5

Catalyzing and Sustaining the Adoption and Integration of a Population Health Concept

One of the hoped-for effects of the Affordable Care Act (ACA) is innovations in payment reform, public policy, community benefits, and community transformation that can in turn produce sustained improvements in population health. To explore how the ACA can create opportunities for innovation, six panelists discussed their thoughts on how to transform the current health system in a way that benefits population health. Debbie Chang, Vice President for Policy and Prevention at Nemours, spoke about two approaches to innovation to link the clinic and the community to improve population health. Genoveva Islas-Hooker, Regional Program Director of the Central California Regional Obesity Prevention Program, discussed how grassroots efforts can produce sustainable increases in healthy behaviors. James Hester, former Acting Director of the Population Health Models Group at the Centers for Medicare & Medicaid Services (CMS) Innovation Center and now an independent consultant, spoke about the opportunity to create new funding streams to reward improvements in population health, using Vermont’s experience as an example. Wilma Wooten, Director of the San Diego County Department of Public Health, described the county-level Live Well San Diego program. John Auerbach, Professor and Director of the Institute on Urban Health Research at Northeastern University, described several ways in which population health is being funded and prioritized, and Julie Trocchio, Senior Director of Community Benefit and Continuing Care at Catholic Health Associates, discussed how provisions in the ACA are prompting nonprofit hospital systems to incorporate public health



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5 Catalyzing and Sustaining the Adoption and Integration of a Population Health Concept O ne of the hoped-for effects of the Affordable Care Act (ACA) is innovations in payment reform, public policy, community ben- efits, and community transformation that can in turn produce sus- tained improvements in population health. To explore how the ACA can create opportunities for innovation, six panelists discussed their thoughts on how to transform the current health system in a way that benefits pop- ulation health. Debbie Chang, Vice President for Policy and Prevention at Nemours, spoke about two approaches to innovation to link the clinic and the community to improve population health. Genoveva Islas-Hooker, Regional Program Director of the Central California Regional Obesity Pre- vention Program, discussed how grassroots efforts can produce sustain- able increases in healthy behaviors. James Hester, former Acting Director of the Population Health Models Group at the Centers for Medicare & Medicaid Services (CMS) Innovation Center and now an independent consultant, spoke about the opportunity to create new funding streams to reward improvements in population health, using Vermont’s experi- ence as an example. Wilma Wooten, Director of the San Diego County Department of Public Health, described the county-level Live Well San Diego program. John Auerbach, Professor and Director of the Institute on Urban Health Research at Northeastern University, described several ways in which population health is being funded and prioritized, and Julie Trocchio, Senior Director of Community Benefit and Continuing Care at Catholic Health Associates, discussed how provisions in the ACA are prompting nonprofit hospital systems to incorporate public health 25

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26 POPULATION HEALTH IMPLICATIONS OF THE AFFORDABLE CARE ACT into their operations. An open discussion moderated by Dave Chokshi, a White House Fellow at the Department of Veterans Affairs and member of the workshop planning committee, followed the panel presentations. PERSPECTIVES FROM AN INTEGRATED CHILD HEALTH SYSTEM There are two ways to approach population health, said Debbie Chang—either by (1) starting from the community and thinking about the needs of populations and then integrating with clinical care, or (2) start- ing from the individual needs of patients and learning about the social or community factors that are impacting their health and addressing these needs through policy or systems change. At Nemours, a nonprofit, full- continuum child health system in Delaware and Florida, she and her col- leagues have taken advantage of funding opportunities provided through the ACA to launch innovative programs that have used both approaches successfully, in one case to address the problem of childhood obesity and in the other instance to improve treatment of children with asthma. In both projects, the aim was to connect clinical care and population health in an integrated health system that encourages productive interactions between informed, activated patient, family, and community partners and an organized, prepared, proactive health team. The goal of the obesity prevention project was to reduce the preva- lence of overweight and obese children across the state of Delaware by 2015. Once the geographic population and shared outcome were defined, Nemours developed a multisector strategy that first established partner- ships that engaged child care, schools, primary care, and other commu- nity settings—the places where children live, learn, and play. The purpose of this outreach effort, Chang explained, was to have those systems of care work together to provide a consistent message that would support a child’s overall health and well-being. Early on in this effort, the Nemours team developed a set of priority policies that would be needed to sup- port healthy activity and eating by children, including the introduction of new licensing and regulation requirements for the state’s Child and Adult Care Food Program in child care facilities and the requirement to increase physical activity in schools. To leverage new policies, Nemours also pur- sued practice changes that would enable implementation of these policy changes. These activities included establishing learning collaboratives in schools and in child care and primary care settings, developing and adapting tools to promote practice change and adoption of new policies, and providing technical assistance. Chang and her colleagues also conducted a social marketing cam- paign, titled 5-2-1-Almost None (eating at least five servings of fruits and

