5 pag of length no including title or references. READ instructions

Health_Reform_Policy_to_Practice_Oregons_Path_to_..._----_III._Future_Implications_for_State_and_National_Health_Reform.pdf

Home >Nursing homework help >5 pag of length no including title or references. READ instructions

Chapter 17

The Health Care Journey to Population Health: Guideposts From the Oregon Experience

Somava S. Stout1,2,3, Liz Powers4, Rebecca Ramsey5, Jennifer Richter6, Kevin Ewanchyna7 and Kristen Dillon8 1Institute for Healthcare Improvement, Cambridge, MA, United States, 2Cambridge Health

Alliance, Cambridge, MA, United States, 3Harvard Medical School Center for Primary Care,

Boston, MA, United States, 4Winding Waters Medical Clinic, Enterprise, OR, United States, 5CareOregon, Portland, OR, United States, 6Yamhill Community Care Organization,

McMinnville, OR, United States, 7Samaritan Health Plans, Corvallis, OR, United States, 8PacificSource Columbia Gorge CCO, Hood River, OR, United States

I’m on the bus; in fact, I’m driving the bus. I’m “all in” for population health,

for addressing the social determinants of health, for partnering with communi-

ties. I see that this is the only way we will achieve the Triple Aim. But I have

no idea how to get from here to there. I’m in charge of an infrastructure of

buildings and technology and staff designed to take care of people when they

are sick. How do I transform my infrastructure and business model from a sick

care system to a system designed [to] support people to thrive?

CEO, Mid-Sized Safety Net Health Care System

US health care delivery systems are being asked to undertake a monu-

mental transformation on the journey from volume to value. As payment

models shift from fee-for-service to alternate models based on global budgets

or shared savings, health care organizations are feeling the shift from produc-

ing acute, largely reactive sick care services to prevention and proactive pop-

ulation health (Auerbach, 2016). It is difficult to think of another major

industry that needs to so fundamentally change what it is about. There is no

roadmap for this journey—it is an expedition into a new frontier of large-

scale transformation. As health care leaders embark on the journey, they are

building the plane as they are flying; the experiences of states like Oregon

that are a decade into the journey provides critical insight on the routes that

pioneers are discovering that are relevant nationally. This chapter offers

283 Health Reform Policy to Practice. DOI: http://dx.doi.org/10.1016/B978-0-12-809827-1.00017-3

© 2017 Elsevier Inc. All rights reserved.Stock, R., & Goldberg, B. W. (Eds.). (2017). Health reform policy to practice : Oregon's path to a sustainable health system: a study in innovation. Retrieved from http://ebookcentral.proquest.com Created from miami on 2020-04-15 20:59:02.

C op

yr ig

ht ©

2 01

7. E

ls ev

ie r S

ci en

ce &

T ec

hn ol

og y.

A ll

rig ht

s re

se rv

ed .

http://dx.doi.org/10.1016/B978-0-12-809827-1.00017-3

a brief description of Oregon’s transformation in a national context and a

glimpse of stories at the leading edge of transformation. We use the stories

of Oregon’s transformation to delineate a potential framework that illustrates

the interconnected portfolios of population health that health care systems

learn they need to take on to achieve growth of health, well-being, and

equity for people and places in the country.

The notion of the “Triple Aim” (Whittington, 2015) introduced by the

Institute for Healthcare Improvement (IHI) in 2008, of improved population

health, patient experience, and lower health care cost (Berwick, Nolan, &

Whittington, 2008), has been adopted by hundreds of health care organiza-

tions and reform efforts in all parts of the country and at local, state, and

national levels. As hundreds of health care systems have gone on the Triple

Aim journey, in the context of the Affordable Care Act, several findings

have become apparent: (1) health care systems have been less successful at

forming partnerships with other sectors, in part because they do not have

relationships with them. As a result, the vast majority of systems tend to

work within their own walls, although the vast majority of what impacts

health exists where people live, work, and play; (2) while the majority of

high-risk, high-cost patients had social and behavioral drivers of poor health

and cost outcomes, the vast majority of health care systems have not

integrated this into their transformation strategies; and (3) while health care

systems on the journey recognize these changes, there are few supports to

help them make this transition; and the importance of shifting culture

(Whittington, 2015). The level of collaboration across sectors that is needed

to truly achieve population health, the integrated data systems that are

needed to improve outcomes, and the financing mechanisms to sustain the

journey simply are not in place. These collaborations need to be developed in

order to support a critical mass of health care systems to go on this journey—

along with a vast cultural shift that reorients everyone from the frontline to

the C-suite about what they will need to do differently (Pollack, 2015).

