Delivery System Transformation https://trustees.aha.org/ en Creating Age-Friendly Health Systems https://trustees.aha.org/creating-age-friendly-health-systems-0 <span class="title">Creating Age-Friendly Health Systems</span> <span class="uid"><span>emaze_drupal</span></span> <span class="created">May 04, 2020 - 01:02 PM</span> <div class="body"><style type="text/css">#article h3 span { text-transform: uppercase; color: #9D2235 } .articleSidebar h4 { color: #9D2235; } </style> <div id="article"><img alt="doctor speaking to older female patient" src="/sites/default/files/2020-05/TI_0520_cleary_fishman_age_friendly_900.jpg" /> <h4 class="articleKicker"><a href="/resource-repository-trustees?topic=684">New Delivery Models</a></h4> <h1>Creating Age-Friendly Health Systems</h1> <h3 class="articleDeck">An innovative model addresses the unique care needs of older adults</h3> <h4 class="articleByline">by Marie Cleary-Fishman, Jay Bhatt and Jonathan R. McKinney</h4> <p>The nation’s adult population over age 65 is projected to reach 83.7 million by the year 2050, an increase from 21% of the population in 2012 to more than 39% in 2050. This population has unique and complex health care needs, which makes medical care more challenging and complicated. Some challenges that persist: transitions between care settings; side effects and adverse drug interactions from multiple medications; lack of care planning that incorporates culture, values and goals of the patients and their families; communication barriers due to language and hearing; and changing care preferences that favor older adults remaining independent and in their home.</p> <p>Many older adults also face challenges with change in self-identity; social isolation and loneliness; decreased mobility; loss of independence; and change in resources, including food and financial insecurity. These factors call for innovative care delivery models that respond to patients’ personal preferences, medical needs and values. An age-friendly health system could be the key approach to this need.</p> <h3>An Innovative Health Care Model for Older Adults</h3> <p>Age-Friendly Health Systems is an initiative of the John A. Hartford Foundation and the Institute for Healthcare Improvement in partnership with the American Hospital Association and the Catholic Health Association of the United States. The initiative is designed to meet the needs of older adults, looking beyond acute events, engaging the whole community and achieving better health for older adults.</p> <div class="articleSidebar floatRight" style="background-color: transparent;"> <h3>The 4Ms Model</h3> <img alt="4Ms model infographic" src="/sites/default/files/2019-05/4M_Model.png" /></div> <p>Age-Friendly Health Systems is an evidence-based model to support the needs of the aging community by focusing on four key areas: what matters, medications, mobility and mentation — better known as the 4Ms Framework. Through this initiative, we aim to improve patient care, safety and outcomes; improve patient and family engagement in care; and reduce outcomes such as length of stay and readmissions.</p> <h3>The 4Ms Model</h3> <p>This ideal health care system for aging Americans boils down to the 4Ms model where the M’s are considered and addressed together, all the time:</p> <ul> <li><strong>What Matters:</strong> Know and align care with each older adult’s specific health outcome goals and care preferences including, but not limited to, end-of-life care, and across settings of care.</li> <li><strong>Medications:</strong> If medications are necessary, use age-friendly medications that do not interfere with What Matters, Mentation or Mobility.</li> <li><strong>Mentation:</strong> Prevent, identify, treat and manage depression, dementia and delirium across settings of care.</li> <li><strong>Mobility:</strong> Ensure that older adults move safely every day in order to maintain function and to do What Matters.</li> </ul> <h3>4M Action Steps</h3> <ul> <li><strong>What Matters:</strong> <ul> <li>Educating care providers on appropriate conversations with patients who have a serious illness; addressing patients’ concerns and goals.</li> <li>Involving an interdisciplinary team to meet and discuss complicated cases and implement new ideas generated by these discussions.</li> </ul> </li> <li><strong>Medications:</strong> <ul> <li>Scheduling pharmacovigilance meetings among care providers to ensure patient safety.</li> <li>Redesigning medication reconciliation processes.</li> </ul> </li> <li><strong>Mentation:</strong> <ul> <li>Reaching out to inpatient providers to help ensure delirium notification and results are communicated and understood.</li> <li>Studying the impact of dementia on illness presentation.</li> </ul> </li> <li><strong>Mobility:</strong> <ul> <li>Developing a primary care model focused on mobility as a lever for fall risk management.</li> <li>Increasing frequency of 1:1 ambulation with patients.</li> </ul> </li> </ul> <p>Age-Friendly Health Systems elevate traditional models of care for older adults and their caregivers in ways that preserve dignity and encourage independence. An effective age-friendly health system means: older adults get the best care possible; health care-related patient safety incidents approach zero; and patient experience and value are optimized for all — patients, families, caregivers, health care providers and health systems.</p> <h3>Becoming an Age-Friendly Health System: A Case Example</h3> <p>Care New England (CNE) realized to do true population health, it needed to meet the needs of its older adults, particularly at Kent Hospital in Warwick, Rhode Island, where the patient volume is the highest. A needs assessment at Kent Hospital showed that 30% of hospital admissions were patients over the age of 65, and of that group, most were over 85. Since 2014, the health system and Kent leadership teams have supported the growth of a service line in geriatrics and clinical programs to serve the needs of older adults across the continuum of care.</p> <p>CNE’s participation in the Age-Friendly Health Systems initiative focused on building an Acute Care for Elders (ACE) unit at Kent Hospital. At the baseline, many seeds were in place to drive success: Leaders fully supported a mission-driven focus to improve care of older adults; a two-year effort on creating delirium prevention and management protocols had just kicked off; and pharmacy teams had begun working on eliminating potentially inappropriate medications.</p> <div class="articleSidebar floatRight"> <h3>Examples of the 4Ms model in the field</h3> <h4>Anne Arundel Medical Center, Maryland</h4> <p><strong>The challenge: </strong>More than 45% of patients admitted to Anne Arundel Medical Center (AAMC) are over the age of 65. To address falls, inappropriate medication use, delirium and other avoidable harms, AAMC implemented the 4Ms Framework.</p> <p><strong>The impact: </strong></p> <ul> <li>Average length of stay was reduced by 26 hours.</li> <li>Increased patient experience and satisfaction.</li> </ul> <p>&nbsp;</p> <h4>Ascension St. Vincent, Indiana</h4> <p><strong>The challenge:</strong> Indiana-based St. Vincent is working to improve health, quality of care and functional status of adults age 65 and older.</p> <p><strong>The impact: </strong></p> <ul> <li>Over a three-month period, more than 2,000 patients received age-friendly care, which has helped to streamline geriatric consultations.</li> </ul> <p>&nbsp;</p> <h4>Kaiser Permanente Woodland Hills Medical Center, California</h4> <p><strong>The challenge: </strong>More than 22% of patients who visit KP Woodland Hills are over the age of 65. To test strategies that can be adapted and scaled across the care continuum, KP Woodland Hills implemented the 4Ms Framework.</p> <p><strong>The impact: </strong></p> <ul> <li>Increased medical adherence with medications and decrease in readmissions.</li> <li>Increased patient experience and satisfaction.</li> </ul> <p>&nbsp;</p> </div> <p>The team’s aim was to set up the new geriatric unit using the 4Ms model — what matters, medication, mentation and mobility — and focus on 1)&nbsp;documenting “what matters most” and 2)&nbsp;implementing delirium screening and a prevention power plan for all patients admitted to the 10-bed unit. The health system spent just over a year planning and working toward converting an existing hospital unit to serve as the new 10-bed ACE unit.</p> <p>In the ACE unit, each patient is reviewed during typical hospital rounds, and then each of the 4Ms is reviewed to round out the day’s plan and the care plan overall. The geriatrics team uses the 4Ms to organize recommendations for each patient on the unit, as well as across the hospital on the geriatrics consultation service.</p> <p>The health care team uses a dashboard to track the ACE unit outcomes and key performance metrics. Since opening the unit in February 2019, Kent Hospital has served, on average, 76 patients per month with an average age of 86. Length of stay each month has decreased as have patient falls. Staff and patient and family satisfaction has risen tremendously. Kent intends to expand the size of the ACE unit to 20 beds.</p> <p>Since implementing the 4Ms model on Kent’s ACE unit, CNE has begun using the model to frame and organize recommendations on all geriatric consultations hospitalwide. The health system also is enrolling an ambulatory practice to spread the Age-Friendly Health Systems model further. In addition, CNE is beginning to collaborate with its emergency department physician and nursing leaders to implement the 4Ms model for older adults in the ED. Hospital and health system leadership support making the older adult work a high priority and part of is executive action plan.</p> <h3>How Can Trustees Be Involved?</h3> <p>Hospitals and health systems have developed governance committees to review and provide strategic guidance on moving quality forward. It is important for trustees to play a critical role in providing guidance, raising questions and moving forward an age-friendly health system — one that will care for them someday.</p> <p>We encourage hospitals and health systems to join us in deploying the 4Ms Framework and embracing age-friendly care. The benefits of joining this movement include:</p> <ul> <li>Redeploying and prioritizing existing hospital/health system resources.</li> <li>Supporting your health organization’s mission, vision and values.</li> <li>Putting your organization ahead of the curve in preparing for the impending market shift.</li> <li>Achieving “Age-Friendly Health System Participant” or “Committed to Care Excellence” recognition.</li> </ul> <h3>Age-Friendly Recognition</h3> <p>The first AHA Age-Friendly Health Systems action community concluded in early April, with 75 teams achieving “age-friendly” recognition. This cohort of 184 health care teams and 12 allied associations worked simultaneously to implement the 4Ms and provide high-quality care that meets the unique needs of older adults. One care team participating designed a telehealth visit template that includes the 4Ms and is used through a virtual telehealth clinic. At another participating organization, nursing staff are spending time digging deep into the 4Ms, which is improving patient satisfaction and the discharge process.</p> <p>The AHA will be hosting another Age-Friendly Health Systems action community in fall 2020.</p> <p>To get involved, email <a href="mailto:AFHS@aha.org">AFHS@aha.org</a>. You can learn more about the initiative and action community at <a href="https://www.AHA.org/age-friendly" target="_blank">AHA.org/age-friendly</a>.</p> <h4 style="font-size: 1em; border-top: 1px solid #63666A; padding-top: 10px;"><span style="font-weight: bold;">Marie Cleary–Fishman</span> <a href="mailto:mfishman@aha.org">(mfishman@aha.org)</a> is vice president, clinical quality, at the American Hospital Association. <span style="font-weight: bold;">Jay Bhatt, D.O.,</span> <a href="mailto:jay@drjaybhatt.com">(jay@drjaybhatt.com)</a> is a practicing&nbsp;internist and former chief medical officer at the American Hospital Association. <span style="font-weight: bold;">Jonathan R. McKinney</span> <a href="mailto:jmckinney@aha.org">(jmckinney@aha.org)</a> is director, office of the CMO and operations, at the American Hospital Association.</h4> <p class="disclaimer">Please note that the views of the authors do not always reflect the views of the AHA.</p> </div> </div> <article role="article"> <div class="reusable-cta--theme- reusable-cta--container cta-background-color-"> <div class="reusable-cta--text-fields-container "> <div class="reusable-cta--field cta--field-text color-"> <div class="field_text"><style type="text/css">ol > li::marker { font-weight: bold; } #article { max-width: 800px; margin: auto; padding: 20px; } .articleKicker { font-weight: bold; margin: 30px 0 0 0; text-transform: uppercase; } #article h1 { margin: 10px 0 10px 0; line-height: 1.1em; } .articleDeck { line-height: 1.1em; margin: 6px 0 15px; } .articleByline { font-weight: bold; font-size: 1em; margin-bottom: 10px; text-transform: uppercase; } #article li { margin-bottom: 10px; } #article ul { margin-bottom: 0; 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padding-bottom: 20px; border-top: 1px solid lightgrey; padding-top: 20px"><em><strong>Editor’s note:</strong> Excerpted from <a href="https://www.aha.org/system/files/media/file/2019/04/MarketInsights_CareModelsReport.pdf">“Evolving Care Models,”</a> a Market Insights report from the AHA Center for Health Innovation that provides an overview of the successes and challenges providers have experienced in aligning care delivery models with alternative payment models, and that provides lessons for those in the midst of this transition. As payers shift financial risk to providers through more advanced payment models, trustees will need to help their organizations build new capabilities for succeeding under these payment arrangements.</em></p> <p>Hospitals and health systems across the country are redesigning care delivery to improve quality and outcomes, enhance the patient experience, reduce costs and, ultimately, produce better population health. They are testing and implementing new care models to focus on prevention and better coordinate care across the many sites of care that touch patients.</p> <p>The payment landscape for health care services has evolved to support providers’ transition to new care delivery models. Over the past 10 years, payers have transitioned a growing portion of payments made to providers from traditional fee-for-service to alternative payment models (APMs). Also, commonly referred to as value-based payment models, APMs incent providers for quality and value, rather than volume.</p> <p>The AHA Center for Health Innovation based this report on information and insights from a number of sources, including interviews with hospital and health system leaders and other health care experts, surveys of hospitals and health systems, and a number of health care reports and research articles.</p> <h3>Evolution in Care Delivery Models</h3> <p>Among other key points, the report’s collaborators have observed that:</p> <ul> <li>APMs vary in the degree of financial risk they transfer to providers, but most providers today still assume relatively low levels of risk. This approach provides stability to providers as they build up the required capabilities for taking on higher levels of risk.</li> <li>APMs have gained traction in recent years, driven in large part by government payers. Activity across commercial payers varies geographically but is also accelerating. In certain cases, public and private payers are working together — at both the national and state levels — to align payment models.</li> <li>Providers are juggling the challenge of developing the capacity to operate successfully in shared-risk payment models, while still caring for significant numbers of patients in fee-for-service arrangements.</li> </ul> <h3>Four Most Common Alternative Care Delivery Models</h3> <p>Various service-delivery and payment models that aim to achieve better care for patients, smarter spending and healthier communities are still evolving and being tested. Health systems are implementing and refining a wide array of care delivery models. Alternative approaches have clustered around four specific models: accountable care organizations (ACOs), medical homes, integrated service lines (bundled payment programs) and provider-sponsored health plans.