What top five i nterventions would you support to achieve the triple aim of better care, better...

What top five interventions would

you support to achieve the triple aim of

better care, better health, lower cost?

Presented to: Grantmakers in Health

March 7, 2014

ARCHI

Leveraging the Community Benefit Requirements of the Affordable Care Act

for Collective Impact: The Atlanta Regional Collaborative for Health Improvement

(ARCHI)

Changes in Public

Coverage

Changes in Private

Coverage

Improving Health Care

Quality

Improving Health

Atlanta Regional Collaborative for Health Improvement

The CHNA Opportunity in the ACA

• Community health needs assessments (CHNA) are now required every three years of not-for-profit health entities in order to maintain their tax-free status

• CHNA and implementation strategy required for each facility



• CHNA:– A description of “community” and how it was

determined– A description of process and methods, including data

used and information gaps– A description of how input was gathered from those

with a broad interest in the community– A prioritized list of community health needs, including

how the list was prioritized



• Implementation plan:– Must describe how each health need

identified in the CHNA will be met, or– Describe identified needs that will not be met

by that hospital and why– Must be approved by a governing body– Collaboration is encouraged


Solution

Funders (CDC, Kaiser, St. Joseph’s Healthcare, Grady, and the Lead Organizations)

Public Health, Hospitals, FQHCs, Physicians, Behavioral

and Other Providers

Business, Education, County Commissioners, Faith Leaders,

Insurers, Philanthropy

Led by United Way, ARC, and Georgia Health Policy Center


ARCHI Video


Seeding Innovations in Health

ARCHI

Rippel, ReThink Health, & the RTH Dynamics Model

How can we work together to solve complex problems in a complex world using technology that helps us see, understand & talk about the real problems and develop sustainable solutions…

THE RIPPEL FOUNDATIONSeeding Innovations in Health

• Founded in 1953 as a charitable foundation• 6 person Board of Directors • Home office Morristown, NJ; satellite location in Cambridge, MA• $85 million in assets; $6.4 million 2014 budget • 30 full and part time staff and long term contractors… and growing

• Legal Mandate: Women, Elderly, Cancer, Heart Disease, Hospitals• 2007 Mission: “Seed Innovations in Health”• Primary program and investment: ReThink Health

• 75% of total Rippel budget; 95% of program budget • Generated $2.5 million in grants and earned income to date

• After 53 years of primarily making grants…• Almost no grants, not operating foundation; work through DCA

• Commitment to collaboration with like-minded partners

THE FANNIE E. RIPPEL FOUNDATION

13

1959 – We have long known that health care facilities should be adapted to the patients rather than the opposite.

1967 - To avoid becoming sick may be the greatest health and medical challenge to contemporary society.

1968 - Sooner or later some group will find out how to build, organize and operate a hospital which will be better and more flexible than at present, and at a lower cost.

1968 - The greatest opportunity people have to achieve and maintain good health and well-being, at the lowest possible cost, is by their own intelligent methods of daily living habits.

1969 - We need to develop a health care system which will be recognized as distinct from medical care. This is a real key to solving our “medical problem.”

1969 - We must have substantially new manners of thinking to enable mankind to bridge the gap between the things that have been and the things which will be.

JULIUS A. RIPPEL, PRESIDENT, 1953 - 1983

Build & Sustain System-Wide ChangeMeasures

Evidence, Examples, IdeasProblem Identification

45 YEARS LATER, WE BEGAN TO REALIZE….

RETHINK HEALTHA Collaborative Initiative of the Rippel Foundation

… work with leaders to demonstrate that sustainable redesign of regional health systems is possible and can improve health, care, costs, equity, ownership, productivity, regional economies, and communities vitality.

• Better health, better care, lower costs and access for all

• Collaboration by leaders across boundaries (in and out of health)

• Whole system thinking

• Redesign to meet health and care needs

• National purpose, local action

CHALLENGE & PRINCIPLES

18

Action Results

Thinking

ReActing

RETHINKING

18

INTEGRATED APPROACH

19

Active Stewardship

Sustainable Financing

Effective Strategy

20

• Bring system stakeholders together in a way that builds trust, shared vision, and collaborative action.

• Build purposeful and effective stewardship teams that can sustain efforts and achieve measurable results over time.

• Assure that health resources are being spent to achieve the greatest impact.

• Align community priorities with health system priorities.

• Finance and sustain efforts long enough to see real results and avoid rebound experiences.

• Support innovation, implementation, and system redesign in ways that achieve high impact goals and build critical interdependencies.

• Educate leaders to have a whole system and collaborative perspective.

• Engage in action-research

• Develop and share lessons, tools, approaches

WORK WITH LEADERS & COALITIONS TO…

• Grant funding from the California HealthCare Foundation and the Robert Wood Johnson Foundation plus increasing earned income

• Experience in more than 30 regions across the country

• Created and used the Dynamics Model in 50 settings, 9 academic institutions, and thousands of users

• Successful distance learning course with 180 participants

• Building a learning network and community

• Extensive partnerships with motivated leaders, regions and organizations

• Strong enterprise wide evaluation process

• Impact on regional and national levels

SINCE 2007…

21

RETHINK HEALTH DYNAMICS MODEL

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Keehan SP, Cuckler GA, Sisko AM, et al. National Health Expenditure Projections: Modest Annual Growth Until Coverage Expands And Economic Growth Accelerates. Health Affairs 2012.

Heffler S, Smith S, Keehan S, Borger C, Clemens MK, Truffer C. U.S. health spending projections for 2004-2014. Health Affairs 2005:hlthaff.w5.74.

U.S. National Health Expenditures (1998-2020)

Historical Data

How?Why?