Halfon et al. (2014) have described this shift as going from Era 1.0 to

3.0. In 1.0, health care operates as a sick care system. In Era 2.0, there is an

effort to develop a coordinated health care system—with the patient-centered

medical home and accountable care organizations serving as the primary

building blocks for the journey. In Era 3.0, there is an effort to develop a

community integrated health system that focuses on “population and commu-

nity health outcomes; optimizing the health of populations over the life span

and across generations” (Halfon et al., 2014). Major foundations and public

health leaders have suggested that this transformation needs to be contextual-

ized within a major cultural shift that is needed across sectors to prioritize

health and well-being for both people and places (Lavizzo-Mourey, 2014).

The 100 Million Healthier Lives initiative (www.100mlives.org) was con-

vened by IHI in 2014 to help accelerate the journey to population health,

well-being, and equity with an emphasis on facilitating the shift in health

284 SECTION | III Future Implications for State and National Health Reform

Stock, R., & Goldberg, B. W. (Eds.). (2017). Health reform policy to practice : Oregon's path to a sustainable health system: a study in innovation. Retrieved from http://ebookcentral.proquest.com Created from miami on 2020-04-15 20:59:02.

C op

yr ig

ht ©

2 01

7. E

ls ev

ie r S

ci en

ce &

T ec

hn ol

og y.

A ll

rig ht

s re

se rv

ed .

http://www.100mlives.org

care from Era 2.0 to Era 3.0 and supporting the development of a culture of

health in people, organizations, and communities (Lavizzo-Mourey, 2014).

Hundreds of partners joined the initiative. They recognized that an innova-

tive and collaborative system was needed to realize transformative health

improvements for 100 million people by 2020. To this end, the partners iden-

tified six core strategies:

1. Create thriving, equitable communities

2. Build bridges between health care, community, public health, and social

service systems

3. Create a health care system that is good at health and good at care

4. Create peer to peer support systems

5. Create enabling conditions

6. Develop new mindsets.

As partners began to map out the different ways in which health care

systems go on the journey to population health, we looked to places and orga-

nizations that were further along the journey—Vermont, Oregon, Kaiser

Permanente, Southcentral Foundation (Alaska), Cambridge Health Alliance—

to understand how health care systems were making progress (Koch, Stout,

Landon, & Phillips, 2016). We learned, for instance, that transformation most

often occurred in stages, in connected portfolios of work, often starting with a

specific issue or population that was a common concern of partners across

sectors. The work together on these first issues built the groundwork for col-

laboration—trust, an understanding of each other’s assets, etc. In addition, the

work often fell into related, balanced portfolios of work, which were previ-

ously separate and became more and more interconnected over time. They

most often begin addressing issues related to their patient population, and as

they change their financing and go deeper and deeper, begin to understand

the interrelationship between the health and well-being of people and places

and develop the trusting relationships that lead to better understand how real

change is possible.

Over time, from studying these advanced systems and bringing our col-

lective thought leadership together, the 100 Million Healthier Lives Health

Systems Transformation Hub developed the following framework, which has

served as a useful organizing system (Stout, 2017). It is important to note

that in this initiative, health encompasses the World Health Organization

domains of mental, physical, social, and spiritual well-being for people and

places (Stiefel, Riley, Roy, Ramaswamy, & Stout, 2016). Rather than fram-

ing a linear journey toward population health, we have observed that health

systems approach this journey based on an evolving understanding of their

stewardship responsibility and impact. In Levels 1 and 2 of the framework,

health care systems focus on patients and employees as the focus of the

change effort. Levels 3 and 4 reflect an expanded sense of stewardship for

place and a recognition that the well-being of people is directly related to the

The Health Care Journey to Population Health Chapter | 17 285

C op

yr ig

ht ©

2 01

7. E

ls ev

ie r S

ci en

ce &

T ec

hn ol

og y.

A ll

rig ht

s re

se rv

ed .

well-being of the place—the neighborhood and community—they live in.

A health care system likely will have a portfolio of work across multiple

levels—but rarely thinks strategically about these portfolios or balances them

for impact. Health systems in the 100 Million Healthier Lives initiative are

invited to strategically invest across these levels to maximize their impact on

population health (Fig. 17.1).

