Spread, Scale, and Sustainability in Population Health: Workshop Summary (2015)

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Spread and Scale

The opening keynote address was delivered by Anita McGahan, who is the associate dean of research and holds the Rotman Chair in Management at the Rotman School of Management of the University of Toronto. McGahan discussed spread and scale from her perspective as a management scholar. Following the introductory keynote address, all attendees participated in an interactive activity facilitated by Ashley Forman and Fareed Mostoufi, community engagement experts from Arena Stage in Washington, DC. The activity was designed to elicit current perceptions on spread and scale as they relate to population health, and to get participants thinking about questions and solutions for moving forward.

SPREAD, SCALE, AND SUSTAINABILITY IN POPULATION HEALTH

The emphasis of the population health definition adopted by the Institute of Medicine (IOM) roundtable is health outcomes, McGahan said, and therefore what practitioners are seeking to spread, scale, and sustain are better health outcomes at the level of the individual, the community, and the population as a whole.¹ This raises the question, What is health? The

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¹ The roundtable considers population health to be the health outcomes of a group of individuals, including the distribution of such outcomes within the group (Kindig and Stoddart, 2003).

standing definition of “health” adopted by the World Health Organization in 1946 and implemented in 1948 is complete physical, mental, and social well-being. McGahan noted that while about 75 percent of Americans would say they are healthy, few could say they have complete physical, mental, and social well-being. Someone wearing eyeglasses that were not an up-to-date prescription, for example, would not meet this definition. While it is difficult to achieve a goal when the goal is not well defined, she suggested that it is impossible to achieve complete mental, physical, and social well-being.

McGahan suggested that a more robust and actionable definition of health would be “resilience” (Zautra et al., 2010). This would include resilience of the individual to his or her health circumstances, resilience of a community, and resilience of a population, including those who may be disenfranchised. In this regard, she offered a variation of the roundtable definition: Population health is the cultivation of resilience among a group of individuals. There are many facets of resilience, such as prevention and early diagnosis; community engagement; quick, coordinated responses; enfranchisement; happiness, mental health, and agency; deep specialist knowledge and care; and affordability.

Defining Spread, Scale, and Sustainability²

Spread can be thought of as reach, McGahan said—for example, reaching into a population to make sure that everyone who is eligible for a particular health intervention is receiving it and that people are connected to the care they need. While scale is often thought of as replication, from her perspective as a management scholar, McGahan said that scale generally involves investing in fixed costs and creating fixed infrastructure that can serve larger numbers of people with diminishing marginal costs over time. Health care is notoriously unscaled in the sense that each individual needs attention from the health system. Historically, many of the activities associated with care delivery are not scalable in the sense that they are not platform based, she continued. Sustainability is persistence and commitment to dealing with the health care challenges in the community over time.

Cultivating Spread, Scale, and Sustainability in Population Health

McGahan said that there are often tradeoffs among spread, scale, and sustainability, and she highlighted several opportunities for cultivat-

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² These are McGahan’s definitions of these terms. Each subsequent speaker uses these terms as individually understood in the context of the speaker’s own work.

ing spread, scale, and sustainability in prevention, early detection, and treatment.

Big Data and Monitoring Techniques

Reaching more people often requires going deep into a community to find those people who are undiagnosed or who are resisting diagnosis, to identify their health issues, and to support them with health care. Big data and monitoring techniques offer opportunities for spread, helping to find and provide health resources to people in remote corners of the world.

Registration

Another opportunity for better spread and scale is through registration. Registering people for access to the health resources that are available to them, or for which they are eligible by various criteria, helps break the tradeoff between spread and scale. Access to platform-based initiatives offers both spread and scale. For example, a smoker in Ontario, Canada, would be able to use the resources that are available through the province to get online support, access to antismoking communities, and other assistance that is available only to registrants in the health system. Innovating through the challenge of achieving both spread and scale is crucial to the roundtable’s deliberations, McGahan said.

Marketing Health

Marketing health is essential to breaking the tradeoff between scale and sustainability, she said. In global health, the missing link between effectiveness and sustainability involves advertising what is being done, explaining the benefits of the various interventions that are available in a community, and teaching people how to use the system more effectively.