</p> <div style="width: 100%; margin-top: 20px"><a href="/system/files/media/file/2019/10/MarketInsights_CareModelsReport-p8.pdf" rel="noopener noreferrer" target="_blank"><img alt="Four Most Common Alternative Care Delivery Models table" class="shadow" src="/sites/default/files/2019-10/MarketInsights_CareModelsReport-p8_0.jpg" /></a> <div style="float: left; width: 100%;margin-top:20px; padding-bottom: 10px; margin-bottom: 20px; border-bottom: 2px solid lightgrey"> <div style="float: left; padding-right:20px margin-top: 10px; "><img alt="pdf download icon" src="/sites/default/files/pdf_download-Icon.png" style="margin: 6px 0; padding-right: 10px; border: none;" /></div> <div style="float: left; margin-top:6px"> <h3 style="margin:6px 0; font-weight: normal;font-size: 1.3em;"><a href="/system/files/media/file/2019/10/MarketInsights_CareModelsReport-p8.pdf" rel="noopener noreferrer" style="color: #222;" target="_blank">Download a PDF of the table</a></h3> </div> </div> </div> <p>According to the report, health systems without previous experience in alternative care delivery models chose to adopt one of the most common care models for the first time, and those with experience were adopting new processes and/or technologies to make the models more effective.</p> <h3>Maturity Framework for APMs</h3> <p>While government payers have sparked a paradigm shift during the past decade around how to pay for health care, they have allowed for a transition, granting providers time to build new capabilities without significant exposure to downside risk. Many health systems now find themselves with one foot in more traditional fee-for-service payment systems and the other in alternative-reimbursement models. They want to transform their care models, but struggle to finance the required changes to their networks, processes and support systems.</p> <p>Boards can help their organizations evolve toward value-based payment models by employing a “maturity framework” in discussions with their leadership team, see pages 5-6.</p> <p>Each organization can use the maturity framework to assess its current capabilities to determine the best type of value-based care for the organization. All providers need to rethink where they are on the risk continuum, where they will be in the future and whether they have the infrastructure systems needed to manage risk.</p> <div style="width: 100%; margin-top: 20px"><a href="/system/files/media/file/2019/10/MarketInsights_CareModelsReport-p12-13.pdf" rel="noopener noreferrer" target="_blank"><img alt="Four Most Common Alternative Care Delivery Models table" class="shadow" src="/sites/default/files/2019-10/MarketInsights_CareModelsReport-p12-13-1.jpg" /></a> <div style="float: left; width: 100%;margin-top:20px; padding-bottom: 10px; margin-bottom: 20px; border-bottom: 2px solid lightgrey"> <div style="float: left; padding-right:20px margin-top: 10px; "><img alt="pdf download icon" src="/sites/default/files/pdf_download-Icon.png" style="margin: 6px 0; padding-right: 10px; border: none;" /></div> <div style="float: left; margin-top:6px"> <h3 style="margin:6px 0; font-weight: normal;font-size: 1.3em;"><a href="/system/files/media/file/2019/10/MarketInsights_CareModelsReport-p12-13.pdf" rel="noopener noreferrer" style="color: #222;" target="_blank">Download a PDF of the table</a></h3> </div> </div> </div> <h3>Road Map to Advance Along the Maturity Model</h3> <p>Health system leaders who have embarked on care delivery change say they are committed to continuing the evolution toward value-based care because the approach is better for patients, but they caution that there is no silver bullet that can substitute for: setting an inspiring vision for care delivery; engaging clinicians to agree on evidence-based protocols and care plans; retraining staff to support the new approach; and building feedback loops to measure organizational performance and adjust accordingly.</p> <p>The following “road map” offers leadership lessons for those wishing to transform their care models.</p> <div style="width: 100%; margin-top: 20px"><a href="/system/files/media/file/2019/10/MarketInsights_CareModelsReport-p14.pdf" rel="noopener noreferrer" target="_blank"><img alt="Roadmap to advance along the maturity model" class="shadow" src="/sites/default/files/2019-10/MarketInsights_CareModelsReport-roadmap.jpg" /></a> <div style="float: left; width: 100%;margin-top:20px; padding-bottom: 10px; margin-bottom: 20px; border-bottom: 2px solid lightgrey"> <div style="float: left; padding-right:20px margin-top: 10px; "><img alt="pdf download icon" src="/sites/default/files/pdf_download-Icon.png" style="margin: 6px 0; padding-right: 10px; border: none;" /></div> <div style="float: left; margin-top:6px"> <h3 style="margin:6px 0; font-weight: normal;font-size: 1.3em;"><a href="/system/files/media/file/2019/10/MarketInsights_CareModelsReport-p14.pdf" rel="noopener noreferrer" style="color: #222;" target="_blank">Download a PDF of the road map</a></h3> </div> </div> </div> <h3>Conclusion</h3> <p>By building care delivery prototypes, testing their models and bringing a value proposition to payers, health systems can achieve greater alignment among reimbursement from government and commercial payers, thereby further accelerating care delivery transformation. Such an approach creates a virtuous cycle where initial successes in care delivery and payment reform provide feedback to drive bolder care model changes and increased levels of financial risk. As payers continue to shift higher levels of risk onto providers, hospitals and health systems that can leverage this positive feedback loop to transition a substantial portion of their payment stream to APMs will be well positioned for success. Through the hard work of changing their care models, providers are poised to lead care delivery change to improve patient outcomes.</p> <div class="articleSidebar" style="width: 100%; max-width: none"> <h3>Questions for Board Discussion</h3> <ol> <li>How has our organization gained experience with alternative care delivery/payment models? Which models have we adopted and what have we learned?</li> <li>What are the key challenges we have faced in gaining experience with new care delivery/payment models (for example, engaging staff and clinicians, financing the transition to these models, acquiring the technology, tools and capabilities needed to make the change, etc.)? How has our organization addressed these challenges?</li> <li>Will experience with alternate care delivery and payment models require us to change our risk appetite/tolerance and, if so, how?</li> <li>Where does our organization fall on each dimension of the maturity framework shown above?</li> <li>What steps along the above road map might our organization take to continue to advance our capabilities to effectively engage in value-based care delivery and payment?</li> <li>How should our board continue to monitor our organization’s progress toward adopting value-based care and payment models?</li> </ol> </div> <h4 style="font-size: 1em; border-top: 1px solid #63666A; padding-top: 10px;">The report was collaboratively prepared with insights from Benjamin Chu, Naomi Newman and Avi Herring from Manatt Health.</h4> </div> </div> <article role="article"> <div class="reusable-cta--theme- reusable-cta--container cta-background-color-"> <div class="reusable-cta--text-fields-container "> <div class="reusable-cta--field cta--field-text color-"> <div class="field_text"><style type="text/css">ol > li::marker { font-weight: bold; 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} .columnPhoto { width: 100%; max-width: 100% } } @media only screen and (max-width: 600px) { .videoPlayOnPage { width: 100%; } .resourceImage { width: 100% } } #footer div.area div.footer-right { float: right; max-width: 700px; width: 100%; } #footer div.area { max-width: 960px; width: 100% !important; padding: 0 20px; } #footer { margin-top: 30px; } </style> </div> </div> </div> </div> </article> <div class="field_sidebar_elements"> <div class="paragraph paragraph--type--sidebar paragraph--view-mode--default"> </div> </div> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="/system/files/media/file/2019/10/TT_1019_care_delivery_models.pdf" type="application/pdf">Aligning Care Delivery to Emerging Payment Models</a></span> </div> </article> </div> </div> <div class="field_topics"> <div><a href="/topics/delivery-system-transformation" class="topic" hreflang="en">Delivery System Transformation</a></div> </div> Mon, 07 Oct 2019 18:20:03 +0000 acompher_drupal 349954 at https://trustees.aha.org Integrating Behavioral and Physical Health through Primary Care https://trustees.aha.org/integrating-behavioral-and-physical-health-through-primary-care <span class="title">Integrating Behavioral and Physical Health through Primary Care </span> <span class="uid"><span>mmusker_drupal</span></span> <span class="created">Jul 16, 2019 - 12:58 PM</span> <div class="body"><style type="text/css">.collapsible { background-image: url("/sites/default/files/2019-07/plus-icon-black.png"); background-repeat: no-repeat; background-position-x: 95%; background-position-y: 80%; color: #B9D9EB; cursor: pointer; padding: 22px; width: 100%; border: none; text-align: left; outline: none; margin-top: 10px; display: flex; font-weight: bold; } .collapsible h3 span { display: inline !important; } .collapsible h3 { font-size: 1.8em; line-height: 1.1em; margin-top: 0; color: #B9D9EB; width: 95% } .articleSidebar .collapsible h3{ font-size: 1.2em !important;; color: #333; text-transform: none } .collapsible.active { background-image: url("/sites/default/files/2019-07/minus-icon-black.png"); } } .active, .collapsible:hover { background-color: #002855; } .questionBox .content { padding: 0 18px; max-height: 0; overflow: hidden; transition: max-height 0.2s ease-out; background-color: #f6f6f6; } .questionBox .content ul { padding-left:25px; padding-bottom: 10px } .questionBox .content li:nth-child(n+2) { padding-top: 0 !important; } .questionBox .content li { padding: 0 5px; margin: 0; font-size: 1.1em; line-height: 1.2em; } .questionBox .content li a { font-weight: bold; } </style> <div id="article"><img alt="doctor consoling young woman" src="/sites/default/files/2019-07/ti-0719-doctor-counseling-consoling-woman-depression-behavioral-health-900.jpg" /> <h4 class="articleKicker"><a href="//resource-repository-trustees?topic=684">New Delivery Models</a></h4> <h1>Integrating Behavioral and Physical Health through Primary Care</h1> <h3 class="articleDeck">Innovative approaches are improving patient outcomes and lowering health care costs</h3> <h4 class="articleByline">By Lola Butcher</h4> <div class="articleSummaryBox floatRight" style="margin-top: 6px;"> <h3>Trustee Talking Points</h3> <ul> <li>One in five patients may be experiencing a behavioral as well as physical health problem.</li> <li>Behavioral health illnesses can make it harder for providers to treat chronic conditions.</li> <li>Behavioral health illnesses also make it harder for patients to comply with treatment protocols.</li> <li>Poor outcomes and higher costs can result from inattention to behavioral health issues.</li> </ul> </div> <p>As trustees consider how to improve the health of the communities they serve, a key fact needs to be top of mind.</p> <p>“Even if you think you're not in the mental health business, you're in the mental health business,” said Ann Schumacher, president of CHI Health Immanuel in Omaha. “If you are providing care, one in five of your patients has or will experience a mental health condition.”</p> <p>Hospitals and health systems that fail to address that fact suffer the consequences, as do the patients and communities they serve. Patients whose behavioral health problems — including mental and substance use disorders — are not effectively treated often become high utilizers of “physical” health services. Depression, anxiety, schizophrenia, bipolar, substance use and other behavioral health illnesses can make it harder to treat their chronic conditions — and harder for patients to comply with treatment protocols, often leading to poor outcomes and higher health care costs.</p> <p>Among Medicare, Medicaid and dually eligible populations, more than 50% of adults treated for a behavioral health disorder had four or more comorbid physical conditions, according to a recent study. (See K. Thorpe et al., “Prevalence and Spending Associated with Patients Who Have a Behavioral Health Disorder and Other Conditions,” Health Affairs [2017], <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.0875"><span>https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.0875</span></a>.)</p> <p>Certain mental health diagnoses also are associated with a reduction in life expectancy by 7 to 24 years compared to individuals without such disorders — greater than the estimated 8 to 10 years of reduced life expectancy from heavy smoking. (E. Chesney et al., “Risks of All-Cause Suicide Mortality in Mental Disorders: A Meta-Review,” World Psychiatry [2014], <a href="https://www.ncbi.nlm.nih.gov/pubmed/24890068"><span>https://www.ncbi.nlm.nih.gov/pubmed/24890068</span></a>.)</p> <div class="articleSidebar floatLeft"> <h3>Topics for Board Discussion</h3> <p>Brenda Reiss-Brennan, Ph.D., APRN, chief clinical science officer for Alluceo, an Intermountain Health company, has identified five key elements required for successful integration of mental health and physical health services through a primary care team.</p> <p>Trustees might consider addressing them, using the sample questions provided below, as part of their strategic conversations. Click the icons to expand the topics for discussion.</p> <div class="row questionBox"> <div class="col-md-12"><button class="collapsible"></button> <h3><button class="collapsible">[1] Leadership and cultural integration</button></h3> <div class="content"> <p>A population-health mindset is essential, and leadership must be committed to the hard work needed to normalize mental health as a routine part of everyday care.</p> <ul> <li style="padding-top: 15px">Is your organization ready to make this cultural change? Who will lead the charge?</li> <li>Does your organization have an antistigma culture related to psychiatric and substance use disorders?</li> <li>Does your organization’s health plan have robust coverage for behavioral health?</li> </ul> </div> <button class="collapsible"></button> <h3><button class="collapsible">[2] Workflow integration</button></h3> <div class="content"> <p>Successful population health management is based on protocols for specific conditions. The complexity of each patient’s full health story must be understood so that the right level of team can be activated to meet his or her needs.</p> <ul> <li>Does your organization have standardized assessment tools that can identify a patient’s mental and physical health needs? If yes, do you have the processes and resources in place to treat newly identified patient needs?</li> </ul> </div> <button class="collapsible"></button> <h3><button class="collapsible">[3] Information systems integration</button></h3> <div class="content"> <p>Data about patient outcomes, costs, clinical care and operations must be synthesized, analyzed and communicated to the primary care teams in your organization.</p> <ul> <li>Does your organization have the data analytics capability needed to evaluate what works, what doesn’t and how to keep fine-tuning processes for improved performance?</li> </ul> </div> <button class="collapsible"></button> <h3><button class="collapsible">[4] Financing and operations integration</button></h3> <div class="content"> <p>Understanding the right leadership and staffing mix for operational efficiency requires savvy management and the right targeted amount of investment.</p> <ul> <li>Do your teams have quantifiable data about the complexity of your patient population? Can it stratify patients so they receive the right level of care at the right time? And is someone accountable for analyzing the business case for integration?</li> </ul> </div> <button class="collapsible"></button> <h3><button class="collapsible">[5] Community resource integration</button></h3> <div class="content"> <p>A primary care clinic cannot meet every identified patient need. Some patients and families will need referrals to other providers for longer-term or more intensive interventions; some will need ongoing support to succeed after short-term treatment ends.</p> <ul> <li>What other local providers and resources can (has) your organization partner(ed) with to help patients continue to thrive?</li> </ul> </div> </div> </div> </div> <script> var coll = document.getElementsByClassName("collapsible"); var i; for (i = 0; i < coll.length; i++) { coll[i].addEventListener("click", function() { this.classList.toggle("active"); var content = this.nextElementSibling; if (content.style.maxHeight){ content.style.maxHeight = null; } else { content.style.maxHeight = content.scrollHeight + "px"; } }); } </script> <p>CHI Health Immanuel and others have found that integration of behavioral health services with physical care — particularly primary care and behavioral health clinicians working together with patients and families to address their whole health — is essential to providing high-quality care. The payoff: Patients feel better and overall costs are reduced.</p> <p>Executives at three leading organizations have shared the lessons learned from their success at integrating behavioral and primary care. They use different approaches, but each emphasized “integration” — challenging, but essential — as the key.