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ADOPTION AND INTEGRATION OF A POPULATION HEALTH CONCEPT 27 vegetables; no more than 2 hours of screen time per day; at least 1 hour of daily physical activity; and almost no sugary beverages), which stressed a healthy lifestyle based on increasing healthful eating and physical exer- cise and limiting screen time and sugary beverages. They also leveraged the Nemours electronic health record to establish a childhood obesity quality improvement initiative that alerts users when a patient’s body mass index is above the healthy weight range and outlines appropriate follow-up and counseling for families. Finally, Nemours worked with intention and systematically across sectors to improve health and well- being among the state’s children (Nemours, 2012). This program went statewide in 2006, and the most recent data from the 2011 Delaware Survey of Children’s Health indicate that the preva- lence of overweight and obesity among Delaware’s children has remained level, and that overweight and obesity has decreased among African- American males and white females (Nemours, 2011). The survey results showed that behavior changes were occurring, too, with increases in the amount of fruits and vegetables eaten, declines in the consumption of sugar-sweetened beverages, and increases in the overall levels of physi- cal activity. Screen time, however, has increased. “We know there is more work to be done in this area,” said Chang. She noted that in schools where the program piloted 150 minutes of physical activity, students were 1.5 times more likely to achieve an indica- tor of physical fitness compared to students in a control group (Chang et al., 2010). Moreover, she added, recent data show a clear and consistent relationship between fitness and academic achievement and between fitness and student behaviors, an important finding because those data indicate that health and education goals align, thus making it more likely that schools will adopt such a program. In the child care setting, she con- tinued, 100 percent of participants in the first learning collaborative made significant changes in healthful eating or physical activity, and 81 percent made changes in both. Electronic health record data from the primary care setting indicated that lifestyle counseling related to physical activity and healthful eating was provided to 95 percent of Nemours’s patients, which she said is nearly double the national average. Starting in 2009, Chang and her colleagues, in partnership with the Centers for Disease Control and Prevention (CDC), began laying the groundwork for a national effort to address obesity prevention in the childcare setting. The Healthy Kids, Healthy Future Steering Commit- tee, co-chaired by Nemours and the CDC, has brought together some 40 experts in early childhood education and obesity prevention, two groups that have been siloed but who need to work together to be catalysts for positive change for children. The CDC has also provided funding via a cooperative agreement under the ACA to bring the Nemours evidence-

