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Mobilizing Stakeholders For Better Health, Better Care and Lower Costs

April 12, 2012

In health policy circles, we are fond of saying that all health care is local. The research on variations in health care costs, delivery, and outcome bears this out. So, if that is the case, don’t solutions to many of our health care problems also need to be locally generated, locally shaped, and locally implemented? Communities across the country are experimenting with ways to become healthier from the Blue Zone communities to communities like Columbia, South Carolina, the topic of today’s guest blog by Rick Foster, MD, SVP for Quality and Patient Safety at the South Carolina Hospital Association, a key stakeholder in the “Healthy Columbia” campaign. Thanks, Rick for providing this great post on Columbia’s call to action to improve the health of its residents. Pat

Healthy Columbia

by Rick Foster, MD

It is increasingly clear that the sustainability of health care in this country depends on the health of the American people, and that requires a transformational shift on the part of health care providers. Here in Columbia, South Carolina, we are in the process of making that shift, and there’s much that health care providers elsewhere can learn from this effort.

In Columbia, chronic disease and poor health have reached alarming proportions. The 29203 zip code area, on which we have focused, has high rates of diabetes, heart disease, cancer, emergency room use and hospitalization, as well as one of the highest rates of diabetes-related amputations in the United States. With more than 40,000 residents, one in three is uninsured. Those almost 15,000 uninsured residents – with limited or no access to primary care – incur millions of dollars in health care costs.

That’s why the South Carolina Hospital Association and major health care providers in the area have joined with the broader public to develop a community-wide mobilization of stakeholders to improve health and care and better manage the resources collectively available. The campaign – called “Healthy Columbia” – did not originate with the health care providers; it grew out of a shared concern by a broad group of stakeholders: individual residents, churches and other influential nonprofits, local businesses, and health care institutions (providers and insurers).

The Campaign has evolved through an unprecedented sequence of events:

• In July, 130 one-to-one meetings were held with residents of the 29203 community to explore common values and experiences;
• In August, 91 residents came to a Town Hall Assembly to talk about their vision to transform their health and health care;
• In September, 35 community leaders were recruited and equipped to help advance this effort;
• In October, 750 people in the community attended House Meetings to discuss potential campaign strategies;
• In November, nearly 200 residents of the 29203 community came together for an Issues Assembly held at a local middle school, where community members collectively decided on a campaign strategy to transform health and health care within the community;
• In January, another 100 community leaders were recruited and equipped to launch the Campaign.

This is stakeholder mobilization, which helps residents determine their own goals for better health, better care and lower costs, and turn those goals into an action strategy that a broad group of stakeholders embraces.

The process was funded by the Fannie E. Rippel Foundation, a national foundation that serves as a catalyst to identify new ways of thinking and innovative solutions to help address the complex and growing challenges of our health system. It was guided and coached by Organizing for Health, a part of the Foundation’s ReThink Health initiative.

The “ah-ha” moment came when participants recognized that the enemy was not a particular stakeholder – a health care provider or payer – but chronic disease itself. That realization enabled all major stakeholders to come together around a shared commitment, rather than pitting one group against another.

Central to the “Healthy Columbia” Campaign is a Community Covenant that emerged from those months of meetings, representing a public commitment made by all key stakeholder groups to address the failing health care system as one. By signing the Community Covenant, community members, providers, hospitals and insurers each make different commitments:

Providers will work together with the community to produce new ways of accessing primary care, such as longer hours at doctors’ offices, better transportation services to health care facilities, and greater use of volunteer health coaches.
29203 community members pledge to better manage their health, taking steps to prevent disease and using primary care services rather than relying on emergency rooms for non-emergency needs.
As non-emergency use of emergency rooms declines, hospitals and insurers agree to investing savings in the Campaign’s prevention and primary care efforts.
The long-term goal of the Campaign is not only increased access to primary care but that the cost of health care for citizens and providers will decrease. The goal is to reinvest those savings back into community efforts for health and well-being. As part of the Community Covenant, the 29203 community itself will have a voice in how the savings are reinvested by the hospitals and insurers.

