENTATION, FAILURE, AND RAPID ITERATION, THIS MODEL COULD CONTRIBUTE TO A SYSTEMIC SHIFT FROM ILLNESS TO COMMUNITY.

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QUESTIONS?

Josina Vink,MDes Candidate