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28 POPULATION HEALTH IMPLICATIONS OF THE AFFORDABLE CARE ACT based learning collaborative model to scale nationally to increase the number of child care facilities that meet best practices in healthful eat- ing, physical activity, breastfeeding, and screen time and to increase the number of young children attending programs that meet those practices. The goal of the 5-year program, said Chang, is to reach an estimated 840 early childhood education centers serving 84,500 children in 6 states in its first year of operation. In its project aimed at reducing asthma-related emergency depart- ment visits among pediatric Medicaid patients, Nemours is using a CMS Health Care Innovation Award to expand a population-based strategy to create an explicit link to the primary care setting. After briefly describing the logic model that Nemours developed, she explained that the most important consideration is to start with the desired outcomes and work backward to identify primary drivers or agents of change. Nemours has created a new interdisciplinary team that includes the primary care clini- cian, a psychologist, and a community health worker who provide input on what is occurring in the child’s environment that impacts the asthma. In addition, Nemours is linking its electronic health record to the school’s health system to provide input from that setting. Chang concluded her remarks by noting that important lessons are being learned from the Innovation Awards program that need to be dis- seminated and translated into new policies and practices. She added that partnerships and collaborations between public health and Medicaid leaders are needed to increase investments in community-based services and that financing is needed to support integrators who lead these efforts. She proposed that evaluation of integrated payments models be con- ducted over longer periods of time to give prevention strategies time to demonstrate a return on investment and support actuarial analyses of prevention. Pathways for incremental reforms are also needed to help states achieve the long-term goals of delivery reform and population- based health improvement. THE ROLE OF GRASSROOTS LEADERS IN IMPROVING COMMUNITY HEALTH Genoveva Islas-Hooker began her presentation by describing the San Joaquin Valley, an eight-county region in the center of California that has the largest concentration of farm workers in the state and the second largest number of Latinos overall. Agriculture is the booming economy, but there is a striking number of prisons, which have only recently been outpaced by the establishment of kidney dialysis centers. This region, where a bag of carrots costs more than a bag of chips and where drinking water is more expensive than sugar-sweetened beverages, is the setting

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ADOPTION AND INTEGRATION OF A POPULATION HEALTH CONCEPT 29 in which Islas-Hooker has been working to ensure access to healthy food and physical activity as a way of improving population health. One fact about the area is that although it is the “salad bowl” of the nation, the low-income residents of the San Joaquin Valley often do not have access to healthful food. Perhaps not surprisingly, she said, one in three children is obese and one of every two Latino children is at risk of developing diabetes. With support from the Robert Wood Johnson Foundation, Islas- Hooker and her colleagues at the Central California Regional Obesity Prevention Program developed a curriculum on leadership development to engage residents as the agents of change in their community. This program targeted residents who usually do not get involved in decision making, but who are connected to their communities. Once engaged, these individuals have become health advocates who have helped spur their communities to raise funds for playgrounds and create weekly f ­armers’ markets in cooperation with neighborhood schools, which use the markets as a means of teaching children about healthful eating alter- natives. One outcome of this program has been that community leaders are assuming leadership positions within their local community, includ- ing on the school board and school wellness committees. “With resident leadership, we have been able to increase access to healthy foods for chil- dren and increase opportunities for safe places to play,” she said. “What we risk in the absence of engaging these leaders is [retaining] the status quo.” She concluded her remarks by predicting that this type of outreach to improve public health should outlast program funding because it is building capacity and engagement at the grassroots level. By doing so it is generating a passion for improvement that changes the community’s perception of what it can accomplish in improving health. CREATING A FUNDING STREAM TO REWARD IMPROVEMENTS IN POPULATION HEALTH The goal of health care reform, said James Hester, is to provide access to affordable, quality health care for all in a manner that is economically sustainable. To achieve this reform, he said, the health care system must transform to one in which the payment model aligns with and rewards Triple Aim outcomes. A successful transformation could create a funding stream to reward improvements in population health and open a window of opportunity to shift to more sustainable funding models for population health. However, he added, the complexity and relative weakness of key building blocks for population health payment models creates the threat that population health will not be incorporated in new payment models in a meaningful way.

