Phyllis Meadows of The Kresge Foundation reiterated the point by Basch that schools cannot address health barriers to learning by themselves. In this session, speakers described specific case examples of health–education collaborations to improve specific educational outcomes. Examples from the state of Oregon were shared by Lillian Shirley of the Oregon Health Authority, Janet Meyer of Health Share of Oregon, and Dianne Kilkenny of the Morrow County Health Department. An example from Cincinnati, Ohio, was described by Robert Kahn and Uma Kotagal, both of the Cincinnati Children’s Hospital Medical Center (Kotagal participated via videoconference). (Highlights of this session are presented in Box 4-1.)
Healthy Kids Learn Better
Oregon has organized its health care transformation around the triple aim of better health, better care, and lower cost, said Shirley. Oregon’s health care transformation journey began with a focus on Medicaid and clinical services, Shirley said, because Medicaid transformation was an issue that brought many stakeholders to the table. She noted that there is political will for transformation in Oregon, and over time, these efforts have led to increased quality, increased care, and a reduction in cost drivers across the state. The next steps toward system transformation are
public health– and community-based prevention and community problem solving. In developing community-based strategies to achieve the triple aim, payors, providers, and policy makers are engaging community institutions, including schools. She noted that as many as 26 percent of Oregon’s students do not graduate on time and that people are beginning to understand how health and education are integrated.
The Healthy Kids Learn Better Partnership is the state plan to bring together schools, coordinated care organizations (CCOs), and public health interventions at the local and state levels. The partnership has worked on issues such as lack of physical activity, inadequate nutrition, substance abuse, safety concerns, and unintended pregnancy. Information on these and other outcomes is provided by the health sector to the education districts to help them prioritize interventions to meet their specific community needs. Shirley noted that before the state can focus on keeping students in school, it has to get them started in school, and there is also a focus on kindergarten readiness. She listed some key factors that contribute to kindergarten readiness, including health care coverage,
social determinants of health and equity, behavioral health, health system transformation, and home visiting.
In summary, Shirley said, the Oregon approach includes a focus on relationships, including with non-traditional partners; formalized agreements among state agencies to foster sustainability (e.g., memorandums of understanding); targeted initiatives; and tracking progress through metrics and incentives that reflect cross-sector accountability.
Health Share Coordinated Care Organization
Health Share of Oregon is a local CCO that serves members of the Oregon Health Plan (the state Medicaid program) in several counties. Health Share has about 320,000 enrollees and is the largest CCO in the state, covering about one-third of the Medicaid enrollees in Oregon, Meyer said. Oregon employs quality incentive metrics, and funds are awarded to CCOs based on their performance, she explained (she anticipated that Health Share would likely earn around $45 million in incentive metric payments for 2018).
In 2012, as part of the efforts to transform health care under the Oregon Health Plan, Meyer and colleagues were assigned the task of identifying high users of Medicaid services and determining how to reduce unnecessary costs to earn incentive payments. Their investigation revealed a socially constructed pathway to high Medicaid service use. Many of the high users had a life of trauma and adverse events, Meyer said. There was acknowledgment that interventions needed to be applied upstream, and there was a suggestion that kindergarten readiness should be addressed, but Meyer felt at the time that education issues were not within the purview of the Medicaid plan. At the same time, however, many of the performance metrics that the Oregon Health Plan was trying to meet involved children, such as developmental screening, adolescent well visits, and screening for children in foster care. It was not clear what happened to these children after they were screened or where they could go if they needed help. Health Share began to focus on early life health and kindergarten readiness. Meyer noted that, as a Medicaid managed care plan, Health Share produces about 400 kindergarten classes every year (i.e., enough babies to fill 400 future kindergarten classes are born under the plan every year).
