Health System Transformation: Pathways to Population Health

Health System Transformation:

Pathways to Population Health

Somava Stout, MD MS; Vice President, Institute for Healthcare Improvement

and Co-Executive Lead, 100 Million Healthier Lives

Figure 1

Source: The Lancet 2011; 377:1877-1889 (DOI:10.1016/S0140-6736(11)60202-X)

Our care system was built for a different set of population health

issues: Causes of death and design of the health care system

Borrowed with permission from Rob Janett

The IHI 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.

Berwick D, Nolan T, and Whittington J. The Triple Aim: Care, Health, and Cost. Health Affairs 27(3): 759-769.

Cambridge Health Alliance

Integrated care

delivery system serving

130,000 patients(12 community clinics, 2 hospitals, 3 EDs, specialty sites)

Public health

Community(7 cities)

Customers(50% speak language

other than English)

3393 Employees(in 18 labor unions)

Trainees(actively engaged

in creating

Transformation)

Gabe

5

36% Reduction in Hospitalization Rate for Patients with Diabetes

Cost of chronic disease unsustainable

8

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.

Health and Social Inequity are Interconnected and Related to Place

10

A tale of two boys

11https://wsvn.com/news/us-world/color-blind-boys-scheme-to-get-same-haircut-to-trick-teacher/

Chronic place-based inequities are not accidental –there is a system in place that propagates them

12“Countering the Production of Health Inequities” Report from the Prevention Institute

Interrelationship between the health, wellbeing and

equity of people, places and the systems of society

Health, wellbeing

and equity

People

Systems of

SocietyPlaces

5 key shifts we need to make

• From a “sick care system” that is the job of health care to a “health and wellbeing system” that is all of our responsibility

• Take our work from “doing good” to a recognition that we are interconnected and cannot afford the price of poverty and inequity in terms of health outcomes or health care cost

• From pathology to vision – change is possible

• From people and communities of poverty to communities of solutions with trapped and untapped potential

• From scarcity to abundance14

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.”

Convened by the Institute for Healthcare Improvement as a partnership across

organizations.

100 Million Healthier Lives

www.100mlives.org

Theory of change – 100 Million Healthier Lives

Unprecedented collaboration

Innovative improvement

System transformation

100 Million People Living

Healthier Lives by 2020

A growing movement: >1850 members in 30+ countries worldwide reaching >500 million people – we need you! www.100mlives.org/map

https://www.utec-lowell.org/gallery/video

St Ninian’s

100 Million Healthier Lives (100MLives)

Health Systems Transformation Hub:

⚫ Formed to coordinate and align

efforts across organizations that

support health systems in

transformation efforts who agree to

align messaging and move the field

forward together.

⚫ Pathways to Population Health grew

from this effort.

How It Started

[email protected]#Pathways2PopHealth

www.pathways2pophealth.org

Pathways to Population Health (P2PH)

Five Partner Organizations Have Come Together To

1. American Hospital Association/Health Research and Educational Trust

2. Institute for Healthcare Improvement3. Network for Regional Healthcare

Improvement4. Public Health Institute5. Stakeholder Health

• Create and align messaging about what the journey to population health entails for health care organizations

• Build a pathway of support for health care organizations that:

• Helps them identify where they are and where to go next

• Puts tools and resources from the field together in one place

• Engage health care organizations on the journey to population health

[email protected]#Pathways2PopHealth

www.pathways2pophealth.org

+ more than 30 pioneer

sponsors!

Pathways to Population Health

1.Framework

2.Compass

3.Oasis of resources

21

Six Foundational Concepts of Population Health Improvement

What does population health mean to you?

23#100MLives

Two kinds of populations

Geographic or Place-Based Population

Defined by a place

• Children living in three neighborhoods of Chicago

• Residents of rural West Virginia

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

24

What does health mean to you?