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30 POPULATION HEALTH IMPLICATIONS OF THE AFFORDABLE CARE ACT At the federal level, the CMS Innovation Center, which was autho- rized by the ACA, aims to test innovative payment and service deliv- ery models to reduce program expenditures under Medicare, Medicaid, and the State Children’s Health Insurance Program while preserving or enhancing quality of care. To accomplish this task, the Innovation Center has $10 billion in funding through fiscal year 2019, and the ACA gives the Secretary of Health and Human Services the authority to expand success- fully validated models to the national level without supportive legisla- tion. Although the Innovation Center is creating what Hester called the building blocks for transformation, it is at the state and regional level that these building blocks get assembled with CMS acting as a constructive partner, not just for programs in its domain but for all payers. To accommodate providers at various places along the transformation continuum, the Innovation Center has developed a portfolio of initiatives with escalating amounts of risk. For example, a hospital with no experi- ence in risk sharing could try a coordinated care and bundled payment program that would provide a good experience working with physicians and other providers, while a Massachusetts or California provider system that has been working with global budgets for decades could serve as a pioneer accountable care organization (ACO). Today, said Hester, the Innovation Center has more than 40 different model tests in progress and is assessing outcomes according to the Triple Aim metrics, which were included in the Innovation Center’s program announcements. He also explained that the population health program at the Innovation Center has four components: (1) developing a robust set of measures for track- ing changes in population health, (2) testing new models of payment and service, (3) building collaboration among a variety of stakeholders, and (4) promoting and disseminating successful models of transformation. As an example, Hester discussed Vermont’s decade-long effort at transforming its delivery system and its role as a laboratory for health care reform. Vermont has a population of about 600,000 people and 13 hospitals whose service areas do not overlap, which creates a collabora- tive rather than competitive environment. Three commercial payers and two public payers operate in the state, which has one of the lowest rates of uninsured in the nation at approximately 5 percent and ranks eighth in the nation for access to care and seventh for quality of care. At the begin- ning of 2013, 75 percent of Vermont’s population was served by Blueprint for Health medical homes that are testing several payment models based on capacity and performance rather than fee-for-service, and a single Medicare ACO covers an additional 50,000 seniors. Although there is a broad diffusion of the language supporting bet- ter health for populations and for new payment models that are aligning the interests of multiple payers, the evolution of the delivery system lags

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ADOPTION AND INTEGRATION OF A POPULATION HEALTH CONCEPT 31 the rhetoric, Hester cautioned. “Health care systems are comfortable with today’s fee-for-service model, and the task of transforming to a model that manages total cost and patient experience is all consuming,” he said. Complicating the transformation is the fact that improving the popula- tion’s health is complex and requires reinvestment of shared savings from multiple sectors and valuing of long-term impacts. The payment models for population health are still in the early stages of development and the infrastructure and tools for population health improvement are not well developed, Hester added, creating the risk that new payment models will be established with no meaningful population health component. Given that population health traditionally has been funded by grants and taxes, rather than payment for services, the key question becomes one of how to pay for population health in a transformed delivery system. “That’s a simple question to ask, but remarkably difficult to answer,” said Hester. “Do we want to pay for changes in risk factors, life expectancy, or well- being? Until we figure out the answer, we will not get the community health system we need.” BUILDING BETTER HEALTH AT THE COUNTY LEVEL Live Well San Diego is a 10-year strategic vision for creating a county that is healthy, safe, and thriving. The health component of Live Well San Diego,1 Wilma Wooten explained, uses four main strategies: (1) building better service delivery systems, such as improving Medicaid eligibil- ity operations; (2) pursuing policy and environmental changes, such as implementing a farm-to-school program where schools pool procurement efforts to purchase and use produce from local growers; (3) supporting positive and healthy choices, exemplified by increased servings of fruits and vegetables; and (4) improving the culture from within county gov- ernment (“walk-the-walk”) by implementing a robust employee wellness program focused on reducing health risk factors for county employees. Prevention is a mainstay for the 3-4-50 concept: three behaviors (tobacco use, poor diet, and physical inactivity) lead to four diseases (cancer, heart disease and stroke, type 2 diabetes, and respiratory conditions like asthma) that account for more than 50 percent of the deaths in San Diego. San Diego is the fifth largest county in the United States and it has a history of engaging in public–private partnerships to address local public health issues. During the past decade, a series of efforts have evolved that now provide the foundation for the health component of Live Well San 1 Of note, the safety component of Live Well San Diego, or Living Safely, was adopted in fall 2012; the thriving component was in development at the time this summary was prepared.

