Community Health Improvement Strategies That Make A Difference

Speaker A: Welcome to the Policy Huddle. I'm your host, Dave Dillon. In this edition, we'll be discussing community health improvement strategies. I'm joined in this episode by Dr. Gavin Helton, President of primary care at Mercy Health System, and Jenna Hicks, director of quality and population health at Citizens Memorial Hospital in Bolivar, Missouri. Dr. Hilton, welcome to the Policy auto.

Speaker B: Thanks, Dave. I appreciate you thinking about mercy and having us here to share our experiences.

Speaker A: Thanks for being here. Jenna. Welcome, uh, to Policy Huddle.

Speaker C: Happy to join.

Speaker A: Thank you. And so two very different organizations and want to explore a little bit about how your organizations see community health improvement through the lens of their size, through their communities they serve and the like. So maybe we can start, uh, with Dr. Helton. Can you give me some real basic information about how mercy looks at community health improvement, how that fits with mission and the kind of work you've done to help make those two things synchronize?

Speaker B: Mercy is absolutely committed to recognizing dignity of each individual that we serve. And as we connect mission to community health, and I would say population health broadly, that can only really be done effectively through focus on the individual aids of the patients that we're privileged to serve. As we look at a community or a population as a whole, as absolutely some are high risk from, um, a medical standpoint, others may have other barriers to living as many healthy days at home, um, as possible and having the highest quality life. And that might be behavioral health needs, it might be health related social needs. But creating a care model that's able to adjust to the needs of the individual and patient care at an individual level is ultimately how we will care for the community more broadly.

Speaker A: Am I right or wrong in saying that? Seems to be the lens you're looking through is identifying that on an individual basis and probably extending as a community basis the individual's ability to live a healthy and productive life.

Speaker B: Without question, Dave. I answer that by really thinking about with our virtual care services. But over the last 10 years, we very intentionally developed programs for the more complex chronically ill patients keeping their care in the home. And then for patients who either prefer digital interaction or perhaps have transportation concerns, being able to interact with them on their terms, where they are, the individual patient, us understanding what they want to get out of life, what their priorities are, and then providing care in a way that improves their healthy days at home as well as the quality of, uh, care they receive. It's absolutely connected.

Speaker A: Let's shift over to Jenna. Jenna, tell us the True north for Citizens Memorial and how using that as your lens You've been able to build out services.

Speaker C: Yeah, I'd agree with much of any healthcare strategy and what Dr. Helton's reflected as mercies as far as recognizing that healthcare is personal, in the end, it's relational, it requires trust. In order to build that trust, there has to be some sort of access and human component. But you know, ultimately every healthcare facility and system has the challenge of webbing in how do we remain financially sustainable as far as quality outcomes and how do we optimize technology to work smarter, but also prioritizing that in order to care for humans, it takes human care and how do we do that really, really well? And for cmh, how do we ensure that health care is health care and not just sick care, and that we are engaging our expertise in the field in wise ways so that we're all working in the ways that we were intended and we're suited and optimizing those technologies and financial sustainability models as we can to continue doing that good work.

Speaker A: One of the things I've learned from visiting Donna Bolivar is that it takes really good community partners. Dr. Helton. I imagine that's true in every community that is implementing these kind of programs that Mercy represents.

Speaker B: It's a great question when Mercy views care, whether it's in a major metropolitan area or whether it's in an outlying rural area. We still return to the same respect for dignity of individuals that we serve. And what we're committed to is optimizing the care for the patients, regardless of location. As you look over the last 26 years of our virtual programs being deeply integrated with the vet side, one of the guiding factors has been bring the care to the patients very deliberately, bring the care to where they are in the channel of their choice. Instead of focusing on ourselves, we're actually trying to, trying to keep patients as close to home as possible. We know patients prefer that. We know it's less expensive and can be higher quality if we leverage our virtual resources.

Speaker A: We've covered, uh, to some degree the connection between patient, uh, life and the resources a hospital can deliver from a traditional care perspective. I'm wondering relative to partners that provide leverage related to, you know, non clinical factors or the ability of hospitals to connect to resources, what are the um, key partners that you would engage with to do this? Well, in uh, communities of any size. Jenna, thoughts on that?