</p> <p>“I would caution folks across the nation: Don't just replicate a mental health clinic inside a primary care practice,” said Scott Oxley, senior vice president for Northern Light Health in northern Maine. “Make sure it's truly a collaborative, patient-centered model where behavioral health professionals are part of a team managing the overall wellness of all of your patients.”</p> <h3>Why integration matters</h3> <p>Intermountain Healthcare, based in Utah, was a pioneer when it started integrating mental health care into primary care clinics in 1999. Its goal was not just to diagnose and treat mental illness, but to help patients achieve “mental wellness” as a crucial part of their overall health, said Brenda Reiss-Brennan, Ph.D., APRN, Intermountain’s mental health integration director.</p> <p>“That really resonated with our primary care docs because that’s what they needed help with,” she said. “Patients come into their medical visit with many social and mental health-related issues — fatigue, not eating or sleeping, divorce, pain, violence — in addition to their chronic medical conditions.”</p> <p>The benefits of integrating mental and physical health care, for patients and providers alike, have been surmised for years. But Intermountain provided the proof in 2016, when the Journal of the American Medical Association published the results of a 10-year study of integrated care delivered in a team-based primary care setting. The comparison of more than 110,000 adult patients who received care in 113 practices — about a quarter of which delivered integrated care — showed that:</p> <p>• Because so many more patients were screened for depression in the team-based practices, 46% of patients were diagnosed with active depression, nearly double the rate diagnosed in traditional practices.</p> <p>• Nearly 25% of patients in team-based practices were actively addressing their diabetes, compared to less than 20% in traditional practices.</p> <p>• The rate of emergency department visits was 23% lower for patients in team-based practices than in traditional practices. The rate of hospital admissions was nearly 11% lower, and the number of primary care physician encounters was 7% lower.</p> <h3>Innovative points of access</h3> <p>Allan Currie, M.D., an internist at Northern Light, has seen the opportunity for years. Patients’ chronic conditions — diabetes, congestive heart failure, chronic obstructive pulmonary disease — are too often uncontrolled, despite good medical care.</p> <p>“Many, many times the reason for that is not medical, it's psychological,” he said. “They're depressed, or they're stressed, or they have family issues, or financial issues. Until you get the psychological issues better, you can't get the medical issues better.”</p> <p>Dr. Currie is a trustee at Northern Light Acadia Hospital, the system’s tertiary psychiatric hospital and community mental health agency in Bangor, Maine. For the past eight years, Acadia has been providing mental health services in primary care clinics.</p> <p>“That is a big advantage because patients are much more receptive to that,” he said. “They can come right back to my office and see somebody right here down the hallway.”</p> <p>Starting with a single psychiatric mental health nurse practitioner embedded in a primary care clinic, the integrated approach at Northern Light has grown to include 14 nurse practitioners and 13 licensed clinical social workers (LCSW) supporting 40 primary care practices across the state. In most of those practices, the mental health professionals are physically integrated with other members of the care team, but telepsychiatry serves more than 30% of the clinics.</p> <p>“In those cases, we have both a nurse practitioner and an LCSW sitting somewhere else — valued team members who are part of that practice — who are supporting the patients and the care teams through tele-video,” said Oxley, who also serves as president of Acadia Hospital.</p> <p>Telepsychiatry allows Northern Light to provide services in a large number of rural communities in which mental health professionals are often not available. Oxley points to one nurse practitioner — a Northern Light employee — who lives in Indiana and has been supporting five rural Maine primary care clinics for many years.</p> <div class="articleSidebar floatRight"> <h3>Resources on Behavioral Health</h3> <p>The American Hospital Association has a long-standing commitment to support member efforts to deliver high-quality, accessible behavioral health services. Consistent with that commitment, a web page has been designed to provide easy access to information and tools that will assist them in navigating the changing behavioral health care system and understanding national, state and local activities affecting behavioral health.</p> <p>To access the web page, visit <a href="https://www.aha.org/behavioralhealth" target="_blank">https://www.aha.org/behavioralhealth. </a></p> <p>As boards seek to improve access to care and improve the “whole health” of the community, technology can play an important role in addressing behavioral health needs. To assist boards and other health leaders, the American Hospital Association and the National Quality Forum have released “Redesigning Care: A How-to Guide for Hospitals and Health Systems Seeking to Implement, Strengthen and Sustain Telebehavioral Health.” The guide is designed to help hospitals and health systems deliver innovative, high-quality telebehavioral health services.</p> <p>To access the guide, visit <a href="https://www.aha.org/center/emerging-issues/market-insights/telehealth/telebehavioral-health" target="_blank">https://www.aha.org/center/emerging-issues/market-insights/telehealth/telebehavioral-health.</a></p> </div> <p>“If it was not for that model, that would be a part of the state of Maine that just wouldn't have access to these very important services,” he said.</p> <p>In a Northern Light clinic where a mental health professional is present, a primary care provider can make a “warm handoff” (a transfer of care between members of the care team that incorporates the patient and family) for an assessment or treatment of a behavioral health issue. Patients can be treated in the primary care clinic for a few follow-up appointments and medication management, if needed. If they need more significant intervention, they are referred to a specialist at a Northern Light psychiatric clinic or a provider available through telepsychiatry.</p> <p>The integrated model reduces the stigma that some patients had still associated with mental health services, said Michelle Hood, president and CEO of Northern Light Health and an American Hospital Association board member. Spreading that model of care holds enormous potential for improving the value of health care services.</p> <p>“Trustees are in a unique position to be able to advocate on behalf of their community: The more we can do to remove stigma by having behavioral health needs addressed at a primary care site, the healthier our communities will be,” she said.</p> <h3>Adding value to primary care</h3> <p>Schumacher has seen many benefits since CHI Health Immanuel started integrating behavioral health services in primary care clinics in 2015: Patients get mental health evaluations, diagnoses and treatment plans more quickly; primary care physicians increase the number of patients they can see; and emergency department visits, primary care utilization and total cost of care are all reduced.</p> <p>Best of all, patients feel better as their whole health improves. “Integrating behavioral and primary care has helped us improve our patient outcomes because we're identifying and treating the mental health condition sooner,” said Schumacher, who is also former chair of the AHA’s Council for Psychiatric and Substance Abuse Services.</p> <div class="articleSummaryBox floatLeft"> <h3>Trustee Takeaways</h3> <p>Integration of behavioral health services with physical care is essential to providing high-quality care. Among the many benefits are the following:</p> <ul> <li>Patients get mental health evaluations, diagnoses and treatment plans more quickly.</li> <li>Primary care physicians are able to increase the number of patients they can see.</li> <li>Emergency department visits, primary care utilization and total cost of care are all reduced.</li> <li>Best of all, patients feel better as their whole health improves. And professional life is often improved for primary care providers.</li> </ul> </div> <p>CHI Health Immanuel has integrated care in nine mental health/primary care clinics. On average, patients referred to an embedded therapist can be seen within two days of the initial referral — compared with a months-long wait to access services in the community.</p> <p>For most patients — 84%, in fact — a single consultation is sufficient for a treatment plan to be established, with brief therapy and medication management, if needed, handled by the therapist on site. For patients with more complex needs, the therapist coordinates referrals to the appropriate specialist — a psychologist, psychiatrist, chemical dependency counselor or other clinician, all of whom are part of the same service line as the embedded therapist.</p> <p>“We've seen significant improvement in collaboration between our primary care and our service line because the embedded therapists can be the go-between and are the experts in both worlds,” Schumacher said.</p> <p>CHI Health Immanuel has seen a 4% decrease in emergency department visits by patients referred for behavioral care, along with fewer primary care visits and lower total cost of care.</p> <p>A bonus benefit: Professional life is often improved for primary care providers.</p> <p>In a collaborative care or integrated care model, when a primary care physician thinks a patient may be struggling with a mental or substance use disorder, the provider can quickly refer him or her to a behavioral health therapist down the hall for evaluation and treatment. One goal of integrated care is to use the system’s electronic medical record to integrate both behavioral health and primary care needs and treatment plans, so all clinicians can stay apprised of the patient’s diagnoses and services. Moreover, a therapist is nearby when a provider needs advice.</p> <p>“Our primary care providers are on the front lines of caring for people with mental illness, so we are able to provide education and consultation to them in real time,” Schumacher said. “There's a lot more support for that primary care practitioner to serve his or her patients.”</p> <h4 style="font-size: 1em; border-top: 1px solid #63666A; padding-top: 10px;"><span style="font-weight: bold;">Lola Butcher</span> is a contributing writer to <em>Trustee Insights</em>.</h4> </div> </div> <article role="article"> <div class="reusable-cta--theme- reusable-cta--container cta-background-color-"> <div class="reusable-cta--text-fields-container "> <div class="reusable-cta--field cta--field-text color-"> <div class="field_text"><style type="text/css">ol > li::marker { font-weight: bold; } #article { max-width: 800px; margin: auto; padding: 20px; } .articleKicker { font-weight: bold; margin: 30px 0 0 0; text-transform: uppercase; 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overflow: hidden; } .video-container iframe, .video-container object, .video-container embed { position: absolute; top: 0; left: 0; width: 100%; height: 100%; } .videoPlayOnPage { width: 50%; float: left; margin-bottom: 40px } .videoPlayOnPage h3 { color: #003087 } .videoKicker { color: #9D2235; text-transform: uppercase; font-size: .9em; font-weight: bold } .videoRow { padding: 0 .9375rem } .multimediaWrap { padding: 0 20px 30px 20px; } .multimediaWrap h2 { margin: 0.2rem 0px 2rem; padding: 0px; line-height: 1em; font-size: 2.0625rem; width: 100% } .multimedia { width: 50%; float: left; padding: 20px } .multimedia h4 { color: #9D2235; font-size: 1.3em; text-transform: uppercase; margin: 0 0 20px 0; padding: 20px 0 0 0; } .multimedia h3 { margin-top: 20px; line-height: 1.1em; } @media only screen and (max-width: 500px) { .videoBlock { width: 100%; margin-right: 0; } .videoBlock img { align: center; } .columnPhoto { width: 100%; max-width: 100% } } @media only screen and (max-width: 600px) { .videoPlayOnPage { width: 100%; } .resourceImage { width: 100% } } #footer div.area div.footer-right { float: right; max-width: 700px; width: 100%; } #footer div.area { max-width: 960px; width: 100% !important; padding: 0 20px; } #footer { margin-top: 30px; } </style> </div> </div> </div> </div> </article> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="/system/files/media/file/2019/07/TI_0719_behavioral_health.pdf" type="application/pdf">TI_0719_behavioral_health.pdf</a></span> </div> </article> </div> </div> <div class="field_topics"> <div><a href="/topics/delivery-system-transformation" class="topic" hreflang="en">Delivery System Transformation</a></div> <div><a href="/topics/behavioral-health-care-delivery" hreflang="en">Behavioral Health Care Delivery</a></div> </div> Tue, 16 Jul 2019 17:58:08 +0000 mmusker_drupal 268595 at https://trustees.aha.org Building an Age-friendly Health Care System https://trustees.aha.org/newdeliverymodels/articles/building-an-age-friendly-health-care-system <span class="title">Building an Age-friendly Health Care System</span> <span class="uid"><span>aha</span></span> <span class="created">Feb 14, 2019 - 10:40 AM</span> <div class="body"><div id="article"> <div data-embed-button="media" data-entity-embed-display="view_mode:media.full" data-entity-type="media" data-entity-uuid="7db95cc7-3975-4ac9-a611-587ad8212d6d" data-langcode="en" class="embedded-entity"><article><div class="field_media_image"> <img src="/sites/default/files/stock-elderly-woman-escorted-by-younger-from-behind_900x400.jpg" width="900" height="349" alt="stock-elderly-woman-escorted-by-younger-from-behind_900x400.jpg" title="stock-elderly-woman-escorted-by-younger-from-behind_900x400.jpg" loading="lazy" /></div> </article></div> <h4 class="articleKicker"><a href="/resource-repository-trustees?topic=684" target="_blank">New Delivery Models</a></h4> <h1>Building an Age-friendly Health Care System</h1> <h3 class="articleDeck">Changing demographics are forcing new attention on health care for seniors</h3> <h4 class="articleByline">By Lola Butcher</h4> <p>Seven primary care physicians at Providence St. Joseph Health recently tried to serve themselves food while blindfolded. They put their hands in mittens and tried to get dressed. They used wheelchairs to get from one floor of the hospital to another.</p> <p>They were learning what it feels like to be a frail, elderly person navigating a world that is set up for the young, strong and speedy.</p> <div class="articleSummaryBox floatRight"> <h3>Trustee Talking Points</h3> <ul><li>Roughly 10,000 Americans are turning age 65 every day.</li> <li>Many seniors experience physical and mental changes that make everyday life harder.</li> <li>Age-Friendly Health Systems is a movement to promote best practices in senior care.</li> <li>Age-friendly practices align with the mission, vision and values of health care providers.</li> </ul></div> <p>“The main reaction I heard was ‘Oh, I had no idea,’” says Ruth Johanson, executive director of the Senior Health Program for the health system’s Oregon region, based in Portland.</p> <p>But the physicians — and their administrative colleagues who joined them in the exercise — are gaining a better perspective on an important segment of the patients they serve. Their learning is one facet of the work that Providence St. Joseph Health is undertaking as a leader in the Age-Friendly Health Systems initiative.</p> <p>Age-Friendly Health Systems is a movement — a plan to systematically spread best practices in the care of older adults across the country — developed through a partnership of the Health Research &amp; Educational Trust, an affiliate of the American Hospital Association; the Catholic Health Association; the Institute for Healthcare Improvement; and The John A. Hartford Foundation.</p> <p>“We’re calling this a movement because there’s a lot of energy and a groundswell of excitement that’s building up about this effort,” says HRET President Jay Bhatt, D.O., senior vice president and chief medical officer of the AHA. “And we know how important it is given the issues of affordability and poor outcomes among older adults.”</p> <p>The philanthropic John A. Hartford Foundation has worked on behalf of older adults for more than 35 years, supporting the development of many proven care models. But none has spread universally throughout the continuum of care, says Terry Fulmer, Ph.D., R.N., the foundation’s president, speaking on why we need age-friendly health systems.