The health care system is the one social system that reaches children consistently until age 5, Meyer said, and she briefly described several programs targeted to this demographic. Project ECHO (Extension for Community Healthcare Outcomes) is a tele-mentoring program focused on helping providers enhance skills and build capacity. Health Share focused its ECHO program on capacity building for pediatricians and
other child-age providers in developmental pediatrics. Health Share also invested in launching the Help Me Grow program across the state, which helps vulnerable children and their families connect to services. Health Share’s current plan is Ready + Resilient. The ready component focuses on starting strong through kindergarten readiness and connecting families to the resources they need to be successful. The resilient component supports recovery, including mental health and addiction services. Both take an “equity first” approach to eliminating disparities in health and health care. Health Share is also focused on collective impact, working in partnership with early learning hubs and community-based organizations on kindergarten readiness. The scope of screening and referrals to services spans “before 9 to 5,” Meyer said, which is from effective contraceptive use to kindergarten readiness. Other special populations Health Share is focused on include pregnant women who have substance use disorders and children in foster care.
Meyer said it took a 6-year conversation to convince the board of Health Share to invest in early child health. This is an investment in infrastructure and in building out the system of care, she explained, and the return on investment is not to Health Share but to the families, the community, and the taxpayers in the United States and Oregon. Medicaid will always be a safety net system, she said, but Medicaid can also be the scaffolding that helps families receive the services they need to get out of poverty. In closing, Meyer stated that if Medicaid can improve kindergarten readiness and help the next generation to avoid poverty and become high users of Medicaid services, then this is an appropriate use of Medicaid funding.
School-Based Wellness Hubs
Morrow is a rural frontier Oregon county. Many agencies and organizations in Morrow have interactions with individuals who have unmet health needs, Kilkenny said. Often, these needs are outside the scope of a given agency or beyond the agency’s available resources to address. Other local concerns include absenteeism in schools and an inability to retain teachers, falling health indicators, and a lack of funding.
Morrow is 1 of 12 counties included in the Eastern Oregon CCO, which is geographically the largest CCO in Oregon. Each county has a local community advisory committee (LCAC). The LCAC includes Morrow government, Morrow public health and department of human services, school districts, Umatilla-Morrow County Head Start, businesses, community partners, and other agencies and organizations. The Morrow County LCAC is focused on bringing better health, better care, and lower cost to Morrow residents, Kilkenny said. Morrow is diverse with regard to culture,
ethnicity, language, socioeconomics, and geography, but all community partners desire a healthier future for residents, she said. Employers are looking for a future workforce, schools want to foster regular attendance, public health wants to achieve better health outcomes and healthier populations, and county government aims to spend less money. A healthy future depends on educational attainment, Kilkenny said, and priority has been given to providing wrap-around services to children ages 0 to 21 years and their families to keep students healthy and in schools. Services offered address physical, mental, and social determinants of health. By building partnerships and sharing resources, school wellness hubs have been established that bring health care and prevention into Morrow County schools. Kilkenny added that using existing services promotes sustainability and builds better health care and health equity for all county residents.
Kilkenny emphasized the importance of braiding funds to create this wrap-around system. The Morrow County School District has developed public–private partnerships with community stakeholders to facilitate community health transformation at the county level, she said. This has allowed the school district to offer school-based services, such as kindergarten readiness, workforce readiness, community counseling and outreach, school resource officers, care coordinators who provide screenings and referrals to services, dental sealants for all grade-school children, and nurses in each school who provide direct care and health education. The care team handles the wellness activities at the school so that teachers and superintendents can focus on education. Wrap-around services handled by the care team include billing, charting, referrals to health services and community resources (e.g., food stamps, food banks), arranging transportation, and health insurance enrollment.
In summary, the LCAC has worked to develop new health care partnerships and pathways to deliver transformational health care access to county residents. As a result of these partnerships, the care teams at the wellness hubs are able to connect students and families to health care services in the community. This enhances local access to critical care and prevention services and impacts many CCO incentive metric targets (e.g., well care, immunizations, dental sealants, contraception).