Speaker C: That adage of, you know, it takes a village didn't come out of nowhere. You know, I can't speak in a larger system, but in a, in a system it's really Evident that we're working with limited resources and we have to lean on our neighbors. Sometimes we talk about strategy and how do we build those relationships. And sometimes the answer is, well, I made a lot of homemade cannolis and I handed them out, built relationships and it can get really simple. But you know, for us, our local health department has been huge. Um, we lean on our FQHC for a lot of the behavioral health needs in our community. Our local food pantry, uh, Community Outreach Ministries has been a huge partner as well. We've been blessed with a variety of funding mechanisms to support mobile integrated health and that really was a community initiative. So we pulled together stakeholders and community integrated health care was to be flexible enough to serve as a gap filler at the patient level and get them connected with the traditional healthcare modality or the community partner and then also recognize the experts in the field in that way. So rural healthcare isn't unique in that we are advocating and fighting all the time to remain sustainable because we believe in the good work of what that provides. But we have experts in that space in our local communities too for non clinical needs as well. And that really takes us coming together and building systems to communicate and process processes for referrals. But it doesn't happen on accident.

Speaker A: Mercenary has a significant number of small hospitals in addition to fairly uh, sizable ones. And so maybe uh, Dr. Huntley, if you could give us a sense of how that approach, both in urban suburban environment and a, uh, more rural environment is driven by the values that you guys have.

Speaker B: I appreciate the question. We're really focused on leveraging our internal investments and the whole care model to be much more deeply integrated around the needs of the individuals that we serve. An example of that could certainly be the deep integration of the virtual team with the traditional team. Not disintermediating, but really augmenting what the traditional team is focused on in a highly patient centric manner. The other aspect is we can't do an iro. Um, we have partnerships in each of our communities and I think some of the examples that Jenna hit on are spot on. We know that community based organizations can play a key role and do play a key role in helping meet especially some of the non clinical barriers specific to health related social needs. We also know I mentioned earlier, an engaged patient has better outcomes and many patients engage through their, through their church, through their senior center, all locally and being able to leverage those relationships to optimize patient care, uh, for these individuals and for the community. It's the only way that these patients will have in the communities will have more of the healthier days at home that we talked about earlier.

Speaker A: So it's interesting because you went to something that Jenna mentioned earlier, which is, is trust. If the message is delivered from the pulpit in a community about managing care or uh, diabetes for example, or uh, the high rate of heart disease, and then gives permissions to those individuals to engage themselves with the healthcare system, that is a true trust moment that helps extend people into their best life. You know, at the end of every episode of care or every interaction of healthcare, uh, individuals with the communities they've served, there's usually a story.

Speaker C: An example this past week was a heart failure patient who had been readmitted a couple times both at our facility and elsewhere. And she was navigating at home with a walker. And so she'd been admitted again for heart failure and had just decompensated and needed a wheelchair when she went home to get along in her house. We had tried to refer her for home health to work on just heart failure literacy as a whole, and she had declined it. That's not unique. We often have folks decline resources available to them and ultimately, you know, she uh, disclosed a bit of embarrassment or shame m or fear of judgment of someone entering our home. That just tells us even more reason for us to wrap our arms around her and that there's some risk, uh, going on. While she declined home health, she was interested to engage with, um, mobile integrated health care. Sometimes the MIH team is welcomed because we speak to the fact that they're, you know, they're community paramedics and there's an element of trust with the paramedics that I think sometimes translate even in the nursing field as well. But even when you have those partnerships, it's at the individual level of who they trust, what they trust, what they're willing to engage in. We take that one little open door and we run with it. MIH did do a one time home visit and they identified the reason she keeps bouncing back for these heart failure admissions is, you know, she's stretching her medication because she can't afford it. So she's taking old prescriptions of her diuretic and at, uh, lower dosages than she needs to prevent that readmission. And because she's not taking her prescribed medications as they're prescribed, she's coming back to the hospital with the same problem. They also identified that she went home with a wheelchair, but she's not bathing because her shower isn't wheelchair accessible. So she hadn't bathed for Some time and we were able to, through the TORCH program or Transformation of Rural Community Health, there is funding available for safety related housing needs. So we were able to get her a uh, wheelchair accessible shower which just, I always think that that's so big long term because you think of an individual who goes home, who needed home health, who has active Medicaid, but they don't engage in services, they don't have a means to care for themselves safely at home. So ultimately they typically end up in our long term care facilities in which Medicaid pays that full bill every day. So when uh, you look at, sometimes we get shortsighted in the care delivery model where, where we think perhaps payers or systems are saving money in one capacity long term, uh, it's far more expensive and not only is it more expensive, but it's malaligned with what that individual wanted to do in the first place, which was likely respectfully age at home, age in place and do that safely. That was just a big win as far as like utilizing internal resources, finding the one that the patient would engage with and would meet them where they're at, and braiding different funding mechanisms and resources to meet that true intent.

Speaker A: Dr. Eldon?