</p> <p>America’s changing demographics are forcing new attention on the need. More than 46 million Americans are 65 or older today, and that number will double by 2060. Currently, 77 percent of U.S. seniors have chronic diseases. Many seniors live well past age 80, and the majority of them will require some type of long-term care.</p> <div class="articlePullquote floatLeft"> <p>“We’re calling this a movement because there’s a lot of energy and a groundswell of excitement that’s building up about this effort. And we know how important it is given the issues of affordability and poor outcomes among older adults.”</p> <p style="font-size: 1.1em; color: #002855;"><span style="text-transform: uppercase; font-weight: bold">Jay Bhatt, D.O., </span>HRET president and senior vice president and chief medical officer of the AHA</p> </div> <p>The foundation provided grant funding to help five systems — Providence St. Joseph; Anne Arundel Health System, Annapolis, Md.; Ascension, St. Louis; Kaiser Permanente, Woodland Hills, Calif.; and Trinity Health, Livonia, Mich. — develop and test new care processes for older adults. The goal is to make life easier and better for health care providers and older adults alike.</p> <p>“We want to be effective, add value and be measurably impactful so that every CEO in this country says, ‘I want my system to be age friendly,’” says Fulmer. “We are creating a social movement where our further goal is for every person to say, ‘I demand age-friendly health care for me and my family.’”</p> <h3>What “Age-friendly” Looks Like</h3> <p>As they age, many seniors experience decreased mobility, social isolation, loss of independence and changes in their self-identity that make everyday life harder. On top of this, the challenges inherent in America’s fragmented health care system are magnified when viewed through the lens of their complex needs.</p> <p>“That includes transitions between care settings, potential side effects or problems with adverse drug interactions, the lack of care planning and poor coordination between caregivers,” says Marie Cleary-Fishman, HRET vice president of clinical quality.</p> <p>The best response from health care providers, Bhatt says, is the age-friendly “4M” model, which takes its name from four broad priorities:</p> <ul><li><strong>What Matters:</strong> Knowing and adhering to each older adult’s personal health goals and care preferences.</li> <li><strong>Medications:</strong> Limiting medications to those that, as much as possible, do not interfere with the patient’s mental functioning, mobility or personal preferences.</li> <li><strong>Mentation:</strong> Recognizing and managing depression, dementia and delirium across care settings.</li> <li><strong>Mobility:</strong> Ensuring that older adults move safely every day, at home or in any care setting, so they maintain function and can do what matters to them.</li> </ul><p>The four M’s line up with the goals of hospitals and health systems that seek to use evidence-based practices to improve the quality, efficiency and patient/family experience of the care they deliver, Fulmer says.</p> <p>For example, preventing a serious, fall-related injury during a hospital stay can decrease a patient’s length of stay by an average of 6.3 days, according to a review of 57 hospital inpatients discharged between Jan. 1, 2004, and Oct.16, 2006. (See “The Cost of Serious Fall-related Injuries at Three Midwestern Hospitals,” by C. A. Wong et al., Jt Comm J Qual Patient Saf. 2011 Feb; 37[2]: 81-87.)</p> <p>And delirium detection and treatment programs save $16 for every $1 investment, according to a review of the 2008 performance of an inpatient delirium-prevention program. (See “Sustainability and Scalability of the Hospital Elder Life Program at a Community Hospital,” by Fred H. Rubin et al., J Am Geriatr Soc. 2011 Feb; 59[2]: 359–365.)</p> <h3>Birthing a Movement</h3> <p>The 4M model was born out of an extensive process to determine the most important elements of good care for older adults. Staff at the Institute for Healthcare Improvement (IHI) examined 22 evidence-based care models developed in recent years to identify 13 core features, says Kedar Mate, M.D., IHI’s chief innovation and education officer. Staff members then assembled a group of geriatricians, health system executives and other stakeholders to prioritize the most important ones.</p> <div class="articlePullquote floatRight"> <p>“Distilling our work to the four M’s — what matters, medications, mentation, mobility — looks simplistic, but it was very hard to do. Thanks to IHI and our clinical partners, we’ve got a parsimonious, elegant model, which we think of as the gateway into excellent geriatric care.”</p> <p style="font-size: 1.1em; color: #002855;"><span style="text-transform: uppercase; font-weight: bold">Terry Fulmer, Ph.D., R.N., </span>president, John A. Hartford Foundation</p> </div> <p>“Distilling our work to the four M’s — what matters, medications, mentation, mobility — looks simplistic, but it was very hard to do,” Fulmer says. “Thanks to IHI and our clinical partners, we’ve got a parsimonious, elegant model, which we think of as the gateway into excellent geriatric care.”</p> <p>By design, each of the four elements reinforces the others. For example, making sure that medications are properly managed increases an older adult’s ability to move safely and think clearly. Likewise, managing dementia and delirium increases the likelihood that medications will be taken properly and patients can express their “what matters to me.”</p> <p>Also by design, the 4M priorities cross the continuum of care, Mate says. Mobility — staying as active as possible without falling — is as important on a hospital unit as it is in a patient’s home, doctor’s office or skilled nursing facility. So leaders at all settings of care can share that priority when thinking about how they care for patients.</p> <p>Another intention was to create a care model that could be adopted widely. The five health systems are currently prototyping and testing ways to operationalize the four M’s. They are starting with small-scale tests, then spreading that knowledge within their organizations.</p> <p>“They will teach us what it would take for those systems to reliably implement those four M’s for every patient who crosses their thresholds,” Mate says.</p> <p>That learning will be used for an Age-Friendly Health Systems campaign next year with the goal of having 1,000 care sites — including ambulatory, inpatient, and post-acute — committed to age-friendly care by 2020.</p> <p>That does not suggest that all systems will be using identical protocols; rather, they will all be embedding the tenets of the 4M care model as it makes sense for their own organizations. And because of their focus on best care for older adults, they will be learning from experience and from each other.</p> <p>“I fully expect that we will continue to improve the content of what it means to be ‘age-friendly’ so that we will be constantly pushing the field forward towards improving care for older adults over time,” Mate says.</p> <h3>Age-friendly Care in Action</h3> <p>The pilot sites, each of which has its own goals, are experimenting with different practices in different settings.</p> <p>For example, Kaiser Permanente’s (KP) goal is to reach nearly 3,500 older adults served in Acute Care of the Elderly (ACE) units, a nursing and rehab center and palliative care clinic at the Woodland Hills Medical Center. Initial steps included developing patient-facing medication lists and a patient survey to determine “what matters.” Looking ahead, KP will work with physical therapists to develop “My Daily Exercise” sheets to keep patients and clinicians focused on improving mobility.</p> <div class="articlePullquote floatLeft"> <p>“Being part of the Age-Friendly Health Systems network allows us to learn inpatient practices from others and to share our outpatient findings with them as we get further down the road.”</p> <p style="font-size: 1.1em; color: #002855;"><span style="text-transform: uppercase; font-weight: bold">Ruth Johanson, </span>executive director of the Senior Health Program for the health system’s Oregon region</p> </div> <p>Anne Arundel Health System, meanwhile, is trying to reach nearly 20,000 older adults in nine acute-care units, the emergency department and 25 assisted-living homes. The system started by incorporating “what matters” responses into patients’ electronic health records, improving patient and family education and working to reduce inpatient average lengths of stay for older adults.</p> <p>HRET staff will help evaluate the results of the prototype sites and identify the best metrics to track going forward.</p> <h3>Age-friendly Care in Oregon</h3> <p>While other health systems are testing age-friendly practices in acute-care settings, Providence St. Joseph is focusing its work in the outpatient arena.</p> <p>“It would be a slow pace for us if we tried to create all the best practices for both inpatient and outpatient,” Johanson says. “Being part of the Age-Friendly Health Systems network allows us to learn inpatient practices from others and to share our outpatient findings with them as we get further down the road.”</p> <p>To focus on mobility, Providence St. Joseph recruited a nurse practitioner with geriatrics expertise to develop a comprehensive fall-prevention program to serve patients in their homes, when they visit medical clinics, and in the community.</p> <p>While some of the health system’s primary-care clinics have routinely conducted fall risk assessments in the past, Johanson says, there has not been a standard process for referring at-risk patients for physical therapy, a medication assessment, or a home-safety evaluation.</p> <p>“We are working to make that a really efficient loop so that providers are equipped to make that happen very easily,” she says.</p> <p>The health system is working to optimize the use of the STEADI — Stopping Elderly Accidents, Deaths &amp; Injuries — toolkit developed by the Centers for Disease Control and Prevention. That includes educating patients and their family members on how to reduce the chance of falling at home; developing a Tai Chi training program that makes people steadier on their feet; and coaching providers on how to incorporate a fall risk assessment into a patient visit.</p> <p>For the medication “M,” Providence St. Joseph is encouraging providers to limit the use of “Z drugs” — insomnia treatments that are associated with falls and injuries among seniors. To address mentation, the system plans to develop a dementia-care pathway.</p> <p>And for “what matters,” Providence St. Joseph is creating a conversation guide that will help staff members learn about an older patient’s priorities and preferences and share the information.</p> <p>“Whether it’s a front-desk person or a nurse or a medical assistant or a physician, we need to be able to ask those questions in a way that is natural and respectful,” Johanson says. “And we need to be able to document the information in a consistent way so that any of our caregivers who come into contact with that individual will know what matters to that person.”</p> <h3>Joining the Movement</h3> <p>The age-friendly movement doesn’t ask health systems to add work but rather to redeploy existing hospital resources in a way that intentionally addresses the needs and preferences of their ever-growing population of older patients, Bhatt says. Age-friendly practices line up with the mission, vision, and values of American health care providers.</p> <div class="articleSummaryBox floatRight"> <h3>Trustee Takeaways</h3> <ul><li>Discuss how age-friendly practices align with your organization’s mission, vision and values.</li> <li>Consider ways your organization can embed the tenets of the 4M care model.</li> <li>Ask how existing resources could be redeployed to address needs among older patients.</li> <li>Determine how age-friendly practices fit into your organization’s strategic priorities.</li> </ul></div> <p>“This puts hospitals ahead of the curve in preparing for this continued demographic change,” he says. “It reduces the costs associated with inappropriate utilization and variation in care delivery. And it honors the wishes and preferences of patients and their families.”</p> <p>Fulmer says that’s why more than 200 individuals and groups are participating in “Friends of Age-Friendly” quarterly conference calls so they can start learning from the test sites and embedding the best practices in their own institutions. (Send an email to <a href="mailto:AFHS@aha.org">AFHS@aha.org</a> or <a href="mailto:AFHS@ihi.org">AFHS@ihi.org</a> to be notified of future calls.)</p> <p>The Age-Friendly Health Systems initiative is inviting up to 100 teams from health care settings across the nation to join the Age-Friendly Health Systems Action Community. Teams will work together to rapidly scale up the 4M model over seven months, starting in September, Mate says. (For more information, visit <a href="http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems" target="_blank">http://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems</a>.) “People are ready, they understand this needs to happen, and they want to leapfrog what has gone relatively slowly over the past decade and accelerate the change,” she says.</p> <p>Roughly 10,000 Americans are turning age 65 every day. By 2050 — just 32 years from now — 4.5 percent of the U.S. population will be 85 or older.</p> <p>“We have known since baby boomers were born that they would get older, and here they are,” Fulmer says. “We have to get ready to care for them with the quality and reliability we would want for ourselves and for our families.”</p> <h4 style="font-size: 1em; border-top: 1px solid #63666A; padding-top: 10px"><span style="font-weight: bold">Lola Butcher</span> is a contributing writer to <em>Trustee Insights.</em></h4> </div> </div> <article role="article"> <div class="reusable-cta--theme- reusable-cta--container cta-background-color-"> <div class="reusable-cta--text-fields-container "> <div class="reusable-cta--field cta--field-text color-"> <div class="field_text"><style type="text/css">ol > li::marker { font-weight: bold; } #article { max-width: 800px; margin: auto; padding: 20px; } .articleKicker { font-weight: bold; margin: 30px 0 0 0; text-transform: uppercase; } #article h1 { margin: 10px 0 10px 0; 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} .resourceImage { width: 100% } } #footer div.area div.footer-right { float: right; max-width: 700px; width: 100%; } #footer div.area { max-width: 960px; width: 100% !important; padding: 0 20px; } #footer { margin-top: 30px; } </style> </div> </div> </div> </div> </article> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="/sites/default/files/TI_0918_butcher_age_health_.pdf" type="application/pdf">TI_0918_butcher_age_health_.pdf</a></span> </div> </article> </div> </div> <div class="field_topics"> <div><a href="/topics/delivery-system-transformation" class="topic" hreflang="en">Delivery System Transformation</a></div> </div> Thu, 14 Feb 2019 16:40:12 +0000 aha 134271 at https://trustees.aha.org Post-Merger Integration: The Board's Role Begins Before the Ink is Dry https://trustees.aha.org/post-merger-integration-boards-role-begins-ink-dry <span class="title">Post-Merger Integration: The Board&#039;s Role Begins Before the Ink is Dry</span> <span class="uid"><span>aha</span></span> <span class="created">Jul 17, 2018 - 12:00 AM</span> <div class="body"><style type="text/css">.page-header { display: none; } </style> <p>by Todd W. Fitz, Timothy Shoger and Kit A. Kamholz</p> <p>Mergers and acquisitions (M&amp;A) are occurring throughout health care, with transactions happening among entities of all provider types and sizes.(According to the latest analysis by Kaufman, Hall &amp; Associates, LLC, 49 transactions were announced in the first half of 2015, up from 43 transactions in the first half of 2014.)</p> <p>A priority objective for hospital partnerships is to build the competencies required to manage population health under new value-oriented care and payment models required by consumers, employers, and government and private payers. Needed competencies and infrastructure include network development, clinical alignment, quality, information technology, and brand recognition.</p> <p>Integration can take numerous paths, but the realization of the partnership’s expected benefits − establishing and strengthening essential competencies − is of paramount importance. The board’s role in facilitating/ensuring that the partnership achieves its anticipated benefits is critical. The discussion below identifies some key questions board members should answer individually and collectively to help the organization clarify and achieve the integration’s intended goals.</p> <h4>To read more...</h4> </div> <h4 class="page-header">Key Resources</h4> <div class="field_related_files file file--mime-application-pdf file--application-pdf"> <div> <article> <div class="field_media_file"><span class="file file--mime-application-pdf file--application-pdf"><a href="/sites/default/files/trustees/post-merger-integration.pdf" type="application/pdf">Post-Merger Integration: The Board?