Demystefying Population Health Social Determinants of Health – Why Healthy is More Than Good Healthcare

@derekfeeleyihi

A little bit about me…

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5 million people $20 billion budget High quality health care Integrated delivery (including social care ) • Health inequalities • Social inequality

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Gail, insert updated IHI Strategy on a page

The Growth and Evolution toward Population Health

• Expanded set of activities related to the medical care system

Population Health

• Still a focused population defined by clinical condition

Population Medicine

• Less direct control and centralized accountability

• Can have direct ROI to the hospital or practice

Key Points of Discussion • Full set of activities aimed at improving health outcomes for a large population • Requires active consideration of nonclinical determinants of health

Clinical Care Delivery/

Medicine

• Partnership and shared accountability are important • Complex ROI calculation

• Population Medicine or Population Health is not a singular choice – they sit on a continuum and you will have a mix in your portfolio at the same time

• The shift toward Population Health is more of an evolution than a revolution

• Example: Infant Mortality

• Example: CCO

• Specific activities of the medical care system • Focused on clinical care for the individual patient most often to resolve illness • Most direct control and centralized accountability • Most direct ROI to the hospital or practice • Example: Urgent Care visit

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Recognizing the Social Determinants of Health

Improving Health A 25 year old with Bachelors degree will live 9 years longer than a peer who doesn’t get their high school diploma.

We all have a part to play in creating health

It is all connected

And it’s complicated…… “Too bad all the people who know how to run the country are busy driving cabs and cutting hair.” - George Burns

Updated for 2015:

“It's too bad that everyone who has a solution for everything is at home commenting on the internet.” - Twitter user Rasta Pasta (@rastahipsta)

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5 keys to population health 1. Deeply understand your population 2. Assets not Deficits 3. Collaborate for the Early Years 4. Radical redesign of health care 5. Shared Leadership

1. Deeply understand your population

Life expectancy trends Life expectancy: Scotland & other Western European Countries, 1851-2005 Source: Human Mortality Database 90.0

80.0

70.0

60.0

50.0

Portugal

Scotland

40.0

30.0

20.0

3 7 1 5 9 3 7 1 5 9 3 7 1 5 9 3 7 1 5 9 3 7 1 5 9 3 7 1 5 9 3 7 1 5 9 3 7 1 5 85 85 86 86 86 87 87 88 88 88 89 89 90 90 90 91 91 92 92 92 93 93 94 94 94 95 95 96 96 96 97 97 98 98 98 99 99 00 00 -1 5-1 9-1 3-1 7-1 1-1 5-1 9-1 3-1 7-1 1-1 5-1 9-1 3-1 7-1 1-1 5-1 9-1 3-1 7-1 1-1 5-1 9-1 3-1 7-1 1-1 5-1 9-1 3-1 7-1 1-1 5-1 9-1 3-1 7-1 1-1 5-1 9-2 3-2 1 5 5 5 6 6 7 7 7 8 8 9 9 9 0 0 1 1 1 2 2 3 3 3 4 4 5 5 5 6 6 7 7 7 8 8 9 9 9 0 18 18 18 18 18 18 18 18 18 18 18 18 18 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20

Relative inequalities in mortality by cause Men, Scotland 2000-02 Slope index of inequality divided by mean rate

2.0 All other causes

Disorders due to use of alcohol

1.5 Assault

Accidents 1.0

Disorders due to use of drugs

Chronic lower respiratory diseases Chronic liver disease

Cerebrovascular disease

All neoplasms 0.5

Suicide

Ischaemic Heart Disease 0.0 0-

5-

10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+ Age

Contra Costa County: Barriers to Health Food (62%) Housing (58%) Jobs (56%) Help with utility bills (51%) Emergency Medical Care (47%)

SMOKADIABESITY

Risk Factors- mortality

Blair et al BJSM 2009

Risk reduction associated with physical activity Chronic condition All cause mortality CVD, stroke Diabetes Hip fractures Colon cancer Breast cancer Loss of function Depression/dementia

Risk reduction 30% risk reduction 20-35% reduction 30-40% reduction 36-68% reduction 30% reduction 20% reduction 30% reduction 20-30% reduction

Another way to look at it……..