Speaker B: Sure, sure. Thank you. I think immediately about a single patient. You know, right now we have uh, within our program for complex chronically ill patients and bringing care to them in the home. Their quality of life improves when we decrease unnecessary emergency department visits or decrease unnecessary inpatient admissions. I think about a particular individual. He is a disabled veteran of the Vietnam War and had moved out after post retirement, had moved to a rural area just over an hour away from the closest hospital and was taking care of his disabled wife. And he had been admitted over the past year for his congestive heart failure. He had multiple comorbid conditions, but uh, congestive heart failure was his predominant one in terms of leading to his symptomatology and the suffering he experienced day to day and especially living with just the two of them, um, out in an ah, isolated rural area. So he had been to the hospital and admitted six times in the prior year for this condition. We decided to bring the care to him into his home. And part of that was leveraging a primary care provider that he had, that was closer in town to see the patient more frequently and certainly helping support health related social needs, access to prescription medication, making certain that he was on the most up to date guideline direction, medical therapy. That was part of the solution. The other part of it was bringing the care to him in the home in direct coordination with both facility based care and specialty care and his primary care provider. And in doing so, what we found is he had no broadband service and so the idea of a video visit was not possible. What we were able to do was leverage his wand line to put an old school modem that was able to connect his care with the team back at Mercy Virtual and the Virtual Care center here in Chesterfield, Missouri. Tremendous success. He made the comment that when he left Vietnam, he never thought he'd see the inside of the helicopter again. And now he has seen it six times going back and forth into a hospital because of his congestive heart failure. The reality is for this individual, we were able to keep him out of the hospital long term without any air evacuations and without any hospital admissions going forward by bringing highly personalized and predictive care to him. And you think about the tremendous impact that had on this individual. So that's an example that I think about regularly. And that's how we end up with a higher quality of life, that's higher quality care at a lower cost. So that's a, uh, that's an example or patient that I can immediately think about.

Speaker A: I think I just heard the triple aim there. One of the things, uh, that Jenna mentioned earlier is that there are some things that you do as healthcare organizations that are paid for and other ones you do because they're the right thing and both can have an effect on health. I'm fascinated by the, the misalignment and incentives in our system that will incentivize care in an environment often before it will incentivize the much smaller investment to make that person independent and allow them to live, uh, their best life.

Speaker C: Uh, in rural healthcare particularly, we kind of have to be scrappy and scroungy as far as, you know, those financial resources go. So we were really intentional, particularly in light of just limited resources as a whole of what can we learn about current funding mechanisms today and what do we agree is good work? Because if it's good work for that, um, specific patient population and it's funded today for that specific patient population, we should just web that into the way we provide care for everybody. So that despite the payer, despite the program, that particular seed is what's bearing fruit everywhere for everyone. And we're not having to chase ourselves after the dollar really, because ultimately knowing the work is good and having faith that it will be fruitful has thus far proven a very wise strategy in our healthcare delivery. So not only have we been able to Optimize on current funding mechanisms. We've been really well suited and prepared for upcoming uh, funding mechanisms that learn from their prior reiterations because we've already been engaging with that work at scale to the best that we can. So it's just the way we do health care.

Speaker A: It's a very subtle way to talk about torch and torch care and uh, well played. It is absolutely true that what's going on at Citizens is a great model for how other hospitals who are going to be addressing this for the first time can see how to do community health improvement and care delivery more efficiently, better.

Speaker B: I think from my standpoint, the healthcare economics and the shift from fee for service to value does allow for us to really think about care in a more holistic manner. It allows us to address the health related social needs. It allows us to address behavioral health needs. Things that often would have been pushed off to the side in a fee for service mentality. In a value base where uh, a provider is held accountable for total cost of care and high quality care, you then are reimbursed in a way that, that you have aligned incentives to have that patient be healthier, to have that patient be engaged in playing an active role in their own healthcare. We strongly believe in the foundation of uh, primary care and the role in primary care plays in a value based, more holistic care model in that we want to be as far upstream as possible in a patient's care so we prevent complications, we're proactive in our approach. We're able to leverage the lowest cost, highest quality side of care. And to do that, that really does require a system ness approach. Again it goes back to bringing the care to the patients where and when they want it, not simply where and when we've historically provided it.

Speaker A: Always an interesting conversation to have. Um, I think that is so counterintuitive to most of our patients and communities that hospitals do this work. I appreciate you both being here. Talk about both what your organizations are doing and kind of the trends that are emerging relative to community health improvement. Dr. Helton, uh, appreciate your uh, time, uh, and your wisdom on this.

Speaker B: Thank you. Nice meeting you both.

Speaker A: Uh, yeah, once again, I mean it's always a good day to talk about good work and uh, Jenna, again, always look to you for uh, what's going on and how we should be doing it. So thanks for being here.

Speaker C: Thank you both.

Speaker A: Thanks for joining us on the policy huddle. Remember, hit subscribe to be alerted when new episodes are available. Until next time, I'm your host, Dave Dillon.