¢‚Ǩ‚Ñ¢s Role Begins Before the Ink is Dry</a></span> </div> </article> </div> </div> <div class="field_topics"> <div><a href="/topics/delivery-system-transformation" class="topic" hreflang="en">Delivery System Transformation</a></div> </div> Tue, 17 Jul 2018 05:00:00 +0000 aha 128517 at https://trustees.aha.org Becoming a visionary board https://trustees.aha.org/articles/1381-becoming-a-visionary-board <span class="title">Becoming a visionary board</span> <span class="uid"><span>aha</span></span> <span class="created">Jun 11, 2018 - 12:00 AM</span> <div class="field_page_subtitle">Forward-thinking boards prepare for and embrace the changes ahead</div> <div class="body"><p>Hospital trustees sometimes&nbsp;question&nbsp;how they can determine a strategic future when so much in health care is changing&nbsp;and the future is seemingly unknown and unpredictable. But this is precisely the time when boards must be at their best. Forward-thinking, visionary boards anticipate potential futures. They prepare for and embrace the changes ahead.</p> <p>In their book <em>Governance as Leadership: Reframing the Work of Nonprofit Boards</em>, Richard P. Chait, William P. Ryan and Barbara E. Taylor define three types of governance: fiduciary governance, strategic governance and generative governance. Fiduciary governance is the cornerstone of the board&rsquo;s responsibilities and involves stewardship of organizational assets, ensuring legal and regulatory compliance, and providing operational oversight. When practicing strategic governance, boards ensure that the organization is working toward fulfilling its vision and mission by setting strategic priorities and goals and monitoring performance against them.</p> <p>Generative governance also must be a priority for trustees in today&rsquo;s environment, characterized by fast-paced change and&nbsp;offering&nbsp;only a hazy view of tomorrow. It involves envisioning the organization&rsquo;s purpose and meaning in an evolving world of shifting stakeholder needs and preferences. Boards that practice generative governance take time to question assumptions, explore nontraditional scenarios and perspectives, and discover new and innovative ways of accomplishing goals, achieving visions and fulfilling missions.</p> <h2>&#39;What if?&#39;&nbsp;and &#39;So what?&#39;</h2> <p>Visionary trustees consistently ask themselves a series of questions, including, &ldquo;What do we know today that we didn&rsquo;t know yesterday?&rdquo; By staying well-informed with a continuing flow of new information and evidence, visionary boards can anticipate emerging trends. They begin to envision potential futures by asking themselves, &ldquo;What if &hellip; ?&rdquo; For example: &ldquo;What if our patient volume continues to decline as preventive and wellness efforts succeed in improving our community&rsquo;s health, as our initiatives succeed in reducing readmissions and as care continues to shift to outpatient settings?&rdquo; &ldquo;What if health care is no longer hospital-centric?&rdquo; &ldquo;What if retail pharmacies become a preferred source of diabetic care?&rdquo; &ldquo;What if we formed a partnership with &hellip; ?&rdquo; &ldquo;What if we look at this differently?&rdquo;</p> <p>Boards move another step closer to becoming visionary&nbsp;when they also ask: &ldquo;What could that mean to us? What implications does it have for our hospital?&rdquo; and &ldquo;What could or should we do to be prepared?&rdquo; These are questions that begin to generate deeper understanding of new paradigms and their implications for the hospitals and health systems that boards are responsible for leading. They are the questions that prompt challenges to the assumptions and status quo that may hold organizations back.</p> <p>By considering a variety of potential scenarios and possible responses, visionary boards are able to consider carefully what possible actions they must take to capitalize on the forces for change. They are better prepared to act quickly, confidently and on their own timetable&nbsp;instead of reacting to situations that may be forced upon them.</p> <h2>Some obstacles&nbsp;&nbsp;<strong>&nbsp; </strong></h2> <p>While there are many potential challenges that prevent trustees from maximizing their visionary potential, here&nbsp;are a few of the most common causes that derail boards.</p> <p><strong>Failing to stay well-informed:</strong>&nbsp;Without credible and current information and data, trustees cannot hope to recognize or anticipate the forces, trends and changes happening in the environment around them. They must develop a high level of understanding in the areas most critical to organizational success and performance. Passing knowledge is not enough. Today&rsquo;s board members must be continuous learners in and outside of the boardroom. Well-informed boards search out opinions, ideas and perspectives that may be different from their own. They listen to a variety of voices outside the organization, engaging the viewpoints of people with unique experiences and perspectives. In doing so, visionary boards expand their knowledge base and open new lines of thinking.</p> <p><strong>Poor agenda planning and meeting management:</strong>&nbsp;Confronted with multiple challenges and competing priorities, effective boards must focus their time and attention on the issues most critical to achieving the organization&rsquo;s mission and vision. Board chairs must ensure that meeting agendas allow the board to focus on strategic issues. The board chair also must manage meetings to engage trustees at high&nbsp;levels of thinking and planning, enabling and facilitating the inquiry, dialogue&nbsp;and debate needed to be visionary.</p> <p>AtlantiCare board chair Michael Charlton meets with the organization&rsquo;s CEO weekly to discuss strategic priorities and any changes in course that may be emerging to understand where the organization is going and determine issues that need to be discussed at upcoming board meetings. Senior staff draft meeting agendas organized around the Egg Harbor Township, N.J.-based health system&rsquo;s strategic priorities.</p> <p>Charlton then meets with the CEO, chief of staff and board liaison to ask questions, reflect on committee issues and staff reports, and finalize the board agenda, which includes a consent agenda to address fiduciary items and open up board meeting time for strategic and generative discussion. Board meeting materials are distributed a week in advance for review. A few days before&nbsp;each meeting, Charlton talks with board members to understand their issues and perspectives so he can draft questions that will tee up issues for board discussion.</p> <p>&ldquo;Our board is composed of many CEOs, including myself, but, as board chair, I don&rsquo;t play that role,&rdquo; he says. &ldquo;My job is to pose thought-provoking questions. What I&rsquo;ve learned through board chair coaching and my own experience is that when I talk less, meetings are more productive.&rdquo;</p> <p><strong>Focus on the wrong issues:</strong>&nbsp;Boards must continually adjust their attention to deal with the issues of the future, not the issues of the past. Time should be concentrated on understanding trends and priorities&nbsp;and their implications for the organization&nbsp;rather than dealing with operational details. The board&rsquo;s focus should be on visionary-focused dialogue about the challenges, issues and opportunities ahead.</p> <p><strong>Disengaged trustees:</strong>&nbsp;Board service has never been more challenging. Trustees must know and understand more&nbsp;and take on greater responsibility than they have in the past. Board members must have the time, availability and discipline to act on their commitment to the board and the responsibilities of trusteeship, and those expectations should be part of a job description shared with board candidates and reviewed by the full board annually. Board members also should possess personal attributes and qualities, outlined in more detail below, that&nbsp;ensure the caliber of engagement and contribution required for effective, visionary governance.</p> <p><strong>Failing to engage in deep, decisive dialogue:</strong>&nbsp;Visionary board members ensure that their governance conversations are always vibrant, vital and focused on purpose and outcomes. Dialogue should be the board&rsquo;s &ldquo;social operating mechanism.&rdquo; Through synergistic discussions, boards can generate innovative solutions by grappling with new concepts, ideas and solutions. Without constructive challenges to conventional wisdom and thought, the best solutions may never surface.</p> <p>Visionary boards regularly confront issues by challenging assumptions and exploring alternatives to traditional thinking. They ask questions such as: &ldquo;What are other hospitals and health systems doing to address this issue?&rdquo; &ldquo;What alternatives did we explore and why did we decide not to pursue them?&rdquo; &ldquo;With whom might we partner to make the greatest impact?&rdquo;</p> <p><strong>Holding on to the status quo:</strong>&nbsp;Holding on to the status quo will not push organizations to excel. Improvement and advancement are the keys to future viability in a complex, evolving health care world. <span style="background-color:#FFFF00;"> </span>Trustees must lead their organization in a way that lets it capitalize on new opportunities. Innovation and change must be encouraged and rewarded in all areas and levels of the organization. This requires trustees to provide leadership of thought, ideas, creativity, accountability and purpose. It also means letting go to embrace a future that may be markedly different from the past.</p> <p><strong>Lack of a common purpose:</strong>&nbsp;As organizations grow through mergers, joint ventures, partnerships&nbsp;and collaborations across the continuum of care, all stakeholders must share a common purpose or mission. Nothing is more motivating than a clear picture of a bright and successful future. Accomplishing this demands that the board develop an exciting, shared mission that will stimulate enthusiastic followers&nbsp;and ensure development of a common culture that supports and empowers mission fulfillment.</p> <h2>Attributes of visionary trustees</h2> <p>Visionary trustees possess the personal attributes and qualities that ensure the caliber of engagement and contribution required for generative governance. Developing the needed expertise requires motivation, commitment and time. High-caliber trustees voluntarily seek to be well-informed and knowledgeable, and demonstrate intelligence and quick understanding.</p> <p>Visionary trustees are big-picture thinkers open to new ideas. They think and speak strategically in discussions about complex scenarios and situations. Visionary trustees analyze trends to determine possible implications to the hospital or health system. They display creative and resourceful thinking, considering situations from multiple angles and perspectives.</p> <p>Visionary trustees use &ldquo;reasonable inquiry&rdquo; to pursue new solutions and opportunities, asking thoughtful and insightful questions. Visionary trustees also are willing to challenge the status quo and take calculated risks in the interest of moving their organization&nbsp;forward and fulfilling its&nbsp;mission. These individuals look into the future and imagine what might be achieved.</p> <p>Visionary boards do not develop&nbsp;by chance. They build on the sound foundation of their organization&#39;s&nbsp;mission, a good understanding of their communities&rsquo; health care concerns and the bigger perspective of how health care is evolving.</p> <p>When boards ask penetrating questions and engage in vibrant conversations that explore new possibilities, their visionary focus can stimulate creative thinking, dialogue&nbsp;and debate. Such deliberation helps trustees to identify and evaluate new and different strategies, overcome challenges and barriers, and encourage calculated risk-taking that leads to visionary futures.</p> <p><strong>Mary K. Totten</strong> <em>(<a href="mailto:marykaytotten@gmail.com">marykaytotten@gmail.com</a>) is a senior governance consultant to the American Hospital Association.</em></p> <hr /> <h2>Visionary governance starts&nbsp;with strong board leadership</h2> <p>Board leadership focused on mission and community helped chair Michael Charlton and his board guide AtlantiCare to take a significant first step toward improving community health and quality of life by addressing social determinants of health&nbsp;such as poverty, violence, lack of education and unhealthy behaviors. AtlantiCare, based in Egg Harbor Township, N.J., convened 1,800 people in the community through survey and discussion to determine how the health system could make a difference.</p> <p>&ldquo;Many participants were wedded to their own personal views about how AtlantiCare should help,&rdquo; Charlton said. &ldquo;But it was the involvement of our board and many tough conversations and board-level discussions that helped move the ball forward.&rdquo;</p> <p>The board stayed focused on the organization&rsquo;s mission and embedded itself in the community&rsquo;s view of key needs that should be addressed. After 14 months, AtlantiCare is poised to launch efforts toward reducing opioid deaths in the community, and it is now aligning health system and community performance metrics to monitor progress.</p> <p>&ldquo;A focus on our community is the board&rsquo;s true north,&rdquo; Charlton says. &ldquo;We can&rsquo;t move away from this. If health systems talk about population health and community&nbsp;but all they do is create greater size and scale to improve reimbursement, then they&rsquo;ve lost their key focus. Pursuing true north takes courage. Boards need to ask themselves, &lsquo;Are we doing what we need to do to take care of this community and the people we serve?&rsquo;&rdquo;</p> <p>&mdash;&nbsp;<em>Mary K. Totten</em></p> <hr /> <h2>10 board transformations</h2> <p>Here&#39;s what trustees can do to ensure visionary governance.</p> <ol> <li>Develop new levels of expertise in the issues driving health care.</li> <li>Focus on strategic issues.</li> <li>Understand the community&rsquo;s health concerns.</li> <li>Envision multiple futures.</li> <li>Focus more on the emergent and less on the urgent.</li> <li>Ensure high-quality trustee engagement, commitment and contribution.</li> <li>Engage in deep, decisive dialogue.</li> <li>Be catalysts for change, challenge assumptions&nbsp;and generate new thinking.</li> <li>Listen to outside views and perspectives.</li> <li>Maintain a constant focus on mission and value.</li> </ol> <p>&mdash;&nbsp;<em>Mary K. Totten</em></p> <h2>&nbsp;</h2></div> <div class="field_author">By <span><a href="/node/135390" hreflang="en">Mary K. Totten</a></span> </div> <div class="field_topics"> <div><a href="/topics/delivery-system-transformation" class="topic" hreflang="en">Delivery System Transformation</a></div> <div><a href="/topics/strategic-planning" hreflang="en">Strategic Planning</a></div> <div><a href="/taxonomy/term/555" hreflang="en">Issues &amp; Trends</a></div> </div> Mon, 11 Jun 2018 05:00:00 +0000 aha 140210 at https://trustees.aha.org Anchoring hospitals in the community https://trustees.aha.org/articles/1377-anchoring-hospitals-in-the-community <span class="title">Anchoring hospitals in the community</span> <span class="uid"><span>aha</span></span> <span class="created">Jun 11, 2018 - 12:00 AM</span> <div class="field_page_subtitle">Growing network of health systems takes on social determinants</div> <div class="body"><p>A few months ago, a group of &ldquo;citizen journalists&rdquo; &mdash;&nbsp;two dozen Newark, N.J., high school students supported by RWJBarnabas Health, Newark Beth Israel Medical Center and other civic partners &mdash;&nbsp;created a full-length documentary on food insecurity in their city, defining its prevalence, reporting on local entrepreneurial solutions and sharing their vision of a healthier hometown.</p> <p>Theirs is just one example of the work emerging from the Healthcare Anchor Network, a blooming consortium of nearly three dozen health systems launched in May 2017. The network&#39;s overarching goal is to &ldquo;reach a critical mass of U.S. health systems [that are] strategically improving community health and well-being by leveraging all of their institutional assets, including intentionally integrating local economic inclusion strategies in hiring, purchasing and investing.