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3 How Leadership and Organizational Structure Can Address Health-Related Social Needs and Advance Health Equity The first panel, moderated by Philip Alberti of the Association of American Medical Colleges (AAMC), featured two speakers who spoke about how leadership and structure can support the work of addressing social and community needs beyond clinical care. The panel was intended to address how health care organizations can coordinate and organize these types of activities in a cohesive, effective, iterative, and evaluated system. As Alberti explained, a goal could be coordinating and integrat- ing siloed groups in an organization focused on community-partnered science, conducting community health needs assessments, and population health management, for example. A health care organization, he added, should âhave its own internal house in orderâ in order to be an effective partner in a multisectoral collaboration to address health and health care inequities. Highlights from the two presentations and subsequent discussion are provided in Box 3-1. REDESIGNING A HEALTH SYSTEM TO CREATE WELL COMMUNITIES Benjamin Carter of Trinity Health described what his organization is doing to manage and balance its ongoing tension between being a provider-based system with episodic health care management, population health management, and community health and well-being. As Carter explained, Trinity Health is a $19.3 billion Catholic health care organization based in Livonia, Michigan. The organization operates 19 PREPUBLICATION COPYâUncorrected Proofs
20 MODELS FOR POPULATION HEALTH IMPROVEMENT BOX 3-1 Key Points Made by Individual Speakers and Participants â¢ health care organization must âhave its own internal house in orderâ in order A to be an effective partner in a multisectoral collaborative to address health and health care inequities. (Alberti) â¢ here is a need to better include and reflect the voices of the community in T the design of programs and activities. Health systemsâ work with communi- ties often involves a âhelicopterâ approach (i.e., sporadic, short-lived) rather than true investment in communities (e.g., in hiring, engagement in decision Âmaking). (Wilkins) â¢ aking health equity part of the organizationâs mission, a priority of the board M of directors (with firm commitments and accountability), and integrated into incentive systems led to increased investment in, and effect on, community health. (Carter) â¢ ith a large, siloed organization, leadership support and commitment (with W a health equity metric as part of executive-level incentives and performance goals) and organizational structure (with institutional investment in an Office of Health Equity and related education and training) are precursors to influencing culture. (Wilkins) â¢ ealth care systems can engage in advocacy at the federal and state levels, H as well as in shareholder advocacy to influence companies in their investment portfolio to align with their priorities. (Carter) in 19 regions across 22 states. Its mission, which was established in 2013 when Catholic Health East and Trinity came together to form Trinity Health, is to be transformative and healing in the communities it serves. Its vision is to be a people-centered health system that delivers on the triple aim of better health, better care, and lower cost for individuals, populations, and communities. Its three core services are (1) episodic care, meaning fee-for-service care provided to individuals; (2) popula- tion health, which involves creating incentives to move to value-based care and alternative payment models; and (3) community health and well-being. Trinity Healthâs journey toward a well community has three focus areas: (1) transform communities through policy, systems, and environ- mental changes; (2) ensure care delivery models that assess and address the needs of vulnerable patients; and (3) expand use and availability of community-based services. As Carter explained, the organization also has three main strategic initiatives. The first is to address the social influencers of health, which involves tackling at least one social influence of health in each community. The other two strategic initiatives are to reduce tobacco use and obesity across the health care system. PREPUBLICATION COPYâUncorrected Proofs
LEADERSHIP AND ORGANIZATIONAL STRUCTURE 21 Carter described how Trinity Health is investing in policy, systems, and environmental change strategies to improve health. Its Transforming Communities Initiative began in March 2016 and operates in eight loca- tions, providing $18 million in grants, which has resulted in $7 million in matching funds at the community level and $40 million in community loan investments. The program addresses social influencers such as hous- ing, food, and transportation. Trinity Health operates the initiatives in collaboration with several national technical assistance partners. For example, as Carter explained, to address food deserts and lack of food access in Springfield, Massachusetts, where 100 percent of students qualify for free or reduced-price meals, Trinity partnered with Sodexo and the Springfield public schools to create a $21 million culinary and nutrition center. Another example of a community partnership is the Wellspring Greenhouse, which provides local fresh produce for hospital operations. Carter concluded by outlining Trinity Healthâs four areas of focus in addressing health equity: (1) assess the delivery of equitable care; (2) develop equity plans; (3) provide cultural competency education; and (4) reflect the diversity of our communities, which the organization strives to do through employment, vendor relationships, and purchasing. ENTERPRISE-WIDE INFRASTRUCTURE TO ADVANCE HEALTH EQUITY Consuelo H. Wilkins of the Meharry-Vanderbilt Alliance, the Â anderbilt V University Medical Center (VUMC), and the Meharry Medical College, spoke about VUMCâs approach to health equity. The health system began by exploring what it was already doing related to community health and health equity as part of a project with AAMC. As Wilkins explained, the research identified more than 180 internal programs and initiatives involv- ing research, education, and community engagement focused on commu- nity health and health equity. When leaders in population health, diversity and inclusion, academic medicine, and nursing from across the health system gathered to discuss the existing health equity initiatives, they recog- nized that many of them were siloed and disconnected. Wilkins noted that one result of the discussions was the realization that the voices of the com- munity needed to be included and reflected in the design of the systemâs programs and activities. She lamented that much of VUMCâs work with communities could be viewed as a âhelicopterâ approach (i.e., short-lived or sporadic) rather than true, sustained investment in communities (e.g., in hiring practices and in engaging the community in decision making). Wilkins described how VUMC has taken an enterprise-wide approach to addressing health disparities and advancing health equity. Earlier in PREPUBLICATION COPYâUncorrected Proofs