The vision of the Cincinnati Children’s Hospital Medical Center is to be the leader in improving child health. One goal of its 2020 Strategic Plan calls for the hospital to help Cincinnati’s 66,000 children to be the healthiest in the nation through strong community partnerships, Kahn said. The first two specific outcomes for this goal address morbidity and mortality: reduce annual infant deaths and reduce the disparity in hospital bed days,
focusing on two high-risk neighborhoods. The other two outcomes focus on helping children to thrive: ensure 5-year-olds have healthy minds and bodies and increase the percentage of children reading proficiently or above by third grade in Cincinnati public schools. A learning network was created for these four outcomes, improvement teams were convened to drive the work, and a series of core activities were developed to support the work of the improvement teams (see Figure 4-1). For the workshop, Kahn expanded on the third-grade reading outcome, the third-grade reading improvement team, and activities in support of community quality improvement (QI) capability.
Partnering with Education
In this community partnership, the educators are the content experts, Kahn said. The role of the hospital is to help facilitate progress by sharing knowledge and skills, specifically theory; small-scale, rapid testing; implementation approaches; and population segmentation and data over time. These are shared in the form of QI training, coaching, and tools.
Kahn shared the key driver diagram that was used by the assistant superintendent of Cincinnati public schools to outline current and future aims and drivers of success for the third-grade initiative. He noted that this diagram continues to be modified over time and that a third column was added that lists explicit interventions that will be tested against the drivers (see Figure 4-2).
Small-Scale, Rapid Testing
The model for improvement, Kahn explained, asks three basic questions. What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? The answers then lead to a cycle of planning, doing, studying, and acting. Kahn observed that teachers are adept at this type of testing strategy that involves making a prediction, understanding what happened relative to the original plan, comparing results to predictions, and then adapting, adopting, or abandoning the original plan.
Teachers are often presented with an entirely new curriculum that they use for 9 months, and they do not know if there has been any improvement in learning until student proficiency test results become available the following year. In contrast, the model for improvement pro-
vides more rapid feedback on small-scale changes. The data do not need to be perfect, Kahn said; the model just has to be useful.
The Cincinnati Children’s Hospital Medical Center also shared a practice called a “huddle,” which has been implemented successfully at the hospital. Each day, in a highly structured, highly efficient manner, staff come together to share key information, learn from one another, and problem solve together. At the hospital, for example, there is a safety huddle for 30 minutes at the start of each day. Teachers have limited opportunities to learn from each other, Kahn said, and a weekly 30-minute QI learning huddle was implemented so that teachers would have a safe space to share successes, failures, and QI learning from the week. In this way, an approach that one teacher finds is working can quickly be spread to other teachers. Similarly, if several teachers find that an approach does not work at all, there is no reason for 38 other elementary schools to spend time on it. This ability to connect with their colleagues has been well received by the teachers, Kahn reported, and many said they took greater joy in teaching.
Another aspect of implementation is student engagement. For example, a “plan, do, study, act” chart for a particular curriculum was posted on the classroom wall. On Friday, students who met their goals for the week got to wear a special badge proclaiming their success. The children took great pride in this process, Kahn said.
Kotagal raised the issue of the “dosage” of the intervention being implemented. Teachers have good intentions, she said, but the classroom can be chaotic, and a teacher might go for days or longer without being able to give attention to a child in need of an intervention. Teachers and reading specialists can improve outcomes by having individual charts that keep track of whether students have reliably received a needed intervention. Kahn added that absenteeism results in a zero dose of an intervention received, for example, and poorly controlled attention-deficit/hyperactivity disorder leads to a diminished dose. Similarly, if the teacher is being interrupted or pulled out of the classroom or there is excessive noise, that diminishes the dose of intervention they can provide.
Population Segmentation and Trajectories
Another element of QI is population segmentation and trajectory. Kahn shared third-grade reading proficiency results displayed as average proficiency, annually from 2005 onward. In this situation, it is difficult to learn and adapt if proficiency results are only available yearly, many
months after testing. One approach is to group the data into actionable segments (e.g., proficient, on track, below/in need of intervention) and be able to track the academic progress of students in the intervention group as they move to higher-level proficiency segments.