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32 POPULATION HEALTH IMPLICATIONS OF THE AFFORDABLE CARE ACT Diego. The county has had a childhood obesity initiative ongoing since 2004. Wooten noted that between 2005 and 2010, the percentage of the county’s children that were overweight or obese decreased 3.7 percent, the biggest decline of all of Southern California’s counties. This outcome is thought to be due, in part, to the collective effort of the San Diego Child- hood Obesity Initiative. In 2008, the county expanded on this initiative by focusing on prevention as a key pillar to address chronic diseases in gen- eral. In 2009, the County of San Diego Board of Supervisors approved the Nutrition Security Plan to promote nutrition education for county food stamp recipients. In 2010, the county was awarded the Communities Put- ting Prevention to Work (CPPW) grant, known locally as Healthy Works. This obesity prevention grant focused on policy, system, and environmen- tal changes to support healthful eating and increased physical activity across the three broad areas of healthy food, healthy schools, and healthy places. As examples of the activities implemented by the Healthy Works CPPW program, Wooten highlighted the Fresh Fund incentives project that brought fresh produce into areas with limited access to healthy food by offering a one-to-one dollar match that provided up to $20 per month for purchasing fresh fruits and vegetables at neighborhood farmers’ mar- kets. This program benefited more than 8,000 low-income individuals. She noted that eight school districts implemented wellness policies that increased student physical activity and five districts started providing breakfast in classrooms. San Diego also adopted a regional transportation plan that included adding automated bicycle facilities in 13 jurisdictions. All of the programs described above have supported the Live Well San Diego plan since it was approved by the Board of Supervisors in 2010. What began as a Health and Human Services Agency (HHSA) initiative, remarked Wooten, was soon embraced by the other four groups of the County of San Diego government, and spread quickly to engage mul- tiple community sectors, including businesses, schools, community- and faith-based organizations, the military, hospitals, and city governments. The outgrowth of this initiative will focus on transforming the health of the San Diego community through a combination of behavioral and systems change to create an accountable care community—a community that is integrated across health, social, and behavioral services. As the HHSA physically combined health and social services in 1998, becom- ing an “Agency of One,” this change has driven greater integration and collaboration. To support the Live Well San Diego strategy of integration, the County of San Diego HHSA has initiated the development of the Knowledge Inte- gration Program, which includes an electronic information exchange for county public health, social service, behavioral and physical health, and probation data. Wooten added that the program includes service delivery

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ADOPTION AND INTEGRATION OF A POPULATION HEALTH CONCEPT 33 improvements to support person-centered, strength-based, and trauma- informed practice using the integrated information. The functional capa- bilities of this program will implement new technologies and policies that will enable staff to share information, identify what services a client is using, make electronic referrals, coordinate service delivery, obtain rel- evant notifications, and produce population-based shared analytics. This new service model will support efforts to provide the analytics and pre- dictive modeling capabilities needed to transform the delivery of health and social services across the county. In the future, the program will be expanded so information will be shared across the entire region, includ- ing interface with the San Diego Regional Health Information Exchange (health and meaningful use data) and the San Diego Community Informa- tion Exchange (social services data). Several ACA-funded programs also support Live Well San Diego, Wooten stated. The California Home Visitation Program provides com- prehensive, coordinated in-home services to 100 first-time mothers and their children up to age 2 to support positive parenting and improve outcomes for families residing in at-risk communities. Among the goals of the program are to promote maternal health and well-being, improve infant and child health and development, prevent childhood injuries and abuse, reduce emergency department visits, and improve school readiness. A Community Transformation grant is funding chronic disease prevention efforts that include continuation of 11 interventions developed under the Healthy Works CPPW program. It emphasizes tobacco-free living, active living and healthful eating, clinical preventive services, social and emotional wellness, and healthy and safe physical environ- ments. The San Diego Care Transitions Program is participating in the CMS Innovation Center–funded Community-Based Care Transitions Pro- gram to test ­ odels for improving transitions from the inpatient hospi- m tal setting to home or other post-acute care for high-risk fee-for-service Medicare patients. HHSA’s Aging & Independence Services Division, the Area Agency on Aging and Aging & Disability Resource Connection for San Diego County, has partnered with 11 hospitals with 13 campuses to provide innovative care transitions services for more than 21,000 fee-for- service Medicare patients each year with the goal of reducing all-cause 30-day readmissions by 20 percent. Wooten noted that the County of San Diego also has a National Pub- lic Health Improvement Initiative2 grant that supports voluntary public 2 The National Public Health Improvement Initiative provides support to state, tribal, local, and territorial health departments through the Prevention and Public Health Fund established by the ACA. In 2012, 73 health departments at various levels received support from the Fund to “make fundamental changes and enhancements in their organizations