• People define health for themselves

• Adaptation of World Health Organization domains:

“mental, physical, social, [and spiritual] wellbeing…”

• “Health is not the absence of disease but the addition of confidence, skills, knowledge and connection. But most importantly, it is simply a means to an end—which is a joyful, meaningful life.”

Cristin LindCristin Lind, with Gabe and Dagney

Population Health

Patients and

Employees Communities

Population Health

4 Interconnected Portfolios of Work

Improving the health and wellbeing of people

Improving the health and wellbeing of places

Improving the systems of society

Portfolio 1: Physical and/or Mental Health

Health care organizations are improving the physical and/or mental health of individuals within a defined population

Activities for this domain may include:• Patient empanelment and care

management; • Focus on access, evidence-based

practice and risk stratification; • Partnering with patients and families; • Engaging in performance improvement; • Partnering with patients and families• Engaging in performance improvement

• Data utilization• Improvement

[email protected]#Pathways2PopHealthwww.pathways2pophealth.org

Portfolio 1: Optimize mental and/or physical health and cost

• 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

28

Southcentral Foundation

• Alaska Native people who took over their health care system

• Built a health system based on relationships, trauma informed care

• Integrated mental health

• Community based treatment of trauma

• 50-75% improvement in outcomes and cost

29

https://www.youtube.com/watch?v=V1DL62iUxgU

Portfolio 2: Social and/or Spiritual Well-being

Activities for this domain may include:• Screening and addressing the

social determinants and spiritual drivers of health and well-being;

• Developing and utilizing key partnerships;

• Tracking improvement in the activities for the defined population in order to establish the value proposition.

Health care organizations consistently screen for and address the social and spiritual drivers of health and well-being for a defined population.

[email protected]#Pathways2PopHealthwww.pathways2pophealth.org

Connecting people to services: Aunt Bertha31

Portfolio 2: Address social and spiritual

drivers or health and wellbeing

Portfolio 2: Address social and spiritual drivers or health and wellbeing

32Pathways Community Hub Model

Pathways Hubs lead to Triple Aim Outcomes

6.1

13.0

0

2

4

6

8

10

12

14

16

18

Pe

rce

nt L

ow

Birth

We

ight

33

Pathway intervention

over 4 years

Cost Savings: $3.36 for 1st

year of life; $5.59 long-term

for every $1 spent

Portfolio 2 Address social and spiritual drivers or health and wellbeing

34

https://vimeo.com/83703623

Palo Alto Medical Foundation

Portfolio 3: Community Health and Well-being

Activities for this domain may include:• Collaboratively performing a

community health needs assessment– CHNA’s

• Setting goals and identify a collection of improvement projects.

• Establishing a learning and improvement system

• Co-investing in infrastructure that facilitates collaboration and the sharing of data, improvement methods, learning, and resources

Health care organizations work together with community partners to improve specific health and well-being outcomes for a place-based population.

[email protected]#Pathways2PopHealthwww.pathways2pophealth.org

Portfolio 3 Community Health and wellbeing: Childhood Asthma Outcomes at Cambridge Health Alliance

School Home

Pediatrician

0%

2%

4%

6%

8%

10%

12%

Jan-2002

(N-Pilot = 125)

(N-Rest = 18)

Jan-2003

(N-Pilot =369)

(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

% P

ati

en

t C

ou

nt

Pilot Sites (PEDO & SOPED) Rest of CHA

Goal <=0.5%

Childhood Asthma:

% Patients with Asthma Admissions

Portfolio 4: Community of Solutions

Activities for this domain may include:• Leveraging roles such as a

purchaser, employer, investor, and an environmental steward to improve overall community well-being.

• In community coalitions, mapping assets, creating a vision for the community, and identifying leaders at multiple levels.

• Addressing policy and system changes to promote health, well-being, and equity

Health care organizations actively engage in contributing to the long-term, overall well-being of the community as part of their mission and responsibility.