&rdquo;</p> <p>HAN is the brainchild of the Democracy Collaborative, an economic development&nbsp;agency&nbsp;in Cleveland, which was launched as a &ldquo;democratic renewal&rdquo; research center at the University of Maryland in 2000. The collaborative has since moved well beyond its research roots, offering field activities to expand community wealth-building, hosting nationwide roundtables to discuss transformative economic development solutions, and advising local governments, foundations and anchor institutions such as health systems on new strategies for addressing the root causes of socio-economic inequity in their communities.</p> <div class="relatedcontent drop"> <h4 class="show_hide_desk">Trustee talking points</h4> <div class="slidingDiv"> <ul> <li>Anchor institutions like hospitals can play an important role in population health in their communities.</li> <li>The Healthcare Anchor Network, a consortium&nbsp;of health systems sparked by the University of Maryland&#39;s Democracy Collaborative, works to improve community health in underserved communities by addressing the social determinants of health.</li> <li>Local hiring and sourcing, resident involvement and community investment are some of the initiative&#39;s strategies.</li> <li>An array of resources is available for hospitals and health systems to take on the challenge of community health improvement.&nbsp;</li> </ul> </div> </div> <p>The collaborative seeks to rebuild underserved, particularly low-income neighborhoods along more equitable and sustainable lines. Anchor institutions play a crucial role in achieving that goal. By definition, an anchor institution &mdash;&nbsp;typically an academic or health care organization &mdash;&nbsp;is place-based and,&nbsp;as such, tied to the long-term well-being of its community, often as its largest employer&nbsp;as well as a source of neighborhood stability.</p> <p>&ldquo;It is a moral and business imperative for health systems to consider their anchor role in their communities,&rdquo; says David Zuckerman, director for health care engagement with the Democracy Collaborative. &ldquo;This work is grounded in [looking through] an equity lens, realizing that social and economic inequities fall most often on low-income neighborhoods and communities of color. The long-term business case of health systems must address these inequities and find new ways of doing business.&rdquo;</p> <h2>Evolution of the network</h2> <p>Three systems committed to advancing that anchor mission &mdash;&nbsp;Dignity Health and&nbsp;Kaiser Permanente, based in California, and Trinity Health, based in Michigan&nbsp;&mdash;&nbsp;wanted to learn from one&nbsp;another&rsquo;s efforts, as well as those of other systems, and sought the support of the Democracy Collaborative.</p> <p>&ldquo;They asked us to convene a national meeting to elevate the discussion around social determinants of health and concentrate on solutions that had not yet been discussed,&rdquo; Zuckerman says. The three systems co-sponsored that meeting in December 2016, hoping to attract&nbsp;30 to 50 interested health leaders: 90 leaders from 40 systems wanted to attend.</p> <p>Eleven &ldquo;backbone coordinator&rdquo; health systems helped build the HAN structure over several months, and additional targeted work groups have since evolved, bringing in those involved in their system&#39;s&nbsp;hiring, purchasing and place-based investments to learn from their peers and determine how to connect anchor mission goals to local community resources. There are currently 33 systems actively involved in the Healthcare Anchor Network, all paying a nominal fee to contribute to its sustainability. HAN leaders also have convened several all-network meetings to support the continued spread of new ideas.</p> <p>&ldquo;Change happens at the speed of trust,&rdquo; Zuckerman says. &ldquo;Through this peer-support network, we want to create a collaborative voice and collective work that can accelerate learning and make change happen faster. We know there is no one right answer, so we want to draw people together across a wide spectrum. The whole purpose of this approach is to get organizations to ask different sets of questions and to think differently about hiring, purchasing and investment &mdash;&nbsp;and we have to listen to local residents.&rdquo;</p> <p>As an example, the Newark student documentary will be shown at area community centers and churches, and used as a launching point for discussions with local residents on the greatest challenges their neighborhoods face&nbsp;in obtaining healthful, affordable food &mdash;&nbsp;and gather further insights from there.</p> <p>&ldquo;We are very intentional in asking for community input &mdash;&nbsp;what residents tell us will inform our policies and practices to change systems and structures,&rdquo; says Michellene Davis, executive vice president and chief corporate affairs officer at RWJBarnabas Health, based in West Orange, N.J.</p> <h2>Rethinking business practices</h2> <p>HAN advisers have met with RWJBarnabas leaders and helped them develop a corporate anchor roundtable, co-chaired by Davis and the system&rsquo;s CEO, that includes system leaders in human resources, supply chain and construction. Davis says HAN is helping the system change its business practices in revolutionary&nbsp;ways. As an example, &ldquo;there is a natural strategic tension that happens when you start looking at procuring [supplies] locally,&rdquo; she says. &ldquo;It requires you to shift your practices, which are likely exclusionary in being a member of a group purchasing organization. Local businesses can&rsquo;t come in at that global GPO price point &mdash; but we have the power to change that.&rdquo;</p> <p>Although RWJBarnabas still will work with GPOs, contracts for supplies that can easily be procured locally, such as paper towels and light bulbs, will now be supplied by local vendors. But challenges still remain for system departments like finance. &ldquo;Our typical 45-day or 60-day revenue cycle won&rsquo;t work for local businesses,&rdquo; Davis says. &ldquo;They have to be paid more quickly or they risk shutting down, so we must develop separate accounts-payable schedules for local versus national accounts.&rdquo;</p> <p>To support local hiring in better-paying jobs, RWJBarnabas has partnered with the city of Newark to offer classes that teach local residents &ldquo;soft skills,&rdquo; such as gaining the math knowledge needed to pass required tests for local utility company jobs. The system next wants to tackle affordable housing, providing more local jobs in the process&nbsp;and &ldquo;developing a corridor where the new employees we hire will want to live,&rdquo; Davis says, thereby championing neighborhood development. &ldquo;This isn&rsquo;t &lsquo;either/or&rsquo; work, it&rsquo;s &lsquo;yes and&rsquo; work,&rdquo; she adds. &ldquo;To embed these changes in our institution is difficult but rewarding.&rdquo;</p> <p>Zuckerman says:&nbsp;&ldquo;I really believe the first thing health care leadership must do is to find the moral imperative for this work. We have found that often some alarming statistic about a health system&rsquo;s neighborhood hits home, pointing out a disconnect between the hospital and its community, and that spurs action.&rdquo;</p> <h2>Writing a new playbook</h2> <p>For Chicago&rsquo;s Rush University Medical Center, that alarming statistic came from discovering what it has called the &ldquo;death gap&rdquo; in its city. In the downtown Loop, life expectancy is 85 years; only six miles away on the West Side, not far from RUMC, it&rsquo;s 69. &ldquo;We knew we needed to redefine business as usual,&nbsp;with these disturbing life-expectancy gaps,&rdquo; says David Ansell, M.D., senior vice president for community health equity at Rush. &ldquo;We jumped at the opportunity to work with the Healthcare Anchor Network&nbsp;because the timing couldn&rsquo;t have been better. We&rsquo;ve learned that we are necessary&nbsp;but not sufficient to make these kinds of changes happen. It&rsquo;s been a rich collaboration &mdash;&nbsp;this is a vanguard movement in its infancy, and we are teaching each other how to walk.&rdquo;</p> <p>Much of what Rush&nbsp;has learned has come through organizing West Side United, a group of residents, civic leaders, community organizations, health care professionals and hospitals representing nine West Side Chicago neighborhoods&nbsp;with&nbsp;500,000 residents. The group meets monthly to address its&nbsp;communities&rsquo; many challenges, developing&nbsp;ways to increase local hiring, purchasing and investing, among other potential long-term solutions to social and economic disparities. Rush&nbsp;has committed $6 million over three years to support West Side investments.</p> <p>Ansell attributes three key factors to the initiative&#39;s&nbsp;success to date. &ldquo;First, we couldn&rsquo;t have done this without our board&#39;s endorsing health equity as a strategy,&rdquo; he says. &ldquo;Second, our leaders had to operationalize this, creating a designated position among senior leadership. And finally, we named our employees as the first community we needed to support. They offer incredible insights into our neighborhoods &mdash;&nbsp;they have so much to teach us. This is an opportunity to help build our neighborhood wealth, along with better supporting our employees.&rdquo;</p> <p>To share its&nbsp;journey and lessons learned, Rush published <em>The Anchor Mission Playbook</em>&nbsp;in&nbsp;September, a how-to guide on&nbsp;becoming an effective anchor institution, partially supported by the Democracy Collaborative, and now part of the HAN resource library. Offering recommendations on how to &ldquo;lift an anchor mission,&rdquo; Ansell says the book is designed to help other health systems accelerate and align their efforts with local economic needs.</p> <p>In addition to the Playbook and other publications, the Democracy Collaborative has collaborated with the Robert Wood Johnson Foundation to create three HAN toolkits on workforce, purchasing and investment that teach health systems how to create more inclusive local hiring, implement local sourcing practices and support place-based investments. The toolkits include case studies, key strategies, expected return on investments and common challenges. HAN plans to launch a fourth toolkit on anchor philanthropy in the near future.</p> <p>&ldquo;There is an urgency to fixing these historically perpetuated inequities, the structural racism and economic exploitation,&rdquo; Ansell says. &ldquo;As health systems, we are organized to heal and prevent suffering. Our healing now has to be around neighborhoods and the root causes of inequity.&rdquo;</p> <p>He adds:&nbsp;&ldquo;What we mean by addressing inequity is not a rising tide that raises all boats.&nbsp;We are focusing on leaky boats and those who don&rsquo;t have boats at all. Those who cannot thrive need our help the most.&rdquo;</p> <h2>Reaching critical mass</h2> <p>&ldquo;My ultimate vision for the Healthcare Anchor&nbsp;Network would be that all hospitals would do this work at some level,&rdquo; Davis says. &ldquo;States and municipalities would support policies to accelerate this work, and we would eliminate, not just reduce, disparities. It would no longer be a network.&nbsp;It would be the way things simply are.&rdquo;</p> <p>For Zuckerman:&nbsp;&ldquo;We have what we need to do this work.&nbsp;We just need to better connect it all &ndash;&ndash; and if we don&rsquo;t take this on, who will?&rdquo;</p> <p><strong>Laurie Larson</strong> <em>is a contributing writer to </em>Trustee.</p> <hr /> <h2>Want to take part?</h2> <p>Health systems interested in joining the <a href="http://www.healthcareanchor.network">Healthcare Anchor Network</a> should contact David Zuckerman, director for health care engagement, at <a href="mailto:dave@democracycollaborative.org">dave@democracycollaborative.org</a>. In addition, the Democracy Collaborative will host a panel discussion on the anchor mission of health care at the American Hospital Association&rsquo;s <a href="https://www.healthforum.com/events/summit/aha-leadership-summit.shtml">2018 Leadership Summit</a> from July 26 to 28 in San Diego.</p> <hr /> <h2>Pathways to population health</h2> <p><em>By Julia Resnick</em></p> <p>The American Hospital Association&rsquo;s Health Research &amp; Educational Trust, along with the Institute for Healthcare Improvement, Network for Regional Healthcare Improvement, Public Health Institute&nbsp;and Stakeholder Health, partnered to develop <em>Pathways to Population Health:&nbsp;An Invitation to Health Care Change Agents. </em>Funded by the Robert Wood Johnson Foundation, <em>Pathways to Population Health</em> posits a framework for four portfolios of work that span the scope of population health, from clinical population health management to community well-being creation.</p> <p>Foundational principles of the pathways framework are:</p> <h3>What creates health</h3> <ul> <li>Health and well-being develop over a lifetime.</li> <li>Social determinants drive health and well-being outcomes throughout the life course.</li> <li>Place is a determinant of health, well-being and equity.</li> </ul> <h3>How can health care engage</h3> <ul> <li>The health system can respond to the key demographic shifts of our time.</li> <li>The health system can embrace innovative financial models and deploy existing assets for greater value.</li> <li>Health creation invites partnership because health care is only one part of the puzzle.</li> </ul> <p>To advance on the pathways to population health, health care organizations can adopt practices from each of four portfolios:</p> <ol> <li>Physical and/or mental health.&nbsp;</li> <li>Social and/or spiritual well-being.</li> <li>Community health and well-being.&nbsp;</li> <li>Communities of solutions.</li> </ol> <p>In the framework, the portfolios are interconnected with one another and by equity, with each portfolio powering the others.</p> <p>The<em> </em><a href="http://pathways2pophealth.org/">Pathways to Population Health</a><em> </em>website offers several tools, including the &quot;Compass.&quot; Health care change agents can use the Compass to determine the balance of their population health efforts within and across portfolios and also to identify areas for further focus and to assess progress.&nbsp;</p> <p><strong>Julia Resnick</strong> <em>is senior program manager at the American Hospital Association&rsquo;s Health Research &amp; Educational Trust and Association for Community Health Improvement.</em></p></div> <div class="field_author">By <span><a href="/node/135383" hreflang="en">Laurie Larson</a></span> </div> <div class="field_topics"> <div><a href="/topics/delivery-system-transformation" class="topic" hreflang="en">Delivery System Transformation</a></div> <div><a href="/topics/strategic-planning" hreflang="en">Strategic Planning</a></div> </div> Mon, 11 Jun 2018 05:00:00 +0000 aha 140201 at https://trustees.aha.org Investing in healthy cities https://trustees.aha.org/articles/1360-investing-in-healthy-cities <span class="title">Investing in healthy cities</span> <span class="uid"><span>aha</span></span> <span class="created">May 14, 2018 - 12:00 AM</span> <div class="field_page_subtitle">Initiative transforms civic collaboration to improve low-income communities</div> <div class="body"><p>What does it mean for a health system to invest fully in its community? Dozens of health care organizations across the country are learning that the commitment goes beyond typical community benefit programs and requires innovative thinking about partnerships. It&rsquo;s a mindset shift for many health care leaders&nbsp;but one that could be the future of sustainable, preventive population health.</p> <p>With those goals in mind, in May 2016, the Robert Wood Johnson Foundation, in partnership with the Reinvestment Fund, launched Invest Health, an 18-month initiative aimed at transforming how civic leaders collaborate to help their low-income communities thrive, with particular attention to such social determinants of health as access to healthful food, safe and affordable housing, and employment. The partners awarded a total of $3 million &mdash;&nbsp;$60,000 each &mdash;&nbsp;to 50 midsize&nbsp;American cities in 31 states.</p> <div class="relatedcontent drop"> <h4 class="show_hide_desk">Trustee talking points</h4> <div class="slidingDiv"> <ul> <li>Partnerships advance community health and address the social determinants of health.</li> <li>The Robert Wood Johnson Foundation and the Reinvestment Fund have set up Invest Health to deliver grants to midsize cities to invest in community development projects.</li> <li>The resulting partnerships, which include anchor health care institutions,&nbsp;have resulted in innovative approaches to improving community health.</li> <li>One of the program&#39;s keys is finding ways to link capital to community organizing.