Where?

Who?

What?

$ in

Bill

ions

Stewardship Teams

Exploring Simulated Scenarios

in Strategy Labs

REDIRECTING HEALTH FUTURES

23

COMMON PITFALLS• Unsustainable program financing

• Spreading resources over too many initiatives

• Lopsided investments downstream or upstream

• Triggering “supply push” responses to declining utilization

• Exacerbating capacity bottlenecks

• Perpetuating inequity

• Neglecting or focusing only on disadvantaged, children, or seniors

• Pursuing narrow goals and short-term impacts

• Concentrating only on small sub-systems

25

• Hard to see the bigger system and where things/we fit• Stakeholders see different problems and solutions • Stakeholders speak different languages• Don’t recognize that not all solutions are equal – good / bad• Real conversations about money, priorities, strategy, etc. are difficult• Alignment from the community to policy levels is challenging • Pressure for short term results with limited evidence for better planning• System is complex and hard to predict

WHY WE GET CAUGHT….

26

Consider Many

Pathways

Engage in Deeper Dialogue

Anticipate Consequences and Plausible

Futures

UNSTICKING…

RETHINK HEALTH DYNAMICS MODEL

27

• Realistic yet simplified portrait of a local health system (N=8 to date)• Anchored to evidence from dozens of datasets• A common, testable framework and tool for open, experiential learning• Designed with and for diverse stakeholders• Not a prediction, but a way to see and feel how local health system can

change

ReThink Health. Summary of the ReThink Health Dynamics model. Available at http://rippelfoundation.org/docs/RTH-Dynamics-Model-Summary.pdf

http://rippelfoundation.org/docs/RTH-Dynamics-Model-Summary.pdf

http://rippelfoundation.org/docs/RTH-Dynamics-Model-Summary.pdf

Other Trends• Insurance eligibility• Economic conditions• Health care inflation• Primary care slots

Aging

Population tracked separately in 10 segments by age, insurance, and income

Selected Geographic Focus

OVERVIEW

28

Risk Health Care Cost

Capacity

InitiativesCapturedSavings

PaymentScheme

InnovationFunds

Productivity & Equity

SYSTEM CONNECTIONS

Health Status(physical, mental)

Routine Physician& Self-Care

Cost of RoutineCare

AcuteEpisodes

Health Care Costs

Cost per AcuteEpisode

(Ability to work &support family)

PovertyRisky

Behaviors

EnvironmentalHazards

Adequacy ofPrimary Care

Capacity

InsuranceCoverage

Medical Home

Coordinate CarePost-Discharge Care

(to reducereadmission)

Redesign Practicesfor Efficiency

RecruitGeneral PCPs

Recruit FQHCPCPs

Improve ProviderCompliance with Routine

Care Guidelines

Support PatientAdherence

Control MentalIllness

ReduceEnvironmental

Hazards

HealthierBehaviors

Pathways toAdvantage

Insurance expansiondue to federal

mandate

More Use ofHospice

Funds Availablefor Initiatives

Capture Cost Savings(as negotiated with

payers)

Innovation Fund forEarly Investments

Crime

Reduce Crime

Use of ER forminor episodes

Use of Specialistsfor Routine Care

<Poverty>'Supply-Push'Responses to

Reduced Income

Share capturedsavings with

providers

<Health Status(physical, mental)>

Improve HospitalEfficiencyPrevent

Hospital-AcquiredInfections

Specialist &Hospital Net

Income

Mortality

<Adequacy ofPrimary Care

Capacity>

MalpracticeReform

Per-capita (vs.fee-for-service)

payment scheme

Provider Supportfor Initiatives

INITIATIVE OPTIONS

30

EXPLORE THE LIKELY CONSEQUENCES…

SEE DIRECTION, TIMING, MAGNITUDE

32

EXPLORE LIKELY CONSEQUENCES OF DECISIONS…

What happened?Why?What can we do?Funds Available

for Investment

Spending onPrograms

ProgramInvestments

InitialInnovation Fund

Savings

OB

FundDepletion

Health CareCostsO

O

R

Capture &ReinvestSavings

HELPS LEADERS AND COALITIONS ANSWER…Are we doing the right things now?What should commit to do?Do we have the right partners engaged?How do we pay for it?How proud would we be to succeed?What is our plan going forward?

34

www.ReThinkHealth.org

http://www.rethinkhealth.org/


Philanthropy can invest in aligning a community around strategies to

improve health

ARCHI


Philanthropy• Convener• Neutral voice• Demonstrate patience and perseverance• Exhibit and encourage collaboration for

collective impact• Invest• Work behind scenes


Kaiser Permanente• Funded research that identified need/opportunity• Key influencer behind the scenes• Shared value of collective impact• Continuous engagement• Patient capital investment• Aligned CHNA requirement/grant making to

support ARCHI


Philanthropic Collaborative Healthy Georgia

• 20 foundations sought to improve primary care through collaboration, data sharing and joint planning

• Grady Health System & Four Federally Qualified Health Centers (FQHCs)

• Collaborations on Patient Navigator Program, Accountable Care Organization application & Mobile Phone App

• Aligned with ARCHI – Care Coordination

• Grady allows staff privileges for FQHC physicians


United Way of Metro Atlanta

• Aligned major $3.5 M Grant “Forget the Box”• Grantees must

Demonstrate at least two ARCHI priorities Collaborate Participate in Rethink Health learning agenda

• Selected grantee may become ARCHI pilot


Discussion:

Share opportunities for investment in your

community

www.archicollaborative.org

ARCHI

Thank You!

What top five i nterventions would you support to achieve the triple aim of better care, better...

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