Level 1: Patient or Panel Health—The focus is on proactively improv-

ing the mental and physical health of patients (or employees). Proactive pop-

ulation health management in the context of robust primary care

transformation, integration of behavioral health services into primary care,

extension of patient coaching and health education services—are all exam-

ples of activities at this level. Much of Oregon’s transformation has focused

on this level, with early evidence of significant results (Goldberg, 2016).

Level 2: Patient Well-Being—Health care organizations at this level

screen for and address the social and spiritual drivers of health and well-

being. Social drivers encompass both social connectedness and socioeco-

nomic factors, such as food, housing, transportation, and income. Spiritual

drivers describe factors that affect a sense of purpose, meaning, hope, and

resilience. Examples of activities in this portfolio would include screening

for social service needs for a segment of the population and making referrals

to local social service agencies with tracking to completion. Many health

systems start out doing these activities for high-risk, high-cost patients in

their capitated portfolios, and expand the pool to include patients who are at

rising risk or who are in the population as a whole because they recognize

that these social factors drive future cost. The Pathways Community Hub

model, which employs community health workers (CHWs) who screen

people referred by any organization in a community comprehensively in

FIGURE 17.1 Framework for the journey to population health for health care organizations.

From Stout, S., et al. Health System Transformation to Population Health�Emerging

Framework, 2017, 100 Million Healthier Lives, Institute for Healthcare Improvement.

286 SECTION | III Future Implications for State and National Health Reform

C op

yr ig

ht ©

2 01

7. E

ls ev

ie r S

ci en

ce &

T ec

hn ol

og y.

A ll

rig ht

s re

se rv

ed .

terms of medical, social, and behavioral risk, places them into a pathway,

tracks the pathway to completion, has linked incentives to pathway comple-

tion, and represents an advanced example of activities in this level (Redding

et al., 2015). In more advanced systems, there may be interoperable integra-

tion between electronic medical records and the systems of social service

agencies. Faith�health connections might be nurtured, as appropriate, and

life coaching, education, and employment referrals might be made as a rou-

tine part of care. There is emerging evidence of the impact of addressing

social and behavioral needs and ample evidence that these drivers are the

predominant drivers of outcomes (McGinnis & Foege, 1993).

Level 3: Community Well-Being—The health care organization is com-

mitted to improving the well-being at the level of a community and is a

partner at the table along with other leaders in public health and other sec-

tors to support the health and well-being of a community as a whole. They

might begin with a particular issue or a particular place that is of mutual

concern across sectors and grow into full collaboration on a wide range of

complex challenges. Early collective impact efforts fit into this level. They

begin to discover what they can do together that they cannot do alone and

begin to learn how to create system change together. Engagement may be

by people in community benefits and occasionally staff engaged in an

accountable care organization or patient-centered medical home. From

childhood obesity to tobacco control to childhood asthma to efforts aimed at

revitalization of a particular neighborhood, efforts at this level typically

address concerns that are less complex and more amenable to change—the

“low hanging fruit.”

Level 4: Community of Solutions—At Level 4, health systems see them-

selves as stewards of a community’s well-being, in partnership with leaders

of diverse roles and levels in a community. People with lived experience

(community members/supports who have direct experience with a challenge)

are seen as crucial to the process and provide leadership and support in

addressing the health and well-being of the community. Design and copro-

duction approaches are used to rapidly improve processes to meet the needs

of people, and staff is allocated to support the process. Health care organiza-

tions adopt an anchor institution approach, such as the one described in the

Democracy Collaborative monograph, Can Hospitals Heal America’s

Communities? (Norris & Howard, 2015). In this approach, health care lea-

ders, along with leaders from other sectors, see themselves as long-term

stewards of a community’s well-being and leverage their assets in traditional

and nontraditional ways to improve the health and well-being of a commu-

nity, in accordance with the community’s priorities. A health care system,

applying this kind of anchor institution approach, might use its lever as an

employer to support the cradle to career pipeline in a community of concen-

trated poverty or as a food purchaser, having an impact on the local economy

for healthy fruit and vegetable availability within a food “desert.” Together,

The Health Care Journey to Population Health Chapter | 17 287

C op

yr ig

ht ©

2 01

7. E

ls ev

ie r S

ci en

ce &

T ec

hn ol

og y.

A ll

rig ht

s re

se rv

ed .