JOSINA VINK MRP DEFENSE APRIL 12, 2013 FROM BLIND SIDE TO UPSIDE REDESIGNING OUR RESPONSE TO PATIENTS’ SOCIAL NEEDS
From Blind Side to Upside: Redesigning Our Response to Patients' Social Needs
May 07, 2015
Slides from masters defense presentation - Josina Vink.
Masters of Design in Strategic Foresight and Innovation, OCADU.
It has been suggested that as much as 50% of population health outcomes can be attributed to social determinants of health (SDOH), the conditions in which people live (O’Hara, 2005). Despite widespread recognition of the importance of SDOH, little has been done to support primary care in effectively responding to the social aspects of patients’ health (Bloch, Broden, & Rozmovits, 2011). Using a variety of design research methods, including interviews and observations, this study investigated why rural family physicians are unable to successfully address SDOH of low-income patients. This exploration revealed underlying cultural and systemic barriers that inhibit physicians from meeting the social needs of their patients. After understanding the gap around the social aspects of heath that exists in medicine, recently dubbed ‘health care’s blind side’ (Robert Wood Johnson Foundation, 2011), and the related design opportunity, the Community Health Accelerator (CHA) concept was developed. A CHA is a system innovation that catalyzes connections and conversations about the social side of health by leveraging the role of primary care and catalyzing community action. This concept has the potential to create significant population health improvements and long-term reductions in health care expenditures by reorganizing existing resources.
Masters of Design in Strategic Foresight and Innovation, OCADU.
It has been suggested that as much as 50% of population health outcomes can be attributed to social determinants of health (SDOH), the conditions in which people live (O’Hara, 2005). Despite widespread recognition of the importance of SDOH, little has been done to support primary care in effectively responding to the social aspects of patients’ health (Bloch, Broden, & Rozmovits, 2011). Using a variety of design research methods, including interviews and observations, this study investigated why rural family physicians are unable to successfully address SDOH of low-income patients. This exploration revealed underlying cultural and systemic barriers that inhibit physicians from meeting the social needs of their patients. After understanding the gap around the social aspects of heath that exists in medicine, recently dubbed ‘health care’s blind side’ (Robert Wood Johnson Foundation, 2011), and the related design opportunity, the Community Health Accelerator (CHA) concept was developed. A CHA is a system innovation that catalyzes connections and conversations about the social side of health by leveraging the role of primary care and catalyzing community action. This concept has the potential to create significant population health improvements and long-term reductions in health care expenditures by reorganizing existing resources.
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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
3
4
5
6
7
8
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
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