6

Final Thoughts

In his summary remarks, roundtable co-chair George Isham commented on the wide variety of examples that were presented during the day and noted that there is no template yet for integrating public and personal health. “That may be okay for where we are now, but it lays out a challenge of identifying what key common points might be so that we can move from individual programs to a framework that makes sense,” he said.

Before soliciting reflections on the workshop from each member of the roundtable, Isham asked Hilary Heishman from the Robert Wood Johnson Foundation for her observations from the perspective of someone who looks for levers that can be used to align forces for improving the quality of health care. She said the levers she heard pertaining to the system that produces health at the community level included

•   Collaborations involving multiple stakeholders;

•   Using financial incentives to align the interests of physicians and hospitals;

•   Addressing information flow to assess community health and monitor the performance of the health care system;

•   Having a strong integrator1 and involved, committed leadership;

______________

1 See, for example, Chang (2012), who defines integrator as an “entity that serves a convening role and works intentionally and systemically across various sectors to achieve improvements in health and well-being for an entire population in a specific geographic



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6 Final Thoughts I n his summary remarks, roundtable co-chair George Isham com- mented on the wide variety of examples that were presented during the day and noted that there is no template yet for integrating public and personal health. “That may be okay for where we are now, but it lays out a challenge of identifying what key common points might be so that we can move from individual programs to a framework that makes sense,” he said. Before soliciting reflections on the workshop from each member of the roundtable, Isham asked Hilary Heishman from the Robert Wood Johnson Foundation for her observations from the perspective of someone who looks for levers that can be used to align forces for improving the quality of health care. She said the levers she heard pertaining to the system that produces health at the community level included • Collaborations involving multiple stakeholders; • Using financial incentives to align the interests of physicians and hospitals; • Addressing information flow to assess community health and monitor the performance of the health care system; • Having a strong integrator1 and involved, committed leadership; 1 See, for example, Chang (2012), who defines integrator as an “entity that serves a convening role and works intentionally and systemically across various sectors to achieve improvements in health and well-being for an entire population in a specific geographic 41

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42 POPULATION HEALTH IMPLICATIONS OF THE AFFORDABLE CARE ACT • Having agreed-on vision, culture, and goals; • Community engagement in setting priorities and involvement in improving health; • Solid training and defined roles among the health care team members; • Certification and licensing that supports the new roles for population health; and • A learning and improving environment (including, for example, a community health improvement plan that the collaborative group agrees on and works to implement jointly). Having these nine items, she said, can turn a good program into a sustainable program, one that will have the financial resources to succeed, the data to demonstrate success, and the community and professional buy-in to maintain momentum. “These are the pieces that get the system moving in the right direction,” she said. Isham noted that he heard many of the panelists talk about a ten- sion between the cultures of public health and health care delivery and the need to overcome the barriers that lead to treating them as separate cultures. Some speakers referred to analogous challenges, or signs of dissatisfaction on both sides of the cultural fence between health care and public health, including the need for payment reform in health care delivery and the need to address the problems with categorical funding on the public health context. Isham remarked on the fact that presenta- tions listing opportunities under the Affordable Care Act (ACA) referred to the National Prevention Strategy and National Quality Strategy, two parallel, but not yet integrated, national initiatives. Isham also reiter- ated the conditions required for collective impact, mentioned by different speakers: a common agenda, shared measurement, mutually reinforc- ing activities, continuous communication, and a backbone of support or infrastructure. Isham also commented on the importance of having an infrastructure to support population health and remarked on the fact that public health is suffering a loss of funds when they are most needed. Sanne Magnan remarked that she would add to the growing list of topics surfaced during the meeting the ability to sustain focus and the need to demonstrate return on investment—to answer the question that multiple stakeholders will ask “what’s in it for me?”—by helping stakeholders identify how they could participate and potential benefits of working together. Other members commented on the clear need to educate differ- ent health professions to understand and be able to contribute to improv- area. Examples of integrators range from integrated health systems and quasi-governmental agencies to community-based nonprofits and coalitions.”

