Insights

A Five-Part Series
Part III: Organizational Aspect

In our earlier blog entry, we posited that the term “population health” is rrather meaningless unless stated in terms of how it is implemented, which involves the application of the clinical, organizational, and technical aspects of population health management. We previously examined the clinical aspect; now, we focus on the organizational aspect.   
To accomplish the herculean task that lies before core hospital/physician teams as integrators and their broader resource teams of community experts, organizational functionality and discipline are essential. If the goals of the “Triple Aim” are to be realized, the process to be undertaken must result in complete culture change, refocusing the entire enterprise on population health improvement.

Consider that the hospital has thrived on a fee-for-service payment system that relies on the hospital being filled to capacity with its medical staff optimizing the use of its beds, ORs, laboratory, and imaging capabilities. The medical staff members have functioned in silos of specialties, increasing their revenues by the number of times they tested or touched the patient. Both the hospital and its physician staff have been motivated by helping patients with each isolated healthcare issue, a specific episode of illness or injury. Neither has been incentivized to collaborate to achieve better health status outcomes more efficiently.

Now consider that both the hospital and physician staff will be rewarded in the future if they demonstrate patient satisfaction scores superior to their competitors and health outcomes that actually keep people out of the hospital’s expensive confines. In this zero-sum reimbursement environment, those who fail to compare favorably will be penalized financially. The funds realized from the penalties assessed will be used to reward those achieving the superior results.

In addition, metrics have been developed and the analytics capability established that will allow comparisons to be made and published. The results will become public knowledge (read: transparency). As these new payment and reporting models take hold and a grade card becomes public, the very future and continued success of the hospital and its co-dependent medical staff will only be realized through their unified attack on the detriments to population health.
The successful hospital and medical staff must collaboratively develop the systems and processes to meet this challenge. An environment of trust must be created within which both can confront their common challenges. The process also must involve the expanded group of community experts and stakeholders in some meaningful fashion.

The Organizational Hub. The hospital has the requisite organizational and administrative expertise to lead change. It is the most likely candidate to take the lead in establishing the structure and process necessary to develop a population health action plan. In taking the initiative, however, the hospital must solicit and honestly consider the input of its physician staff. The structure in which to house the planning process can be called the “Organizational Hub” for healthcare reform efforts in the community.

The structure will vary in each Organizational Hub, but the Hub must, at its core, provide an environment of trust which encourages creativity and sound decision making.  It must solicit and honor ideas and opinions from all participants.  The structure also must be built for growth in order to include the involvement of community resources and be capable of morphing into an operational structure to implement the plans which are cooperatively developed.

An example of this integrative process was successfully undertaken by Flagler Hospital in St. Augustine, Florida. When challenged by community employers and commercial payers to provide better value in delivered care, the hospital board invited the members of the medical staff to help design a structure and process that would meet the challenge. The hospital board actually asked the medical staff to propose its desired organizational structure, one that would engage physician involvement.

When presented with a carefully developed and well-thought-out proposal, the board accepted and launched – with the medical staff – a separate physician/hospital-owned organization which was designed to harness the respective capabilities of both parties to achieve their common purpose. (See our White Paper, “Zero to CIN in Less Than Nine Months,” which describes the Flagler story.)

As tertiary and quaternary hospitals work to change their culture and orient toward population health management, they also will want to secure relationships with their cohort of referring hospitals, many of which are struggling with the same pressures. Engaging those referring hospitals in the process of population health management will solidify the referral relationship and aid those smaller institutions in their efforts. The formation of collaborative networks designed to engage providers regionally to impact population health is improving patient care across the continuum from rural to quaternary and bringing urban hospital capabilities cost-effectively to the rural bedside.

The University of Missouri Hospital, an academic medical center, has formed such a regional collaborative with five rural community hospitals known as the Health Network of Missouri (HNM). Through a disciplined planning process, the hospitals created a co-owned governing entity. The governing entity provided each of the hospitals, regardless of size, equal participation in the process of creating a clinically integrated network of hospital and physician resources aimed at improving the population health of the residents of Central Missouri.

There are many other examples of structures created to promote the concept of independence through interdependence. Hospitals are able to do the hard work of converting their cultures from volume-focused to value-focused. Each has recognized the need for physician involvement in the process. Each has embraced the Triple Aim as a goal. Each believes that change is possible when trust is given and received in return, collaboration is rewarded, respect for another’s unique capabilities is honored, and the synergy of cooperation is allowed to flourish.

The Community Hub of Wellness and Health. The hospital or health system, in harmony with its medical staff, will naturally serve in the role as the Community Hub of Wellness and Health (CHWH). As financial incentives change to encourage prevention, wellness, and consideration of the social determinants of health, medical care will flow from the CHWH into the community. In this model, the hospital naturally will be relied upon as the primary coordinator of community care toward the end of improving population health.

As a result of the awakening to the importance of population health management, remarkable change is starting to emerge. Take, for instance, a Kaiser program that serves as a great example of a CHWH. It brings farmers’ markets into 30 hospital facilities in four states.

Dr. Preston Maring introduced the Friday Fresh Farmers’ Market at Kaiser Permanente Oakland Medical Center in May 2003. Since then, the market has grown to include a system that supplies locally grown fruits and vegetables for 23 Kaiser hospital kitchens, in addition to supplying the weekly farmers’ markets in those hospital service areas. Dr. Maring also has helped establish a seasonal market at GM-Toyota’s new United Motor Manufacturing Inc., plant in Fremont, California, where 5,000 people work.

Kaiser also worked with Sustainable Economic Enterprises of Los Angeles to open the Watts Healthy Farmers’ Market. That market provides not only farm fresh food options, but also health screenings, nutrition education, and other health promotion activities for the community. Dr. Maring noted, “Markets change the community. They provide good food, fun, and a meeting place.”[1] Such programs also create new, trusting relationships among the hospitals, farmers, food distributors, and other employers and can only increase the standing of the hospital in the community, truly establishing it as the Community’s Hub of Wellness and Health.

The Community Health Needs Assessment. A comprehensive Community Health Needs Assessment (CHNA) can serve as the perfect launching pad for a population health management effort. Bon Secours Baltimore Health System conducted such an assessment over the period of 2009-2012 that included meetings, interviews, community summits, and literature studies. It engaged community members with public health knowledge, the broad interests of the communities it served, as well as individuals with special knowledge of the medically underserved, low-income, and vulnerable populations, and people with chronic diseases.

Bon Secours’ assessment ultimately determined that to address the community’s most significant health needs, it needed to develop an action plan which:

• Helped make the Southwest Baltimore community-of-focus a place where residents could live long, satisfying lives by being proactive about their health and wellness, understand the importance of healthful eating, and have access to healthful foods in a variety of locations and outlets, including the hospital.
• Made the community a place where residents were ready to work, were self-sufficient, and had access to jobs that enabled them to support themselves and their families.
• Helped the community to become more environmentally friendly, more lush with nature and green open spaces, lead-free, and a place with fresh air to breathe and safe water to drink.
• Developed a coalition of senior leaders from the organizations which comprised the community’s health safety net.
• Focused on primary care engagement, expanded primary care capacity, and prepared for healthcare payment and delivery transformation.

Launching this population health management plan-of-action not only has begun improving the lives of the patients served by Bon Secours, but it has cemented the hospital as an integral partner in securing the future of the community it serves. It is thereby securing its own future.

Engaging clinicians and organizing for change are the first two aspects of population health management and improvement which inform the understanding of population health as a concept. Next up, we will discuss the technical aspect of population health.

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