At the Value-Based Care
Summit, community-based care and community connection were front and center.
By Sara Heath
November 13, 2019
- In Vermont, a request for a turtle crossing raised some eyebrows,
especially because that request was coming into RiseVT, an organization within
the OneCare Vermont accountable care organization that helps model and fund
community-based care efforts.
“We had somebody say,
‘We really, really need a turtle crossing. We have a lot of turtles in the road
and we're very worried about them,’” Marissa Parisi, RiseVT’s executive
director, recounted during a panel session at Xtelligent Healthcare Media’s 4th
Annual Value-Based Care Summit. “We said, ‘Okay, but how is that
going to improve the health of the community?’”
RiseVT represents one
of many efforts across the country to place healthcare initiatives at the
center of the community, ultimately aiming to address the social determinants
of health. By working with grassroots wellness specialists across Vermont, the
organization is able to assess population-level social needs and different
action items that can mitigate social risk.
But those action
items usually result in new community gardens or putting telehealth kiosks
inside affordable housing units that have a lot of tenants with high rates of
preventable emergency department utilization.
Not turtle crossings.
But the community
pushed back, Parisi said, outlining the benefits the turtle crossing would have
on education.
“‘We're creating a
program for kids in the school to have full responsibility for these turtles,’”
Parisi recalled the community saying. “My initial reaction was, ‘No, we are not
an environmental organization, we're a health organization.’”
But as the community
made the case for driving educational opportunities for kids and programs that
will improve self-efficacy for community members, Parisi and RiseVT eventually
saw the benefit.
The turtles got their
crossing.
“We have to
de-medicalize a lot of this stuff,” Laura Black, DNP, another panelist and
senior vice president of Care Management and Clinical Services at Commonwealth
Care Alliance, said in reaction to Parisi’s story.
De-medicalizing
social risk factors and the solutions needed to address them is key to establishing trust with patients and the
community, Black said. Most people have some level of distrust with the medical
system, she pointed out, and having a paternalistic relationship between health
systems or payers and community groups will not be effective.
“It's important to
know the population and to establish trust,” Black stated. “People who have had
issues with the traditional medical establishment have felt left down by it. If
you start to de-medicalize and build relationships where you meet Maslow's
hierarchy, when you start meeting that bottom level of that triangle, that does
help engage, that helps build trust, and that helps with progress.”
Of course, getting to
know that community can be hard because of that lack of trust, agreed Black,
Parisi, and Freya Spielberg, MD, MPH, an associate professor at the University
of Texas Austin Dell Medical School and third panelist at the Summit. To get to
the root of community health challenges and the social determinants of health,
organizations need to lean on a link between themselves and populations.
Data will be central to those efforts,
Black stated. At Commonwealth Care Alliance, which offers an HMO plan for
seniors living in Massachusetts and a program for dual-eligibles, access to
patient data as a payer has been essential.
“We have what are
called passive wave assignments that come to us every quarter,” Black
explained. “We are made aware of the members who are assigned to our health
plan, and then we connect with our members and ensure that whatever plans they
perhaps had prior to enrollment stays in place.”
From there, CCA
employs community-based nursing staff who do full member assessments looking at
current medications, social determinants of health, functional status, and
medical status. This data can be extremely actionable and help inform outreach
efforts for CCA.
But the organization,
like RiseVT and many of the Austin- and DC-based organizations Spielberg has
led, also leans on direct patient and community outreach. CCA taps behavioral
health and health outreach workers to ensure members receive key health
assessments and to connect members to relevant community services.
For Spielberg,
partnering with community members has been essential. These outreach workers
are familiar with, and in many cases peers of, some of the vulnerable
populations organizations are trying to target.
“There's a lot of
distrust of the medical system, so we hired community health workers from the
housing projects,” Spielberg explained. “These are people that live in the
housing projects. They were certified nurse assistants, so they had a little
bit of training but not much. They have pretty low health literacy, but we put
them through extensive training and supervision. And because they are part of
the community, they know what's needed there and they're able to guide
everything that we do, but they also have trust from the community.”
The next step is
understanding the impact that these programs are going to have and the space
they will actually fill in a value-based care landscape. Social determinants of
health programming promises to keep patients healthier longer, helping to
reduce high-cost care episodes that result from certain environmental or social
stressors.
The challenge going
forward is proving just how preventative these efforts can be. How can an
organization justify investing in something it can only hope will work?
Organizations need to focus on heavy data collection to track outcomes and
augment efforts, the panelists agreed.
Healthcare leaders
should also look into key, high-impact areas. Big-ticket items will have a
larger, longer-term impact that can push efforts the extra mile.
“There can be very
high-dose activities, like changing policy,” Parisi stated. “If you change a food
policy at a school where all kids are able to eat, the food is much more
nutritious, and everyone has access, that is a high-dose policy change. versus
maybe a one-off walking event in a community.”
Organizations need to
look for those high-dose activities to see true return on investment.
“We're looking at the
whole portfolio of work and actually trying to give it a score to see how well
we think we're doing in those communities so we get a little more real-time
data on what we hope we can see as longer-term outcomes,” Parisi concluded.
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