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34 POPULATION HEALTH IMPLICATIONS OF THE AFFORDABLE CARE ACT health department accreditation based on performance against a set of nationally recognized, practice-focused, and evidence-based standards. The goal of this program, she explained, is to improve and protect public health by advancing continuous quality improvement and performance. In her closing comments, Wooten noted that Live Well San Diego sup- ports the Triple Aim of improved population health, enhanced individual quality of care, and reduced per capita health care costs. THE MASSACHUSETTS EXPERIENCE WITH INNOVATIONS IN INTEGRATING POPULATION HEALTH In John Auerbach’s view, there are two approaches to funding and pri- oritizing population health. The traditional approach, he said, is through grants to public health, and he said this approach merits continuing and expanding. The state of Massachusetts’ Mass in Motion public–private partnership to reduce obesity, which reaches about one-third of the state’s population, is an example of this approach. In this case, the state had no money to fund the initiative, so it took the role of identifying the issues, bringing together interested parties, and persuading five Massachusetts foundations, one insurer, and one hospital system to fund this program. Since then, Mass in Motion has also received Community Transformation Grants through the ACA. The program now funds 50 city and town coali- tions to change policies and conditions that negatively affect the public’s health. For example, coalitions have used these grants to leverage city funding for sidewalks near schools and to promote walking and biking to school. Communities have used grants to support incentives for stores selling healthy foods in low-income neighborhoods and to create safe communities that keep local gyms open late. Auerbach noted that this program, like the one that Islas-Hooker discussed earlier, relies heavily on grassroots involvement to mobilize communities to promote and engage in healthy behaviors. The state will be using ACA innovation funds from CMS to evaluate the Mass in Motion program and link it to primary care providers. The Massachusetts Prevention and Wellness Trust Fund is another example of the traditional approach to funding public health. The $60 million Trust Fund was created by the Massachusetts legislature through a one-time assessment on insurance plans and hospitals. The state public health department and an advisory board will oversee the disbursement of these funds over 4 years. Auerbach explained that 75 percent of the and implement practices that improve the delivery and impact of public health services” (http://www.cdc.gov/stltpublichealth/nphii/about.html [accessed September 13, 2013]).

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ADOPTION AND INTEGRATION OF A POPULATION HEALTH CONCEPT 35 money must be spent on competitive grants to reduce costly preventable health conditions, reduce health disparities, increase healthy behaviors, adopt workplace-based wellness programs, and develop an evidence base of effective prevention programs. Municipalities, community orga- nizations, providers, health plans, and regional planning activities can apply for grants from the Trust Fund. He noted, too, “that the insurance plans and hospitals were at the table when this was discussed and did not oppose the creation of the trust (although they were not pleased that it was supported with an assessment). Their recognition of the value of expanded prevention was a result of years of working to develop the cultural atmosphere in which we could float an idea like this and have it be considered and ultimately passed.” The second, novel approach to funding public health would create incentives for insurers and providers to redirect a portion of their funding to go toward efforts to improve the health of the overall population. This approach is getting increasing attention in this era of global payments and the ACA, said Auerbach, and Massachusetts is examining this approach in two ways. The first involves the work of a legislatively mandated statewide quality advisory committee to identify performance metrics and create a reporting system for population health measures. The idea here, he explained, is to guide the state division of insurance in its efforts to set standards that all insurers would follow. But in trying to formulate a set of metrics for population health, the committee came to the conclu- sion that it was too difficult to add new indicators of population health to the data collection burden. He added that the committee will explore whether there are better fits with accountable care organization-level or hospital-wide indicators. The state is also looking at whether it could reduce costs and promote population health by standardizing the use of community health workers (CHWs) as members of clinical teams who would have an outward focus on population-based conditions. The state created a board of certification with legislative support to give clinical providers, hospitals, and health care centers confidence about the training and skills of these individuals. The certification board is housed in the public health department, the same location as the certification boards for nurses and other health care professions. The board is now reviewing what the training and certifica- tion requirements should be and how often CHWs should be recertified. This work is expected to be completed by the end of 2013, Auerbach said in closing.