22 MODELS FOR POPULATION HEALTH IMPROVEMENT 2019, the health system launched a new office of health equity intended to bring together education, training, research, community, and population health efforts from across the enterprise. Wilkins noted that this institu- tional investment in health equity is critical to the initiativeâs success. With respect to education and training of health professionals, VUMC is working to ensure that all health professionals across specialties have expertise in health equity. With respect to research, the health system is working to better understand social risks and the social determinants of health and how they can be addressed, as well as the intersection between genetics and race as a social construct. Within VUMC, the enterprise is considering how to address the needs of the diverse 24,000 VUMC employees with varying needs, priorities, social risks, and incomes. As an example of strong institutional commit- ment, Wilkins described how a health equity metric would be part of the executivesâ performance goals and incentive plans across mission areas. AUDIENCE DISCUSSION Alberti began the audience discussion by pointing out that in the case of Trinity Health, the mission drove the infrastructure, strategy, and plan- ning, while with VUMC, the organizationâs new structure created a cul- ture of health equity across the institution. He asked Carter and Wilkins the âchicken and eggâ question of whether culture or structure should come first. Carter responded that in the case of Trinity Health, as a faith- based and provider-driven organization, community health and health equity have always been part of the mission. From a financial perspective, the organization invests in community benefit ministry, which includes the unfunded costs of Medicaid. However, he pointed out that commu- nity health was not receiving the attention and focus needed to make an improvement in the communities being served. In 2013, Â rinity Health T adopted a mission to be transformative, which drove it to approach com- munity health, well-being, and health equity in a different way, which would involve firm commitments, accountability, and ongoing consid- eration of the effect on the community. Carter noted that having health equity as part of the organizationâs mission and a priority of the board of directors and incentive systems was what made a difference regarding investment inâand the improvement ofâcommunity health. Wilkins stated that, for her organization, structure was the vehicle for changing the culture. She suggested that with a relatively large, siloed organization like VUMC, it would be difficult to influence the culture without both leadership support and organizational structure. Wilkins noted that changing the culture internally has been more challenging than forming relationships with the community. PREPUBLICATION COPYâUncorrected Proofs
LEADERSHIP AND ORGANIZATIONAL STRUCTURE 23 Wilkins described several barriers to institutional change. For exam- ple, academic leaders were pleased with the curriculum, yet there was student demand for a health equity certificate program. As another exam- ple, VUMC provided grant funding for community organizations, but required them to complete detailed forms and pay up front for expenses. Wilkins suggested that changes to the culture are needed to remove b Â arriers such as these. She pointed out that a wellness program designed for people who, for example, can afford child care and have not struggled with food insecurity may not work for people facing these and other social factors. She concluded by emphasizing that the structure provides the opportunity to change the culture through access to, and incentives for, leadership support. Alberti asked Carter and Wilkins which person or entity at each of their organizations is accountable for the outcomes of their health equity work and how each of the stakeholders are involved in the development of metrics and incentives that are meaningful for all. Wilkins responded that at VUMC, her position is partially responsible for the outcomes of the work, and executive-level incentives and performance goals provide additional accountability. She would like for the community to do a better job of holding VUMC accountable for investing in projects that meet the communityâs needs, including them in decision-making processes, and hiring from the community. Carter noted that at Trinity Health, the board holds the organization accountable through 25 percent of the organizationâs strategic plan being related to community health and well-being, equal to the weight given to financial success. The executives of all 19 regions have the same goals related to community health and well-being as the chief executive officer. In addition, there is a senior vice president for community health who is on the executive leadership team and vice presidents in each region responsible for objectives related to community health and well-being locally. Carter pointed out that much of the community health work is accomplished through partnerships. Building on Albertiâs question about accountability, Sally Kraft of Dartmouth-Hitchcock asked about what accountability measures are being used and whether there are community health metrics. She noted that many factors outside of the health system may influence a commuÂ nityâs health status. Wilkins responded that, as a first step, VUMC is focused on identifying which measures are being used, or could be used, to collect data, using its employees as the sample population. The health system is working to develop metrics in all mission areas, including stu- dentsâ competencies, knowledge, and willingness to work in underserved areas, and exploring better ways to integrate into studentsâ work the perspectives of the communities served. PREPUBLICATION COPYâUncorrected Proofs
24 MODELS FOR POPULATION HEALTH IMPROVEMENT Carter noted that Trinity Health has objective measurable outcomes related to issues such as reducing tobacco use and obesity. The health system uses electronic medical records to determine the extent to which it is making a difference in these areas. There is also a new metric related to social influences of health. Trinity Health uses process measures to assess its effect throughout the community in areas where it works in collabora- tion with community partners. John Auerbach of Trust for Americaâs Health asked Carter and Wilkins whether their organizations have considered advocating for policy change at the federal, state, and local levels. Auerbach pointed out that in his experience as a former state health official, health systems were effective advocates, but often they did not prioritize policies that would improve the overall health within the state. Carter responded that Trinity Health has been active in advocacy at the federal and state levels, including push- ing for legislation to increase the minimum tobacco sales age to 21, change opioid prescribing, increase housing access, and address gun violence. Given its large investment portfolio, the organization also engages in shareholder advocacy to influence companies such as CVS and Walmart to align with its priorities. Mylynn Tufte of the North Dakota Department of Health asked Carter and Wilkins about how the language used can influence the level of sup- port among people in their organizations who are not well versed in issues related to health equity. Wilkins responded that she sometimes uses dif- ferent language to communicate about her work with different audiences within the medical center. She also pointed out that different communities may face different challenges. PREPUBLICATION COPYâUncorrected Proofs