&nbsp;</li> </ul> </div> </div> <p>&ldquo;We know we need to change how we achieve health in America, and we saw Invest Health as a way to convene leaders across sectors to collectively problem-solve by learning how health care, community development and finance could work together,&rdquo; says Abbey Cofsky, managing director with the Robert Wood Johnson Foundation. &ldquo;The Reinvestment Fund has long been involved in community development, and we saw this partnership as an opportunity to make use of their reputation and expertise within a learning community infrastructure. There was no existing playbook &mdash;&nbsp;this has been a chance for cities to learn from their partners and for us to learn from them.&rdquo;</p> <h2>A new dialogue</h2> <p>The Reinvestment Fund is a community development financial institution that brings together investors, foundations, government officials and community organizations to invest in infrastructures that improve the long-term quality of life in low-income communities. For more than 30 years, it has funded affordable housing, grocery stores, schools and health centers in underserved areas &mdash;&nbsp;investments that traditional banks typically find too risky.</p> <p>&ldquo;In large part because of the [Affordable Care Act], there has been increasing momentum around community development and health outcomes,&rdquo; says&nbsp;Amanda High, chief of strategic initiatives with the Reinvestment Fund. &ldquo;The Robert Wood Johnson Foundation has been a critical thought leader in that conversation and, although we&rsquo;ve supported healthier communities since our beginnings, we haven&rsquo;t [previously] been in a robust, direct dialogue with health systems and similar stakeholders. We are mission-driven lenders, and with Invest Health we are asking: &lsquo;What does health equity mean? What maintains a system of disparities? And what levers need to be moved to improve that disinvestment over time?&rsquo;&rdquo;</p> <p>Each Invest Health awardee city was asked to form a team of five key stakeholders, including representatives from the public sector, community development and an anchor institution &mdash;&nbsp;typically academic- or health-related. &ldquo;Health systems are natural partners for what it takes to effect this type of change,&rdquo; High says. &ldquo;They have relationships that allow them to tap those with other types of expertise, such as real estate, purchasing and policy, as well as access to unique data to refine our initiatives.&rdquo; Team members also came from public schools, local philanthropies and chambers of commerce, among other city-specific sectors.</p> <p>Over the initiative&rsquo;s 18 months, all 50 teams convened several times as a larger learning community, sharing knowledge, challenges and successes, as well as working with Invest Health faculty advisers and coaches.</p> <h2>Why midsize&nbsp;cities?</h2> <p>Invest Health cities launched their community improvement efforts from a base of varying levels of experience.&nbsp;&ldquo;We chose midsize&nbsp;cities for this effort, not only because they have enormous needs to improve health and address poverty, but because they are small enough to get things done,&rdquo;&nbsp;Cofsky says.</p> <p>Some cities already had established initiatives and partners, while others met for the first time as an Invest Health team. Those with more experience have been able to &ldquo;charge ahead,&rdquo; High says, but those new to such multisector collaborations have often brought original perspectives to the table. The combination of seasoned and nascent groups &ldquo;pushed all the teams to look with fresh eyes at problems they thought they understood in new ways,&rdquo; High says.</p> <p>One such seasoned Invest Health city is Grand Rapids, Mich., where Spectrum Health has long been involved in community benefit programming with multiple civic partners. &ldquo;We examined our census tracts and decided to focus on a specific geographic area,&rdquo; says Jeremy Moore, Spectrum Health&rsquo;s director of community health innovations. Targeting southeast Grand Rapids, the team identified five priority areas: affordable housing development,&nbsp;food security,&nbsp;economic security,&nbsp;improved birth outcomes&nbsp;and lower infant mortality.</p> <p>&ldquo;We then asked, &lsquo;What are the interactions that will create something better, using investments?&rsquo;&rdquo; Moore says. &ldquo;Once you identify who&rsquo;s already doing good work, you bring them to the table and ask, &lsquo;What do you need?&rsquo; That allows equally passionate people to have powerful conversations.&rdquo; The team eventually decided to further hone its focus on housing and employment.</p> <p>To increase the amount of affordable low-income housing in the target area, the team sought support from LINC UP, a local nonprofit organization dedicated precisely to community improvement in the southeast part of the city. In presenting its report to gain LINC UP funding, the Invest Health team had a further realization: &ldquo;A light bulb went off for us that healthful housing is as important as affordable housing, so we&rsquo;ve also focused on home remediation &mdash; getting rid of problems like asthma triggers and lead removal,&rdquo; Moore says.</p> <p>Similarly, understanding that employment is directly linked to health outcomes, the Invest Health team analyzed what basic income levels, along with social service support, would allow area residents to live healthier lives. As Grand Rapids&rsquo; largest employer, Spectrum Health&rsquo;s human resources department was able to supply considerable data to answer that question. &ldquo;We can&rsquo;t expect people to get healthier without focusing on their wealth,&rdquo; Moore says. &ldquo;We know intuitively that when we invest in pulling people out of poverty, there are health benefits.&rdquo;</p> <h2>Changing plans</h2> <p>In contrast to Grand Rapids, the Tennessee city of Jackson and its anchor institution, West Tennessee Healthcare, centered grant funding on a single project. The city&#39;s&nbsp;Invest Health team wanted to renovate a&nbsp;historic but largely vacant high school in east Jackson. The team originally had envisioned turning the school into a wellness and fitness center with an additional farmers&nbsp;market. But in door-to-door surveys in the low-income neighborhood bordering the school, student canvassers from team member Lane College learned that its primarily elderly residents had more basic needs.</p> <p>&ldquo;They were concerned with safety, education and life skills,&rdquo; says&nbsp;Lisa Piercey, M.D., executive vice president, West Tennessee Healthcare. &ldquo;They told us they wanted a safe place to socialize and learn &mdash;&nbsp;we didn&rsquo;t even realize the number of elderly who lived in this blighted area.&rdquo; Canvassers received numerous requests for adult education and computer literacy, as well as to mentor neighborhood teens. The team now plans to create a mixed-use facility that includes a senior center, job-training services, a demonstration kitchen, a community history center and mentoring activities to engage local youth, anticipated to improve neighborhood safety.</p> <p>&ldquo;Our plans morphed after asking the community what it wanted,&rdquo; Piercey says. &ldquo;It became very apparent that the aging population was the business case, and that solidified the most valuable use of the space.&rdquo; As the team moves to seek investors and funding for the renovation, Piercey says constructive criticism from the Reinvestment Fund has helped shape its&nbsp;success. &ldquo;They challenged us to think more broadly about social determinants of health, beyond just the building itself,&rdquo; Piercey says. &ldquo;We learned that we had to expand our scope to lift the project, engage ancillary stakeholders and look at the community as a whole. That&rsquo;s been a valuable lesson &mdash;&nbsp;learning to merge everyone&rsquo;s needs to serve a greater purpose.&rdquo;</p> <h2>Lessons learned</h2> <p>Reflecting on the concluded initiative, High says the Invest Health teams varied widely in the number and types of issues they chose to work on and the ways they approached them. &ldquo;We had hoped that community development team members and health systems would come to understand each other&#39;s&nbsp;models and learn how to harmonize their visions and tactics,&rdquo; she says. &ldquo;The most distilled part of that nexus has been between health system and investor team members &mdash;&nbsp;and there [have]&nbsp;been a lot of genuine &lsquo;aha&rsquo; moments on both sides of the table.&rdquo;</p> <p>She adds that the partners&rsquo; periodic all-city&nbsp;meetings have contributed to broader team building. Anchor institutions have discussed common concerns with other anchor institutions, public health officials have compared notes with other public health officials and so on, creating nationwide sector-based teams in addition to the city-based teams &mdash;&nbsp;another overarching goal for Invest Health.</p> <p>&ldquo;The value proposition is to build relationships that create the potential to work together in new ways over time,&rdquo; Cofsky says. &ldquo;We&rsquo;ve learned that success has to do with leaders who are focused on mission. This is an opportunity to learn how the whole is bigger than the parts,&nbsp;and that a larger agenda can be a focus for creating change.&rdquo;</p> <p>&ldquo;Health systems can benefit from understanding that CDFIs like the Reinvestment Fund are really good at gathering different capital streams and partners together into one structure,&rdquo; Moore says. &ldquo;They have been underused in the health care space &mdash;&nbsp;and this work would be much harder without this type of partner.&rdquo;</p> <p>Cofsky and High say their organizations plan to convene a national summit later this year with all 50 teams to see how they have sustained their momentum and how they envision their future. Lessons&nbsp;from the program also will be disseminated through the Invest Health website.</p> <p>&ldquo;The Invest Health model is effective when we go beyond engagement to community organizing,&rdquo; High says.&nbsp;&ldquo;Organized people plus organized capital plus longitudinal data equals a field of possibilities grounded literally and figuratively in ways to achieve equity. This work is thrilling and daunting &mdash;&nbsp;and it&rsquo;s an entirely different way of doing business.&rdquo;</p> <p><strong>Laurie Larson</strong><em> is a contributing writer to </em>Trustee.</p></div> <div class="field_author">By <span><a href="/node/135383" hreflang="en">Laurie Larson</a></span> </div> <div class="field_topics"> <div><a href="/topics/delivery-system-transformation" class="topic" hreflang="en">Delivery System Transformation</a></div> <div><a href="/topics/strategic-planning" hreflang="en">Strategic Planning</a></div> </div> Mon, 14 May 2018 05:00:00 +0000 aha 140404 at https://trustees.aha.org Are hospital boards paying enough attention to strategic planning? https://trustees.aha.org/articles/1376-are-hospital-boards-paying-enough-attention-to-strategic-planning <span class="title">Are hospital boards paying enough attention to strategic planning?</span> <span class="uid"><span>aha</span></span> <span class="created">May 14, 2018 - 12:00 AM</span> <div class="field_page_subtitle">Health systems can take lessons from publicly traded companies</div> <div class="body"><p>In the 2017-2018 Public Company Governance Survey conducted by the <a href="http://www.NACDonline.org">National Association of Corporate Directors</a>, 600 directors of publicly traded companies were asked what they consider the board&rsquo;s priorities on behalf of the organizations they serve. Their top five:</p> <ul> <li>Meaningful contribution in the development and monitoring of the company&rsquo;s strategy (71 percent).</li> <li>Oversight of risk-management activity (58 percent).</li> <li>Improvements in the board&rsquo;s operational effectiveness to optimize its use of time&nbsp;and encourage more rigor in decision-making procedures (58 percent).</li> <li>Enhancement of the board&rsquo;s culture to enable candid discussion and meaningful deliberation (58 percent).</li> <li>Meaningful consideration and methodical approaches to CEO succession plans (58 percent).</li> </ul> <p>This list reflects growing recognition among boards that the stakes are high for their work. And at the top of the list for the second year is increased participation in corporate&nbsp;strategic planning.</p> <p>The researchers explained:&nbsp;&ldquo;Many boards still struggle to move from a traditional review-and-concur approach to deep and continual engagement with strategy. One obstacle to more robust board engagement with strategy simply may be insufficient time allocation. Fifty-one percent of respondents indicate that the lack of adequate time during board meetings for in-depth strategy discussions is an important barrier to effective strategy engagement, up from 44&nbsp;percent last year&rdquo; (Friso van der Oord, &ldquo;Public Company Board Priorities for 2018,&rdquo; <em>NACD Directorship,</em> January-February&nbsp;2018).</p> <h2>Higher stakes</h2> <p>Like boards of publicly traded companies, hospital boards face unprecedented challenges:</p> <ul> <li>Clinical innovations are changing how and where diagnoses are made and by whom.</li> <li>Operating margins in traditional lines of business are thinning.</li> <li>Consolidation in every sector of health care is expanding the scale and scope of organizational capabilities necessary to remain viable.</li> <li>Expanding regulatory compliance poses greater risks.</li> <li>Lenders and investors are tightening access to capital and costs for their funds.</li> <li>Consumers are demanding convenience, better service, transparent costs, guaranteed outcomes and digital access.</li> </ul> <p>Traditionally, local hospital boards have comprised community representatives who donate their time and expertise pro bono. Boards with oversight over large regional health systems, and multihospital operators (both investor-owned and nonprofit) may include national experts and, in some cases, offer compensation.</p> <p>A hospital board&rsquo;s role and powers are enumerated in their articles of incorporation, bylaws and Internal Revenue Service&nbsp;articles of incorporation. Many function in a purely advisory role, but most operate as the hospital&rsquo;s fiduciary with accountability for the well-being and success of the corporation. That responsibility is directly tied to the board&rsquo;s role in strategic planning to ensure&nbsp;the sustainability of the organization.</p> <h2>Role enhancement</h2> <p>There is no Blue Book of hospital strategic-planning best practices. Rather, hospitals evolve their approaches over many years, usually orchestrated by an experienced CEO with support from strategic planners, legal counsel and meeting organizers. But as strategic planning becomes a more intense focus for hospital boards, lessons from publicly traded companies may be instructive. Four are worth considering:</p> <p><strong>A dedicated strategic review committee:</strong> Most hospital boards use their executive committee&nbsp;for just about everything. In contrast, many investor-owned companies appoint a strategic review committee to review management recommendations and independently assess market conditions. The SRC serves as the board liaison to management for feedback as plans unfold and strategies are discussed. And, ultimately, the SRC is asked by the board chair to independently opine on&nbsp;management&rsquo;s recommended strategies. An important tool&nbsp;widely used by many SRCs is a dashboard that integrates internal performance data with external market and competitive-tracking measures.</p> <p><strong>A deliberate year-round process:</strong> Though occasional retreats are useful, the strategic planning process in most publicly traded companies is ongoing, and structured around frequent activity in the SRC and deliberations by the full board that often consume as much as 40 percent&nbsp;of the board&rsquo;s agenda&nbsp;(Christian Casal and Christian Caspar, &ldquo;Building a Forward-looking Board,&rdquo; <em>McKinsey Quarterly,</em> February&nbsp;2014).</p> <p><strong>Director competence:</strong> Effective public company boards expect members to be educated on key issues and trends. They provide resources and evaluate director competence on a formal basis as a precursor to a director&rsquo;s continued service to the board. By contrast, 80 percent&nbsp;of hospital boards report they&rsquo;ve never had occasion to discharge a director for incompetence&nbsp;(American Hospital Association&nbsp;Center for Healthcare Governance, &ldquo;2014 National Health Care Governance Survey Report&rdquo;).</p> <p><strong>Adequate time:</strong> Investor-owned hospital boards expect at least 40 days annually as a condition of service. Committee activity is a heavy emphasis, and effective meeting orchestration by the chair is an imperative for effectiveness. Most hospital boards put fewer demands on their members. The complexity of today&#39;s hospital marketplace, however, suggests more service time may be needed.