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FINAL THOUGHTS 43 ing population health and on the related need to broaden the reach of system communication beyond patient engagement toward facilitating a richer understanding among the public about the many factors that create health. Comments from other roundtable members also highlighted the importance of developing sustainable sources of funding for population health initiatives, with accompanying policies that create markets for health. To this end, several remarked that they viewed as encouraging the news from the Centers for Medicare & Medicaid Services (CMS) Innovation Center about a second round of grants with a population health focus. Several members reiterated Isham’s observation that the field would benefit from templates and best practices so that success- ful models for financing population health can be scaled and spread in a more systematic manner. One member noted that without a range of efforts to sustain successful programs and demonstrate the value they provide, current population health initiatives, such as those supported by Community Transformation Grants, are at risk of suffering the same fate as substance abuse treatment programs—many were developed in the 1990s, but few had a robust, large, systemic impact. The need to develop a strong research agenda, identified by Stephen Shortell’s keynote presentation, was noted by roundtable members. One member pointed out that despite significant gains in reducing the preva- lence of smoking, some 20 percent of the American population still use tobacco, and that obesity control and injury prevention still call for devel- oping effective interventions. The point was also made that community health assessment, mentioned by several speakers, can be a unifying activity between public health agencies and health care organizations, and population health measurement more broadly can be a means of aligning those different systems. A roundtable member commented that although the topic of health disparities was mentioned numerous times, it would be helpful to have additional information about what communities are doing to address health disparities and how best to measure progress in addressing them. Another member remarked on the creativity demonstrated by the vari- ous programs to improve population health, and especially the notion of moving from collaboration toward collective impact. One roundtable member commented on the importance of establishing a system, such as an activity index, to ascertain the level of involvement of different coun- ties or communities in population health improvement activities, to ulti- mately assess whether a higher level of activity is associated with marked improvement in outcomes. The member added that although there is a rich history of community coalitions in the 1990s organized around such topics as child health and substance use, few of those efforts resulted in robust and systemic change, and many had limited or no effect. One could

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44 POPULATION HEALTH IMPLICATIONS OF THE AFFORDABLE CARE ACT point to good things accomplished by such programs, but they “did not move the needle on drug use on the one hand, or on overall children’s health, on the other hand. I think we need to be a little bit sober and make sure that these things are moving in the right direction.” “Good work dies when the funding dies,” noted another roundtable member, and some of the good programs showcased today are near the end of their funding, so the issue of sustainable funding is crucial. The Community Transforma- tion Grants program could be brought to an end before it has even had a chance to run its full course, the commenter added. Leadership, learning strategy, and efforts to demonstrate returns on investment are required to help prevent the loss of what is being built today. A participant’s comments about the need for population health met- rics indicated that perhaps the field needs to learn when good—in mea- surement and evidence or best practices—is good enough to implement and to share with others in the field. Moreover, a gap remains in the view that many stakeholders have of population health: there is a need to see the population and its health from the community perspective and not merely from the perspective of the clinical care setting. Another member remarked that several presentations referred to youth and children, but most of the large (health care) costs are found at the other extreme of the lifespan, indicating a need to look at that what public health can do to improve health at the end of life. Isham then opened the floor to comments from the general audience. An attendee from the National Association of School Nurses remarked that schools were mentioned frequently during the day’s proceedings, and that schools are a locus of great importance to population health improvement efforts. She suggested that school nurses could serve as valuable partners in getting population health concepts introduced into schools. In a closing comment, one of the roundtable members stated that in the face of pressure individuals may feel to return to their “camps” after a gathering that is cross-sectoral and multidisciplinary, the day’s message is that there is no alternative but to begin to change, moving in the direction of greater collaboration—among public health and health care entities and well beyond—in all the dimensions of work needed to improve the health of the population.