[email protected]#Pathways2PopHealthwww.pathways2pophealth.org

Portfolio 4: Communities of solution

• How could we use all our assets nimbly and creatively to move forward the priority goals of a community?

• How could we partner with people with lived experience and grow their leadership and ownership of the process of change?

• How can we work with leaders across the community across sectors and levers to creating meaningful, measurable, sustainable change?

• How could we disrupt the underlying systems that create inequity?

38

Portfolio 4: Communities of Solutions

• University Hospitals in Cleveland – Economic develop in poorest 7 zip codes surrounding the hospital.

• “Buy local, hire local, live local” in addition to community benefits. Impact: 5200 jobs created, $500 million infused into communities with worst life expectancy.

• Dignity health – Invest a part of the retirement portfolio to give low income loans to community-based businesses, low income housing developers

• MetroHealth and Case Western – Redefining a cradle to career pipeline as part of undefining the red line

39

Loyola School of Medicine and Proviso Partners for Health

• Eliminate food deserts

• Community and youth leadership

• Economic development as a core strategy

• Training site

40

Measuring Our Success Differently: Well-being In the

Nation (WIN) Measurement Framework

1.Core measures

• Well-being of people

• Well-being of places

• Equity

2.Leading indicators

• 12 domains and associated

subdomains related to determinants of

health (upstream, midstream, downstream)

3.Full flexible set (developmental measures)

• 12 domains and associated subdomains

41

www.winmeasures.org

People reported well-being

⚫ Cantril’s ladder -

Two simple

questions

⚫ Administered 2.7

million times,

highly validated

⚫ Relate to morbidity,

mortality, cost

⚫ Useful for risk

stratification

⚫ Work across sectors

42

Age

Sex

Race/Ethnicity

Education

Zip code

Veteran status

% people thriving

% people strugglinh

% people suffering

www.winmeasures.org

Leading Indicators

⚫ Community vitality

⚫ Economy

⚫ Education

⚫ Equity

⚫ Environment

⚫ Food & agriculture

⚫ Health

⚫ Housing

⚫ Public safety

⚫ Transportation

⚫ Well-being of people

⚫ + Demographics

43

Indicators with strong validity, importance, and data availability

44

www.winmeasures.org

WIN Implementers

1. US News & World Report

2. American Heart Association

3. National Councils on Aging

4. HERO (Employers)

5. Health systems - Kaiser Permanente, Health

Partners

6. States – Delaware, New York, California

7. Federal agencies – Veterans Administration

8. Public health agencies – Association of State

and Territorial Health Officials

9. Funders – Wellbeing Trust, Robert Wood

Johnson Foundation

10. Wellbeing Legacy partners

11. Technology groups: Community Commons,

LiveStories

12. Other measurement efforts – CityHealth

Dashboard, USNWR, Healthy Places Index,

SIREN

13. Other sectors: Housing (Enterprise), CDFIs

(Build Healthy Places Network),

Transportation, Business, Media

14. 100 Million Healthier Lives partners – IHI,

DASH, Empath, SCALE communities

15. In coordination with Healthy People 2030

45

www.winmeasures.org

What you can do – we invite you to

1. Commit to thinking and acting differently.

2. Assess your assets and opportunities with fresh eyes and think about how you could use them to address the needs of your patients and communities together with others.

3. Find partners—and join tables where people have been waiting for you.

4. Measure success in a way that really matters and will tell you whether someone’s real life is getting better.

5. Don’t go it alone--join the movement! www.100mlives.orgwww.pathways2pophealth.org 46

“If there is any period one would desire to be born in, is it not the age of revolution; when the old and the new stand side by side, and admit of being compared; when the energies of all men are searched by fear and by hope; when the historic glories of the old can be compensated by the rich possibilities of the new era? This time, like all times, is a very good one, if we but know what to do with it.” (Emerson)

47

Stepping Into Our Leadership In the Moment

www.100mlives.org

@100MLives @somastout [email protected]

48