</p> <p>In the corporate world, the board&rsquo;s active role in strategic planning is taking on added emphasis. The same is true for hospital boards.</p> <p><strong>Paul H. Keckley</strong>, Ph.D.<strong>&nbsp;</strong><em>(</em><a href="mailto:pkeckley@paulkeckley.com" target="_blank"><em>pkeckley@paulkeckley.com</em></a><em>),&nbsp;does independent health research and policy analysis and is managing editor of&nbsp;</em>The Keckley Report.<em>&nbsp;</em></p></div> <div class="field_author">By <span><a href="/node/19198" hreflang="en">Paul Keckley</a></span> </div> <div class="field_topics"> <div><a href="/topics/delivery-system-transformation" class="topic" hreflang="en">Delivery System Transformation</a></div> <div><a href="/topics/strategic-planning" hreflang="en">Strategic Planning</a></div> <div><a href="/taxonomy/term/555" hreflang="en">Issues &amp; Trends</a></div> </div> Mon, 14 May 2018 05:00:00 +0000 aha 140203 at https://trustees.aha.org Affiliations: A clear strategy https://trustees.aha.org/articles/1361-affiliations-a-clear-strategy <span class="title">Affiliations: A clear strategy</span> <span class="uid"><span>aha</span></span> <span class="created">May 14, 2018 - 12:00 AM</span> <div class="field_page_subtitle">Hospital boards should follow a well-thought-out process when linking up with other organizations</div> <div class="body"><p>Many boards and executive teams of independent hospitals or health systems find themselves struggling with how to evaluate what role partnerships or affiliations should play in their organization&rsquo;s strategy. These teams recognize the importance of evaluating their affiliation strategy options&nbsp;but are constrained in this effort by three factors at the board level. Those factors, when combined, make evaluating the organization&rsquo;s true needs a strategic&nbsp;challenge, as management teams try to define a path forward without the board&nbsp;having a clear view of the destination.</p> <p>The three factors in play are:</p> <p><strong>The fear of loss of local control:</strong>&nbsp;The most common concern among&nbsp;boards that&nbsp;are running into the affiliation&nbsp;question is a concern about local control. Frequently, their concern is that potential health care partners that&nbsp;are not part of the community served by the hospital or system will not have the community&rsquo;s best interests at heart, potentially leading to a lack of service, access or other negative outcomes.&nbsp;</p> <p><strong>Understanding the organization&rsquo;s ability to thrive independently:</strong>&nbsp;&ldquo;We can continue to remain independent&rdquo; frequently is a difficult statement for board members to evaluate. Having enough understanding of the organization&rsquo;s needs, its long-term strategic road map&nbsp;and its ability to execute on its strategy to draw a conclusion about an independent future is a difficult proposition. Commonly in this situation, &ldquo;affiliation&rdquo; largely becomes a cure-all term for multifaceted strategic challenges. It also becomes a binary proposition: We are independent&nbsp;or we are pursuing affiliation.</p> <div class="relatedcontent drop"> <h4 class="show_hide_desk">Trustee talking points</h4> <div class="slidingDiv"> <ul> <li>More and more hospitals and health systems are considering partnerships and affiliations.</li> <li>A number of barriers stand in the way of making an informed decision about partnerships.</li> <li>Clear definitions are an essential first step when boards are evaluating their options.</li> <li>A defined process can lead to a partnership strategy that puts an organization on the path to success.</li> </ul> </div> </div> <p>Complicating this discussion is a definitional&nbsp;issue: What does &ldquo;independence&rdquo; truly mean? What does &ldquo;local control&rdquo; entail? What does it mean to pursue an &ldquo;affiliation&rdquo;? In nearly every organization, these are questions that will be answered differently by members of the same board.</p> <p><strong>Understanding affiliation&nbsp;options:</strong>&nbsp;Often, boards struggle with understanding the availability of&nbsp;affiliation options &mdash;&nbsp;the various models in which hospitals can work with one another&nbsp;[see sidebar below]. Significant education (and time) is required to understand each of these models, their applicability to the organization&nbsp;and whether those models will help drive success&nbsp;as the organization defines it. This level of understanding is a challenge for hospitals&nbsp;given board schedules and other management priorities. Ultimately, as decisions need to be made, having a deeper understanding of potential affiliation options will be requisite to a successful process.&nbsp;</p> <p>Getting past each of these barriers is necessary for getting an organization on the right long-term path. To address these&nbsp;challenges, we recommend that the hospital board and leadership team undertake the following six steps to build consensus around the organization&rsquo;s affiliation strategy:</p> <h2>Step 1</h2> <h4>Create common definitions within the leadership team</h4> <p>As many hospital leadership teams have surely experienced, when it comes to &ldquo;independence,&rdquo; &ldquo;local control,&rdquo; &ldquo;partnership&rdquo; and &ldquo;affiliation,&rdquo; there are multiple definitions floating around the boardroom for each term.</p> <p>&ldquo;Independence,&rdquo; for instance, can include&nbsp;definitions as disparate as&nbsp;&ldquo;we control most of the decisions made at the leadership level, and we work closely with a number of other local, regional or national provider organizations to drive success for our community&rdquo; and&nbsp;&ldquo;we control all decision-making for our organization, with a closed medical staff and limited partnerships with other nonacute care providers.&rdquo; The wide array of definitions that exists within a boardroom dampens discussion about future strategy, as leadership team members experience disconnects in debate and conversation.&nbsp;</p> <p>Similarly, &ldquo;affiliation&rdquo; is often seen as the opposite of &ldquo;independent,&rdquo; as opposed to an array of potential arrangements with one or more provider organization partners that may affect&nbsp;local control and decision-making while helping the organization achieve its goals. A complicating factor is the negativity around the term affiliation,&nbsp;which can drive leadership discussion away from the topic. For better or worse, affiliation&nbsp;is commonly viewed as giving up&nbsp;or giving in&nbsp;to the competition, or a general failure of hospital leadership to guide the organization on a successful path.&nbsp;</p> <p>To address such concerns, the leadership team should perform an exercise designed to bring common definitions for these terms to the boardroom. Have each member define &ldquo;independence,&rdquo; &ldquo;sustainability of the organization,&rdquo; &ldquo;local control,&rdquo; &ldquo;affiliation&rdquo; and &ldquo;partnership.&rdquo; Reconcile these definitions and create a common one&nbsp;for use in future leadership team discussions.&nbsp;</p> <h2>Step 2</h2> <h4>Define the board&rsquo;s nonnegotiables</h4> <p>With common definitions for &ldquo;affiliation&rdquo; and other terms in place, the organization must next determine the leadership team&rsquo;s positions on what is acceptable from the board&rsquo;s perspective. Most commonly, the biggest nonnegotiable&nbsp;is a loss of local control of decision-making. With a common definition for local decision-making in place, however, digging into what this means and what parts of it are truly not negotiable become an easier process.</p> <p>Further education for the board may be required relating&nbsp;to the array of affiliation options available to the organization in the future. A mixture of education and discussion should be used to explore, and then explicitly define, what options are truly nonnegotiable, which are not ideal&nbsp;and which are within the board&#39;s realm of comfort. As an exploration of affiliations moves forward, these definitions will help ensure that the process moves smoothly as more concrete steps are taken.</p> <h2>Step 3</h2> <h4>Build the vision for independence</h4> <p>To obtain&nbsp;a true evaluation of affiliation needs, the hospital must also develop a vision that defines its path to sustainability&nbsp;and then work backward, determining whether the capabilities and resources needed are realistic for the organization to execute the plan.&nbsp;</p> <p>While resource availability to address patient needs will always be a core driver of affiliation strategy, in this process the organization should also consider core strategic issues that drive hospital viability, such as:</p> <ul> <li><strong>Provider supply and ability to recruit</strong>&nbsp;&mdash;&nbsp;including the development of a robust primary care base, specialty manpower and depth of capability.</li> <li><strong>Geographic reach</strong>&nbsp;&mdash;&nbsp;focused on the ability of the organization to meet the needs of the population in its service area with sufficient access to care.</li> <li><strong>Provider network management</strong>&nbsp;&mdash;&nbsp;including the personnel capabilities to operate an employed physician network or clinically integrated network.</li> <li><strong>Population health capabilities</strong>&nbsp;&mdash;&nbsp;including the ability to develop competencies in managing care and producing high-quality outcomes that the field seeks, with a special&nbsp;focus on the organization&rsquo;s ability to invest in infrastructure (especially information technology) to facilitate the development of these capabilities.&nbsp;</li> </ul> <h2>Step 4</h2> <h4>Evaluate internal competencies and resources</h4> <p>Once the vision is complete, the organization must develop an honest self-assessment of its ability to execute that vision. Gaps in the ability of&nbsp;the hospital or health system to execute the vision developed in Step 3&nbsp;become the basis of discussions with other hospitals or systems about affiliations in Step 5. These discussions happen within the context of what the organization is willing to give up&nbsp;&mdash;&nbsp;ensuring maximum retention of local control while focusing affiliation discussions&nbsp;strongly on partnership, not acquisition. Overall, such an honest evaluation moves board discussion away from an all-or-nothing&nbsp;approach&nbsp;and instead focuses the organization on getting what it needs without violating the nonnegotiables.&nbsp;</p> <p>To perform this self-assessment, the board should review the plan critically upon its completion. Common questions to ask of leadership as part of this process include:</p> <ul> <li>What competencies must we have to execute each strategy?</li> <li>Do we have the resources we need to develop and strengthen&nbsp;those competencies?</li> <li>What challenges will occur as we try to acquire those resources?</li> <li>Do we have the internal capabilities to execute this plan?</li> <li>How realistic is success?</li> <li>What metrics will we use to judge whether we are creating success for the organization?</li> </ul> <p>The answers to these questions will create a crystal-clear picture of what, if anything, the organization will need out of an affiliation strategy.</p> <h2>Step 5</h2> <h4>Determine&nbsp;affiliation strategy to address organizational needs</h4> <p>With an honest evaluation of the organization&rsquo;s capabilities and resources in place, the board should use information gathered from the previous steps to develop an effective request for information. This document communicates the hospital&rsquo;s needs to potential partners as part of an affiliation strategy.&nbsp;</p> <p>The RFI must be streamlined around the core needs of the organization. As such, the organization will see a number of potential benefits as it communicates the RFI to potential partners:</p> <ul> <li>The organization will be in a stronger position in its negotiations with potential partners, given that it is asking for assistance with a defined number of critical items&nbsp;rather than a more general request for affiliation information. Organizations that have not gone through a process to specifically define their core needs often submit more general affiliation RFIs, which at their core ask, &ldquo;How can you help us?&rdquo; This oversight results in the responding organizations&nbsp;being general in their responses&nbsp;and focusing more on replicating the same relationships that they have created with other organizations&nbsp;regardless of whether those situations are beneficial to the requesting organization.</li> <li>When needs are defined, the affiliation process will move much more quickly. Whereas a more general affiliation discussion can drag on for multiple quarters, if not years, a targeted discussion can quickly get the hospital to the right people in the targeted organizations&nbsp;and facilitate quicker discussions and resolutions.&nbsp;</li> <li>The board approval process within the hospital should move much more quickly, as the work of vetting (&ldquo;Are we comfortable with this?&rdquo; and &ldquo;What are we getting out of it?&rdquo;) has largely been completed before the RFI goes out.&nbsp;</li> </ul> <h2>Step 6</h2> <h4>Evaluate partners and execute the strategy</h4> <p>The organization should now be fully prepared to submit an effective RFI. Once the board has vetted potential partners, the hospital should be ready to move forward with its plan.</p> <p>Execution of all these steps is necessary in&nbsp;obtaining&nbsp;the right affiliation strategy for the organization. Following this process results in&nbsp;the organization&#39;s being able to define an affiliation partner that can assist it in meeting its strategic goals&nbsp;while minimizing loss of control and staying within the board&#39;s nonnegotiables. Ultimately, pursuing this process will put the organization on an optimal path toward serving its community&rsquo;s needs.</p> <p><strong>Travis Ansel</strong> <em>(</em><a href="mailto:tansel@hsgadvisors.com)"><em>tansel@hsgadvisors.com)</em></a><em> is a partner with HSG in Louisville, Ky.</em></p> <hr /> <h2>Affiliation options</h2> <ul> <li>Clinical affiliation models (i.e., branding, shared resources).</li> <li>Collaborative models (i.e., regional and statewide networks).</li> <li>Population management network models (e.g., accountable care organizations).</li> <li>Affiliation network models (e.g., clinically integrated networks).</li> <li>Mergers and acquisitions.</li> <li>Management agreements.</li> </ul> <hr /> <h2>Trustee takeaways: Building consensus</h2> <p>When a hospital board is developing its affiliation strategy, trustees may sometimes not be in agreement. Here are some quick&nbsp;tips to achieve consensus:</p> <p><strong>Step 1: Create common definitions within the leadership team.</strong> Break down barriers to productive discussions by getting a common set of definitions for &ldquo;independence,&rdquo; &ldquo;partnership,&rdquo; &ldquo;affiliation&rdquo; and any other commonly used terms in the boardroom when discussing the hospital&rsquo;s path forward as an independent organization.</p> <p><strong>Step 2: Define the board&rsquo;s nonnegotiables.&nbsp;</strong>Document what is critically important to the board so that future strategic discussions can be built to avoid pathways that will be nonstarters for the board.</p> <p><strong>Step 3: Build the vision for independence.</strong> Work collaboratively to build a strategic vision,&nbsp;defining how the hospital or health system will be successful and remain independent.</p> <p><strong>Step 4: Evaluate internal competencies and resources. </strong>Evaluate the organization&rsquo;s ability to execute the strategic vision given its current capabilities and availability of resources, and then define what gaps cannot be addressed realistically without outside assistance.</p> <p><strong>Step 5: Determine an affiliation strategy to address organizational needs. </strong>Use the defined gaps in the ability to execute the strategic vision to define a&nbsp;request for information&nbsp;for affiliation strategy that meets the organization&rsquo;s key needs &mdash;&nbsp;and nothing more.</p> <p><strong>Step 6: Evaluate partners and execute the strategy.</strong>&nbsp;Submit the RFI, vet potential affiliate partners, and move forward.</p></div> <div class="field_author">By <span><a href="/node/135380" hreflang="en">Travis Ansel</a></span> </div> <div class="field_topics"> <div><a href="/topics/delivery-system-transformation" class="topic" hreflang="en">Delivery System Transformation</a></div> <div><a href="/topics/governance-effectiveness" hreflang="en">Governance Effectiveness</a></div> <div><a href="/topics/strategic-planning" hreflang="en">Strategic Planning</a></div> </div> Mon, 14 May 2018 05:00:00 +0000 aha 140181 at https://trustees.aha.org