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36 POPULATION HEALTH IMPLICATIONS OF THE AFFORDABLE CARE ACT MOVING HOSPITALS TOWARD POPULATION HEALTH Today, hospitals are part of the public health system and are engaged in population health, said Julie Trocchio, and the ACA is playing an important role in making that happen. “There are many provisions in the Affordable Care Act that are pushing hospitals towards public health,” she said, including the expansion of coverage, both through commercial insurance and Medicaid, and the development of national prevention strategies and coverage of prevention activities. Also important are the various incentives and penalties included in the ACA, particularly con- cerning rehospitalization, that are changing the focus of hospital admin- istrators to keeping beds empty by keeping people healthy. She predicted, however, that the biggest impact will come from the tax-exempt hospital provisions in ACA that mandate community health needs assessments (CHNAs) and planning and transparency in the way hospitals charge for their services and collect payment. One of the provisions of the ACA is that every tax-exempt hospital facility must conduct a CHNA at least every 3 years and obtain input on CHNA from people who represent the broad interests of the community and those with special knowledge of or expertise in public health. Perhaps the most important requirement, said Trocchio, is that the CHNA must be widely available to the public, which she said will ensure that hospitals do a good job in preparing this assessment. The Internal Revenue Service (IRS) has also proposed additional rules that will require that the input to the CHNA must include at least one state, local, tribal, or regional public health department; members of medically underserved, low-income, and minority populations or their representatives; and written comments from previous CHNAs (IRS, 2011). The CHNA itself must include the definition of the community served and a description of the process and methods used to conduct the assessment. This description must detail how the hos- pital accounted for input, how it prioritized significant community health needs, and what the potential resources are to address those needs. The IRS has also proposed that the CHNA must be adopted by an authorized body of the hospital (IRS, 2011). The ACA also calls for tax-exempt hospitals to develop and adopt an implementation strategy to meet the community needs identified in the CHNA and describe any needs identified in the CHNA that are not being addressed and an explanation for the inaction. In its proposed rules, the IRS will also require that the implementation strategy will specify the actions that a tax-exempt hospital facility intends to take to meet each significant need, the anticipated impact of these actions, and a plan to evaluate the impact. The proposal rules call for the implementation strat- egy to spell out the programs and resources the hospital plans to commit and any planned collaborations. Trocchio said that taken together, themes

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ADOPTION AND INTEGRATION OF A POPULATION HEALTH CONCEPT 37 in the ACA and the IRS’s proposed rules encourage collaboration and the formation of partnerships between hospitals and public health partners, draw attention to disparities and vulnerable populations, and increase transparency. As a result, Trocchio noted, hospitals are collaborating and forming partnerships with public health agencies, and they are using public health resources, such as the County Health Rankings. She added that the assess- ments are not revealing many surprises in that access to health care is the number one issue in many communities across the country. Programs to address low birth weight, mental health issues, dental health, problems with aging, stroke, and heart disease are also needed in many areas of the country. Hospitals are also starting to become aware of and take action to address some of the upstream determinants of health. As examples, she cited a program in Baltimore that is starting programs to keep kids in school and buying up rundown properties and less desirable businesses and turning them into vibrant, community-owned businesses. In Boston, Children’s Hospital has been giving vacuum cleaners to families whose children are repeatedly seen in the emergency department for asthma- related health problems. “The bottom line is that hospitals are finding that they can no longer care just for the person in the hospital bed. They must look at the health of the community that the patient is being discharged into,” said Trocchio, adding in closing that “these requirements are getting the attention of the highest level of leadership in hospitals. Boards are paying attention. Chief executives are paying attention. They are accountable now and that is making a huge difference.” DISCUSSION To start the discussion, George Flores asked the panel to consider the question of how the health care system would change if it emphasized the health needs of children rather than those of older adults, which he believes is the case today. Wooten said she would introduce more play and physical activity into schools because of their demonstrated effect in decreasing obesity. She cited as an example the Chula Vista, California, elementary school district, which has used a Community Challenge Grant to focus on physical activity in the classroom. This program, which also teaches children how to engage and educate their parents about the value of physical activity, has had a significant impact on obesity rates through- out the entire school district. She would also like to see comprehensive wellness programs implemented in schools and daycare facilities. Islas-Hooker voiced the same opinion and agreed that a focus on children can be an important vehicle for changing the behavior of adults.