It is also possible to learn from a population segment of 1 (N of 1). Kahn shared an example where a teacher partnered with a pediatrician to address the classroom behavior of a kindergarten student. The teacher purchased a clicker counter and plotted the number of interruptions from the student each day, adding notations for events in the student’s life (e.g., suspension and absences, starting a behavioral management strategy, starting medication, running out of medication, missing a provider appointment, changing medication administration to school, starting therapy). The teacher connected regularly with the pediatrician and the child’s mother to discuss progress.
Moving Forward in Cincinnati’s Hospital–School Collaboration
As a result of this partnership, the school superintendent has begun to apply these same strategies at the system level, Kahn said. She has sent school leadership staff for QI training and developed a key driver diagram for the entire Cincinnati public school system. The new diagram identifies system-level drivers and projects that improvement teams will undertake across instructional, managerial, parent and student experience, and talent management outcomes.
Kotagal emphasized the role of partnerships in instituting respectful mechanisms by which to learn to from each other. Kahn agreed and added that it is important to engage beyond the classroom level and bring principals and the superintendent on board as well. Kahn also noted the importance of engaging parents in co-producing solutions for their children and organizing a network of informal leaders. Parents, grandparents, and other community members have inherent motivation and passion to participate in promoting the health and success of their children. As an example, he said that many parents in one Cincinnati community have agreed to read to their children twice per week, and the number is growing as parents and other informal community leaders are driving the solution.
Kahn summarized some of the key insights from the third-grade reading initiative. Metrics of child thriving must to be added to deficit metrics, he said. It is not sufficient to simply strive for survival to age 1. The learning network in Cleveland has accelerated the cross-sector work by focusing on shared outcomes, shared methods, and a set of core supports, Kahn said, adding that integration across the sectors should be real and realizable or people will lose faith and drop out of the effort. The effort in Cleveland has led to a common platform for measurement, testing,
learning, and creating the new system. Also, he noted that co-production with parents is essential for truly improving the pathway for the child and their family. His closing comment was that joy in work enables resilience in teaching professionals, health care professionals, and parents and gives everyone the courage to keep going.
Behavior Change in the Classroom
Kahn and Kotagal discussed further the aspects of behavior change in the classroom. Kotagal mentioned the Good Behavior Game, a universal, prosocial intervention that reduces many disciplinary infractions. In response to a question submitted via the Internet, Kahn said the version they have worked with is the PAX Good Behavior Game. He added that, at the other end of the spectrum, when psychiatrists are placed in the schools, this often leads to a medication-based approach to behavior management. An ongoing challenge, he said, is how to weave together behavioral health, early intervention and trauma-informed care, and medical care for the classroom population. The school superintendent has asked for a prototype program to be deployed in six elementary schools to encompass math and reading outcomes and prosocial behavioral health.
Political Will and Readiness for Change
Meadows asked about the sources of the political will to take on these issues and the elements of readiness that need to be in place for change to happen. Shirley observed that a crisis is often a source of political will, and it has been said to “never let a crisis go to waste.” Another element of political will and readiness is leadership. Once an issue is identified, look for champions, she said. In Oregon, the governor was a champion for change, as was some of the leadership from the health systems. Community support is also needed for readiness, she continued. This requires making the problem clear and relevant to the community so that it can participate in the solution. Readiness also takes time, and she noted that many meetings were held.
From the perspective of a very rural frontier town, Kilkenny said, it took a shift at the state level toward health transformation and a push from the department of education to bring the sectors together. This was a culture change for both local organizations and took some work to develop a relationship.
Kotagal said that Cincinnati was also inspired to readiness by crisis. The health system was continuously building more beds for mental health
services, in large part because of a lack of prevention integration, resulting in a social crisis. She noted that the Children’s Hospital board has been a champion and was instrumental in building the political will. Board members went to the communities to understand what the issues were and to ask what people wanted the hospital to do. Using data effectively also helped to build political will and caused the city council to think about children thriving in the city. Most people are not ready to change, she said, but most are persuadable. Kahn added that health care change is also contributing to readiness for change and that hospital leadership is now engaging with educators, school nurses, and parents.