The “Healthy Columbia” Campaign is still in its early stages. It was launched in March at an event at which the Community Covenant, which now has nearly 2,000 signatures, was unveiled. More than 500 members of the 29203 community attended the kickoff event, including leaders from local government and key community organizations, as well as representatives of Eau Claire Cooperative Health Centers, the South Carolina Department of Health and Environmental Control, the South Carolina Department of Health and Human Services, BlueCross BlueShield of South Carolina, Select Health, Palmetto Health, Providence Hospital, the South Carolina Hospital Association and the University of South Carolina.

The Campaign is already proving transformational, however, as it has brought together, for the first time, the major stakeholders in the 29203 area to achieve shared goals in managing the health care resources of the community. The Campaign’s effectiveness in reducing costs and reallocating resources is not yet proven, but its capacity to unite all major stakeholders – in a shared commitment to health and health care improvement – is showing promise that is very exciting for those of us involved.

The author is Senior Vice President for Quality and Patient Safety at the South Carolina Hospital Association.

Morristown, NJ – March 1, 2012 - Elliott S. Fisher, MD, MPH, a renowned expert on health care quality and cost in the United States, has joined the Board of Trustees of the Fannie E. Rippel Foundation. A founding and active member of the Foundation’s ReThink Health initiative, Dr. Fisher is a professor at the Dartmouth Medical School and Director for Population Health and Policy at The Dartmouth Institute for Health Care Policy and Clinical Practice. He is also Co-Principal Investigator on the Dartmouth Atlas of Health Care which has captured the nation’s attention by documenting the two-fold differences in health care spending across U.S. regions and health care systems, as well as the impact of these variations on health quality, outcomes, and costs. Dr. Fisher is a member of the Institute of Medicine.

In his role as Director of Population Health and Policy at The Dartmouth Institute, Dr. Fisher leads a team that is making unique contributions to our country by becoming a local and national resource that studies and advances ways to improve the health system. The Dartmouth team’s work builds on the philosophy that:

• A sustainable health system can only be achieved by striving toward three aims: better health, better care, and lower costs. A focus exclusively on any one will likely diminish positive outcomes for the others.
• A sustainable health system must satisfy our fundamental needs and wants and can best be achieved by redesigning clinical systems and community resources and programs to meet these needs at the lowest cost.
• Health and health care are produced and delivered within communities. Local leadership must design and implement local solutions, with national support.
• New measurement systems and new payment models are needed to support health systems and communities in their efforts to achieve the three aims.

Among his many activities, Dr. Fisher is actively involved in national efforts to improve measures of health system performance, to reform payment systems, to develop patient-reported health measures, and to create new models of health care delivery. Dr. Fisher received his undergraduate and medical degrees from Harvard University and completed his residency in internal medicine at the University of Washington, where he also was a Robert Wood Johnson Clinical Scholar and received a master’s degree in public health.

“We are delighted that Elliott Fisher has joined the Foundation’s Board,” said John D. Campbell, Chairman of the Board of the Fannie E. Rippel Foundation. “Dr. Fisher has been a trusted advisor to the Foundation for many years, and his knowledge of the quality and cost of health care in America is unparalleled. His expertise will be of enormous value as we continue to explore innovative ways to improve health outcomes in the nation.”

About the Rippel Foundation

The Fannie E. Rippel Foundation (www.rippelfoundation.org) is a catalyst for new ways of thinking about our health system – to achieve better health, better care and lower costs. The Foundation actively engages leaders in and outside of health who take a systems-based approach to rethinking and redesigning health and care. The Foundation works with them to explore and implement innovative initiatives in order to improve health outcomes for all Americans.

Thus, it’s reasonable to ask how any of her conclusions could possibly be generalized to the technically complex, politically charged, and economically lucrative subject of health policy. We too were skeptical at first, since we knew that multi-stakeholder collaborations for shared governance of a health commons would have a different set of requirements than community-based resource management. Indeed, our initial research has demonstrated that it is especially important to organize discussions among the representatives of stakeholder organizations in ways that encourage them to express their interests and concerns in an open and honest way. It also helps if they focus on specific goals, so they can build the momentum needed to overcome the many difficult hurdles in their path.