Early Detection

Web-based diagnostics for early detection are a powerful way to achieve scale in health delivery, especially in remote or resource-limited areas, McGahan said. Another approach to early detection is training and making tasks routine for community health workers, physician assistants, and nurses. Providing training is a very effective way to break the tradeoffs between scale and sustainability, she said. Sustainability requires training people to learn how to be more effective in what they are doing over time and to make routine and institutionalize that learning. Identify-

ing which protocols are better and then training rigorously on them can have a sustained impact on outcomes in a particular area.

Incentives

Innovative incentive programs also foster early detection. The right incentives for a particular setting can have significant impact. As an example, McGahan cited Turmo do Bem, a program of the government of Brazil that subsidizes dental care for high school students with relatively minor dental problems. The intent is to create a relationship between dentists and young patients. While the incentive (i.e., subsidized care) is no longer offered after graduation, the relationship has been established, and sustainable health outcomes result from the program. The Brazilian government was presented with evidence that getting students to see a dentist offers benefits to the individuals later in life, such as greater ease of finding a job and being more likely to seek other types of health care.

Franchising and Collaboration

On the topic of treatment, McGahan highlighted the concept of solidarity, the idea that practitioners do what it takes to make patients better and health delivery more effective. Obtaining sustainable resilient health outcomes also depends on enfranchising the patient support system.³ Franchising and collaboration also provide opportunities for spread and scale of treatment.⁴ The Aravind Eye Care System, for example, has been very effective in treating glaucoma and other eye illnesses at a much lower cost by having physicians see many patients, and providing the health care that only doctors are qualified to deliver. Because social workers or others communicate with and prepare the patient, the doctors can see and deliver treatment to many more patients per day. In the case of Aravind, there have been better outcomes, both at the level of treatment and in the cost of care. Aravind is now training other organizations, enfranchising and qualifying them as a way of achieving scale.

Summary

Figuring out how to spread, scale, and sustain effective health interventions will have significant implications for world health in our lifetimes, given the growing and aging U.S. and global populations, McGahan said.

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³ Enfranchising in this context means empowering people typically disenfranchised.

⁴ Franchising—provides high-quality eye treatment at lower cost, linked to enfranchising—which is access to care for people who may not otherwise have access, thus empowering/enfranchising them as patients and the organizations that treat them.

In order to change the culture of an organization to focus on the spread, scale, and sustainability of population resilience, organizations will need to innovate and achieve early successes, McGahan concluded. Measurement of outcomes is also needed to make sure that efforts are successful. The process of spread and scale is not untethered data mining, it is not replication without platforms, and it is not cost reduction without considering incentives, she cautioned. The easiest way to fail in spreading, scaling, and sustaining population resilience, she continued, is to spread interventions that are not effective, to scale non-scalable activities, and to sustain outcomes that patients do not want. The focus should be on outcomes that are desired at the individual, community, and population levels, she said.

DISCUSSION

During the brief discussion that followed the keynote presentation, participants commented on accelerating change; measurement and data mining; scaling ideas, beliefs, and values; population resilience; and trust and relationships.

Accelerating Change

To start the discussion, moderator Debbie Chang of Nemours asked McGahan to expand on the accelerators of spread, scale, and sustainability. From her perspective as a management scholar, McGahan said, she has observed that while there is much discussion about creating health and well-being, it is not entirely clear what that means. Individual experiences of health often have less to do with the administration of health care by a provider, and more to do with the personal choices and experiences that have led to positive health outcomes (e.g., the decision not to smoke). Cultivating healthy behavioral outcomes in communities is related to but different from the question of how to run the health care system more effectively. Most health care institutions are not designed to prevent illness, she noted. The challenge is to redesign the health system to cultivate resilience and to achieve better outcomes more cost effectively and with higher quality.

Measurement and Data Mining

In light of McGahan’s caution against untethered data mining, David Kindig, emeritus vice chancellor for health sciences at the University of Wisconsin School of Medicine and Public Health, raised the issue of measurement. McGahan noted that in this age of computers, mobile devices,

and the Internet, there are volumes of data available for analysis. But there are a host of cautions associated with simply mining existing data, including issues of data privacy. McGahan likened untethered data mining to “looking in the rearview mirror, but only at the car behind you, and trying to drive forward effectively.” It is important to think more deeply about what the questions to be answered are before going to the data, she said. Another concern she raised is that many of the datasets are not temporally deep, and changes in a dataset over time may have more to do with increased access to mobile technology and the Internet by users than with coverage over time of individuals.