Metrics and Scoring
Gourevitch observed that kindergarten readiness as a primary outcome is a complex metric and is measured differently in different places. Meyer responded that, in Oregon, the way that progress toward goals is measured is developed by a metrics and scoring committee and that kindergarten readiness is about to become a statewide incentive metric for all CCOs. Until the state metric is implemented, Health Share is applying a field definition for kindergarten readiness, she said. Part of the metric is identifying how the health care system, early learning hubs, and different segments of the community contribute to kindergarten readiness. Together, the CCO and all of the partners will be held accountable for kindergarten readiness and incentivized toward achieving it.1
Funding Cross-Sector Partnerships
The issue of funding new work, such as health care efforts toward kindergarten readiness or third-grade reading proficiency, was raised by Kaplan. He noted the challenges of reallocating resources across departments or from the health care system to other systems. Kahn replied that the financing for these initiatives is currently mission based, with a multiyear commitment of support from the Cincinnati Children’s Hospital Medical Center. The current chief executive officer (CEO) of the hospital is committed to the initiative, but Kahn was cautious about what might happen if there were a change in leadership, and outside grant funding is being sought. Ideally, he said, he would like to see the managed care organization involved in these partnerships. He noted that there was an innovation fund for testing value-based payments for some of these types of initiatives.
1 Information can be found at https://www.oregon.gov/oha/HPA/ANALYTICS/Pages/KR-Health.aspx (accessed August 22, 2018).
Kotagal emphasized the importance of outcomes in garnering support. Medicaid cannot deliver the outcomes necessary, in large part due to the payment models it is providing, she suggested. The education sector has said that it cannot deliver the education outcomes required if health care does not do its part to deliver healthy children to schools. The Cincinnati Children’s Hospital Medical Center is involved in strategic discussions with decision makers and the Ohio Children’s Hospital Association to develop a work plan for substantial primary care changes, especially in mental health, she said. The evidence for what to do is clear, she continued, and the hurdle is developing the payment models for how to do it. She added that they are working on a proposal that transforms the payment model for Medicaid. The current governor of Ohio has built the Medicaid model through managed care organizations, which she said have been reluctant to come to the table. Inside the Cincinnati Children’s Hospital Medical Center, she said, people doing this work report directly to the CEO and the board to avoid the tension and drama that can result when leadership in academic departments changes over.
Health Share makes investments in programs or infrastructure over 3- and 4-year periods, Meyer said, during which time a sustainability strategy is developed. Health Share uses some of its QI incentives to seed fund these programs, but this an uneven funding source because the QI metric incentive awards must be earned every year. She pointed out that a key difference between Ohio’s and Oregon’s models is that CCOs are not Medicaid managed care plans. They are community organizations assigned the task of cross-sector work between the health care delivery system and the community to improve population health. CCOs are required by contract to develop these types of partnerships. In contrast to Medicaid managed care plans, which are private companies with private boards, Meyer noted that the Oregon legislation establishing CCOs required them to have a community board, which provides a space for transparent and sometimes uncomfortable dialogue. Shirley added that transparency is also important in the realm of metrics and outcomes. As an example, she said, the Oregon Association of Hospitals and Health Systems recently made a major commitment to affordable housing and studying the drivers of homelessness and upstream interventions, which she said stemmed from an understanding of the data across the systems and transparency in outcomes.
Investing in the Community
The Eastern Oregon CCO is very community minded, Kilkenny said, and was the first to offer transformation health grants to the community. The grants are funded with QI incentive award dollars and are open to
anyone with a health transformation concept that is applicable to the community and to the incentive measures, she said. Meyer added that a very small part of health happens in the exam room. Health begins in the community, and the community is where investments need to be focused. Kilkenny noted that in rural frontier counties, everyone goes to the same provider and accesses the same services. It is like “separating grains of sand” to say one person in a small community can access care and another cannot because one is on Medicaid and the other is not. The Eastern Oregon CCO recognizes that expanding services beyond the Medicaid population lifts the whole community.
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