But one lesson from commons research comes through loud and clear: the most critical step occurs when local leaders take ownership of the problems they face. Resource users in Ostrom’s cases had this autonomy conveyed on them by default, but local stewards of a health commons have to actively assert their right to share responsibility for managing the physical, human, social, and economic resources related to health and health care in their own community. They have to defend this right against many external pressures, but they are far from powerless in doing so. To see what else is required, check out this presentation.

Experienced leaders and facilitators who are interested in elevating their group’s or team’s performance to new levels can gain valuable education and practice at a workshop being offered at the Association for Community Health Improvement’s National Conference on “Elevating Community Health Practice,” March 14 in Denver.  Entitled “Diagnosing and Treating Accidental Adversaries in Multi-Stakeholder Health Improvement Teams,” the workshop will be conducted by C. Sherry Immediato, Chief Learning Officer, ReThink Health, Fannie E. Rippel Foundation, and Manoj Pawar, MD, Vice President, Clinical Operations & Physician Leadership Development, Catholic Health Initiatives.

This interactive workshop will use presentation, exercises, sample tools and group discussion to increase capacity to productively address and resolve certain adversarial situations. It will focus on:

• The natural evolution of teams and how to support their development;
• Identifying and addressing “accidental adversaries” (where the action of one partner is seen as undermining the success of another), and the ensuing relationship breakdown;
• Increasing the systems thinking capacity of the team to address health improvement issues by building short term momentum toward a long term vision; and
• Increasing the capacity for a team’s learning and reflection, by engaging in simple practices that apply process improvement methods to the team’s functioning.

The workshop will allow participants to work on specific group-dynamic situations where they see room for improvement, increase their connection to innovative peers, and take home specific tools and practices to integrate into their leadership roles.

Learning Objectives:

At the conclusion of this session, participants will learn how to:

1. Recognize and diagnose accidentally adversarial situations – where those with espoused shared goals have problematic relationships;
2. Develop strategies for avoiding and protocols for addressing accidentally adversarial situations;
3. Integrate a simple systems thinking protocol into diagnostic and strategy discussions; and
4. Use “after action/before action” reviews as a strategy for increasing the effectiveness of health improvement teams.

For more information and to register for the workshop, visit http://www.communityhlth.org/communityhlth/conf2012/annualworkshops12.html#AA

At the Northeast Home Health Leadership Summit for home health agency leaders, C. Sherry Immediato, Chief Learning Officer for ReThink Health, an initiative of the Fannie E. Rippel Foundation, will conduct a workshop session with these key objectives in mind.

In her session “Changing Circumstances”, Ms. Immediato will engage attendees through group conversation in making connections between what was heard and learned throughout the conference and how to integrate these insights into their own everyday practice.  Her session will also demonstrate a technique for hosting “conversations that matter” –The World Café, developed by Juanita Brown and the World Café community  – that participants can use within their own organizations and communities.

As a leadership method, The World Cafe is concerned with strengthening a network of relationships and helping an organization, system or community to see itself. From the perspective of organizational learning, strengthening these relationships in times of uncertainty brought on by changing circumstances such as the economy, regulations, or competition require:

“Out of the box” thinking, not just trying harder.
New ideas often come from those not normally considered key strategic thinkers and/or from a synthesis of ideas from diverse stakeholders.

Being “fleet of foot”.
Strong relationships make change in strategies and procedures requiring coordinated action much easier to accomplish.

Avoiding fight or flight responses which tend to cause us to focus on our own survival (be it individual, department, organization, etc.) vs. the larger whole. Strong relationships help at a practical level in making decisions together on behalf of the whole while also recognizing that the parts need to be cared for. Emotionally, trust makes it possible to take courageous action.

More information on the Summit is available at http://nehomehealthsummit.com/ .

Perhaps best-known as a Principal Investigator on the Dartmouth Atlas of Health Care, Dr. Fisher’s research focuses on the causes, consequences and implications of variations in health system performance. His current work also concentrates on advancing the use of patient-reported measures as tools for improvement and accountability, and the development, pilot testing and evaluation of new models of health care delivery and payment.

Dr. Fisher is a graduate of Harvard University and Harvard Medical School and received his MPH from the University of Washington. He is a member of the Institute of Medicine and has served on major national committees with the National Quality Forum and the National Advisory Council of the Agency for Healthcare Research and Quality.