Scaling Ideas, Beliefs, and Values

George Isham of HealthPartners suggested that from a management and organizational perspective, it is not only programs and interventions that need to be scaled, but also ideas, beliefs, and values. McGahan responded that ideas, beliefs, and values are the ultimate in platforms. From an economics perspective, scale refers to the way that, by growing or adding volume to a particular activity or group of activities, one achieves more effective results for the marginal person who is brought into the fold as well as for everybody else in the fold, by virtue of the growth. A platform may be thought of as an approach, belief, or idea that with more users increases in value for all. Using social networking websites as an example, she explained that the first two people to join find value in being connected to each other, but the value increases vastly when many other people join the network. The platform associated with the social networking website creates an economy of scale. In this simplified example, the cost of running the network is relatively constant (e.g., fixed costs associated with software and servers), and there is no incremental cost associated with more people joining. As a result, the cost per user decreases, and the platform is more effective with more people in it. There is no setup cost to cultivating beliefs, and only marginal additional costs, and hopefully, she said, the result is the creation of a “pandemic of health.”

Population Resilience

Terry Allan of the Cuyahoga County Board of Health and the National Association of County and City Health Officials noted that the term “resilience” is often used in the context of emergency preparedness and the ability to recover after disaster. McGahan replied that getting existing systems to work together more effectively is a first step toward resilience, especially for disaster preparedness and response. But resilience needs to be disseminated into all of the different activities that cultivate health in

that community. Resilience is, for example, coordinated payment systems so that patients can be easily transferred among hospitals for specialist care, activating community resources so people have access to the support that they need, addressing the social determinates of health (e.g., ensuring sanitation), mutual aid agreements among fire departments, or leadership that fosters a sense of calm in a crisis. These may not be what are conventionally thought of as part of the health care system, but they have a tremendous impact on how citizens experience health.

Marc Gourevitch from the Department of Population Health at New York University asked about the relationship between resilience and prevention. McGahan responded that it is a continual process from prevention to resilience.

Sally Herndon from the North Carolina Tobacco Prevention and Control Branch noted the occasional disconnect between behavioral health and physical health providers, including the challenge of different payer mechanisms. McGahan emphasized the need to advocate for patients on patients’ terms and to understand what is going on in their lives that leads them to make choices that may have long-term health consequences. Cultivating awareness and advancing a mutual commitment to long-term health begins with public knowledge about the health consequences of different behaviors.

Trust and Relationships

Sanne Magnan of the Institute for Clinical Systems Improvement raised the issue of building trust and relationships alongside the innovation and the measurement. McGahan agreed that trust and relationships are crucial to performance and motivation, and she added that working as a team accomplishes much more than anyone can achieve individually. She suggested that performance is fostered not by simple measures but by a sophisticated dashboard of objectives. Research suggests that the dashboard has to be built collaboratively and provide guidelines for dealing with exceptional patient circumstances and needs.

INTERACTIVE ACTIVITY: MAKING SENSE OF SPREAD, SCALE, AND SUSTAINABILITY

Workshop speakers and attendees gathered in an open space at the meeting venue for an interactive activity facilitated by Forman and Mostoufi.⁵ Participants first engaged in an ice-breaker activity, grouping and regrouping themselves according to their responses to a series of

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⁵ A video of the activity can be viewed at https://www.youtube.com/watch?feature=player_embedded&v=HJmmXmW46tQ (accessed February 20, 2015).

verbal questions from the facilitators. The resulting groups highlighted both the individuality of and commonalities among the participants. For the next set of activities, participants grouped themselves in response to verbal questions about their awareness of and perceptions about spread and scale in population health. Finally, participants responded individually to questions posted around the room by writing their responses on

sticky notes. Questions asked were: What does a healthy community have/need? What gets in the way of building a healthy community? How do you spread health? How do you scale up your impact? What makes a program sustainable? What questions do you have about spread and scale? What are your hopes for the workshop today? Mostoufi then summarized the responses posted for each question (see Box 2-1).

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