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38 POPULATION HEALTH IMPLICATIONS OF THE AFFORDABLE CARE ACT She noted that students at a high school in Fresno, California, led an effort to eliminate sugary drinks and snacks from their school and are drawing attention to the overt marketing of unhealthy products to themselves and their peers. “I think that youth engagement is powerful and that they are very innovative in terms of how they are trying to inform us about what their needs and issues are,” she said. If there was a greater focus on children, said Chang, there would be a greater focus on prevention and population health. “Children are not just little people. They have developmental needs of their own, and our goal should be to prevent future illness and help them grow up healthy,” she said. A focus solely on cost-cutting works against children, she added. “Children will never be at the table because they are not the cost drivers,” she stated. She believes the only way to have a balanced approach that values children is to place a greater emphasis on the population health piece of the Triple Aim and to make children a focus of that effort. Terry Allan, from the Cuyahoga County (Ohio) Board of Health and a member of the roundtable, asked Islas-Hooker how costly it was to train the grassroots leaders in her community outreach program. She responded that the cost was minuscule, about $100 a person for some of the efforts, and in some cases nothing at all. In one example, the cost was $7 for an exercise video that a resident of the community purchased and used to teach herself and her neighbors the routines. One community raised $1,000 and used it to convert a vacant grass field into a soccer field with goals that served as the foundation for organizing a youth soccer league. ”The return on investment in these small programs is huge,” said Islas-Hooker, who has leveraged the success with these small programs to secure large, multiyear grants that will enable bigger efforts across multiple communities. In response to a question about metrics that the panelists would like to see developed and used to track the impact of programs on popula- tion health, the discussion turned to the subject of how to establish a framework that would enable hospital systems to measure the value of population health efforts given that a particular hospital may not realize all of the benefits of their efforts. One participant commented that there has been a struggle to find consistent characteristics of successful efforts to measure over the long term and across an entire health care system. Other comments concerned the need for a system that can report on the chosen metrics and the difficulty in deciding on how granular to make these measures in terms of balancing the need for useful data with the burden that metrics can place on the provider community. Hester noted that some of the pioneering ACOs have been experi- menting with an enhanced health risk appraisal tool that includes infor- mation on patient risk factors and self-reported outcomes. He said that

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ADOPTION AND INTEGRATION OF A POPULATION HEALTH CONCEPT 39 these ACOs are finding these metrics helpful for tracking what is hap- pening at the population level as well as for managing the population and identifying the people who need care. Another meeting participant voiced the opinion that government, particularly state and local, could play a role in the development and use of metrics by convening groups that would identify metrics that get embedded in the health care system of the facility licensing process. Lawrence Deyton, from the George Washington University School of Medicine and Health Sciences, asked if any thought was being given to the type of training that is needed for the entire health care provider team to become advocates for and partners in population health efforts as opposed to obstacles. He wondered if there was a role for accredita- tion and licensing boards in terms of setting standards for training, and he asked if successful local community groups are talking to their state boards about adding requirements for training in population health to licensing requirements. Chang said that one activity that Nemours has instituted with its innovation grant takes clinical teams into the commu- nity. Although this has been an eye-opening experience for the clinical staff, she said that formal training on population health in addition to gaining experience in the community is important to ensure a sustained impact on how clinicians view these problems. Panelists and participants noted several examples of individual clinicians who have had attitude- changing experiences after going out into the community and seeing how larger issues impact individual health. Trocchio noted that her organiza- tion’s experience has been that when someone with a background in public health joins the staff of one of its hospitals, the community benefit program of the hospital changes from one of random acts of kindness to one that takes focused, strategic action on population health issues.

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