More than 45 years ago, my predecessor, Julius A. Rippel, predicted that our nation’s health system was unsustainable. He said we needed bold new thinking and innovative models to improve population health and fundamentally redesign how care is delivered. Most importantly, he declared that this comprehensive approach was the only path to sustainability.

As many in America increasingly acknowledge the truth of these words, and as visions of alternative futures begin to surface, we are faced with a daunting challenge: how do we get there from here? How do we change a highly complex system characterized by increases in chronic diseases, rising health care costs, entrenched industry structures, over-treatment and lack of data and information? Further, how do we break the cycles of investment and disinvestment and constant rediscovery to leverage the models and lessons that have been shown to work?

Given our history and our mission, the Rippel Foundation was compelled to take on this bold challenge. We committed to addressing how the Foundation, now approaching its 60th year, could best adapt to the changes in our experience of cancer and heart disease, the needs of women and the elderly, and the roles of hospitals – all core elements of our mission. We also seeded our own innovation process to determine how a mid-sized private foundation could become a catalyst for transformation in health and health care.

Our approach has evolved, being ever mindful of Julius A.’s challenge for new thinking, as well as his charge that foundations should do what government and the market either can’t or won’t do. It also grew from a theory of change that drives our activities.

As is evident from our homepage, the centerpiece of the Foundation’s activities is ReThink Health, an initiative we seeded in 2007. It began with Don Berwick and Amory Lovins. Over time, ReThink Health has changed and grown to now include Nobel Prize-winner Elinor Ostrom and The Dartmouth Institute’s Elliott Fisher. In on-going gatherings with these and other leaders and change agents, we collectively dare to ask the unasked questions. We explore what health and health care in America should look like. And we challenge ourselves to help create the new thinking and breakthrough initiatives that will make a difference.

Our new website is a way to share our journey. I invite you to learn with us through our emails, trainings, tools, and resources. I also hope you will add your name to our contact list and become a part of our growing community of ReThinkers.

Sincerely,

Laura K. Landy
President & CEO

Early users of this tool have found value in studying multiple aspects of their system at once, within a single—testable—framework. When equipped with the ability to play out and compare scores of simulated scenarios very quickly, planners can see why narrow, single-issue strategies tend to achieve particular goals at the expense of other priorities.  Conversely, they may also learn to spot hidden synergies that promise more transformational results across the board.

It is no coincidence, therefore, that among the five initial pilot sites in the ReThink Health modeling project are two regional coalitions in the Institute for Healthcare Improvement’s (IHI) Triple Aim community (i.e., Pueblo, CO and Contra Costa, CA).  The goals of IHI’s Triple Aim are explicitly system-oriented: to improve population health, enhance the patient experience of care while also reducing the per capita cost of care. The team in Pueblo, for example, coalesced around scenarios showing how contributions from diverse sectors, ranging from chronic disease counselors to the Chamber of Commerce, consistently out-performed strategies confined either to specific health care or public health interventions alone.  They are now developing an operational business plan to move their work toward the next level of action.

Similarly, even before configuring their own local version of the ReThink Health model, Contra Costa’s leaders used it to explore generic questions about what it takes to finance an effective Triple Aim venture.  At one of their very first meetings, they examined why highly effective initiatives may generate only short-lived improvements when the funding necessary to sustain them is insecure, whereas more self-reliant scenarios, in which the savings generated from initial investments are captured and reinvested to propel wider action, could actually persist indefinitely and amplify long-term impact.

These and other insights about Triple Aim dynamics were also shared at the recent IHI National Forum on Healthcare Improvement, as part of a day-long workshop on innovative leadership. Participants there included IHI’s core constituents: executives and senior strategists from hospitals and health systems, as well as public health officials and several IHI Fellows. Many participants listed the simulation session as a highlight of their experience, applauding its ability to clarify the complex, dynamic nature of local health systems.  One attendee articulated this perspective simply by saying the ReThink Health model offers “an innovative system view that is hugely valuable to me.”

Another interactive session featuring the ReThink Health model will be on the agenda for IHI’s annual gathering of Triple Aim communities in March 2012.