2. Assets not Deficits

Assets “What changes communities are their strengths. No community was ever changed by its needs” America Bracho – Latino Health Access, 2015

Deficit Model

Assets Model

Based on salutogenesis Based on pathogenesis Focuses on problems and needs

Focuses on existing strengths Defines communities and

Tends to define communities and

individuals in terms of the

individuals in terms of what they

resources they have to stay

can’t do, do wrong or don’t have

Encourages dependency Potential to disempower people who are intended beneficiaries

healthy Encourages people to take control of their own health Promotes self esteem and ability to cope

Health Assets: The resources that individuals and communities have at their disposal, which protect against negative health outcomes and promote good health

Individual Community Organisational

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Brighter Futures Together

Asset Based Community Development Shorthand: ABCD Developed by John McKnight and John Kretzman Built on the notion that communities are built on the capacities and assets of the people and the place (not their deficiencies) A rallying point for collective action It does not imply ignoring problems and needs or throwing out rational, strategic planning

Key Elements of ABCD Approach Focus on the capacities or gifts that are present in the community, not what is absent Stress local leadership, investment, and control in both the planning process and the outcome Surface formal, institutional assets (such as programs, facilities, and financial capital) and individual, informal strengths and resources Seek to link the strengths and priorities of all partners, including the people

3. Collaborate for the Early Years

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Power of Prevention “It is easier to build strong children than to repair broken men.”

Frederick Douglass

Making Scotland the Best Place to Grow Up

Reduce Stillbirths and Infant Mortality A reduction of 15% in the rates of stillbirths and infant mortality by 2015

85% of all children have all the developmental skills and abilities expected of a 2730 month old by the end of 2016

EYC stretch aims – making Scotland the best place in the world to grow up!

90% of all children have all the developmental skills and abilities expected at the start of primary school by the end of 2017

90% of all children in each Community Planning Partnership area will have reached all of the expected developmental milestones and learning outcomes by the end of Primary 4, by end2021

Our change theory • A clear and stretch goal • A method • Predictive, iterative testing

• Portfolio of Projects • A learning system

Learning Sessions

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Lochrin Nursery Children receiving a bedtime story 120 Parents survey

Percentage of children

100 Goal Median .

80 60

Books available at collection time.

Grassmarket changes

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introduced.

weekly average displayed for parents

Research information handed to parents.

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P' Chart for Quarterly Stillbirths in Scotland, 2004 - 2014 9.0

8.0

7.0

Rate per 1,000 births

6.0

5.0

UCL

4.0

Average

Rate

3.0

LCL 2.0

1.0

0.0

Quarter

4. Radical redesign of health care

Year 2 Members42 Year 2 Alliance Members • Bellin Health • Canadian Foundation for Healthcare Improvement • CareSouth Carolina • Charleston Area Medical Center • Cincinnati Children’s Hospital Medical Center • Consulate Health Care • Contra Costa Health Services • GBMC HealthCare System • Gundersen Health System • Health Quality Council of Alberta • HealthPartners • Henry Ford Health System • Illinois Hospital Association • Intermountain Healthcare

• • Kaiser Permanente • Kansas Healthcare • Collaborative • • Kittitas Valley Healthcare • • Memorial Hermann • MemorialCare Health System • • Missouri Hospital Association • • National Capital Region • Medical Directorate • • North Shore-LIJ Health • System • • Northern Physicians Organization • • Palmetto Health • • Parkview Health • Providence Health and Services • Qulturum, Region Jönköping

Roanoke Chowan Community Health Center Sanford Health Sentara Healthcare Sibley Memorial Hospital South Carolina Hospital Association Southcentral Foundation St. Joseph Health Texas Children’s Hospital The Dartmouth Institute Thomas Jefferson University Hospital Women's College Hospital WVU Healthcare

Change the Balance of Power – Co-produce health and wellbeing in partnership with patients,

families, and communities

Standardize What Makes Sense – Standardize what is possible to reduce unnecessary variation

and increase the time available for individualized care

Customize to the Individual – Contextualize care to an individual’s needs, values, and

preferences, guided by an understanding of “what matters” to the person in addition to “what’s the matter”

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Promote Wellbeing – Focus on outcomes that matter the most to people, appreciating

that their health and happiness may not require health care

Create Joy in Work – Cultivate and mobilize the pride and joy of the health care

workforce

Make it Easy – Continually reduce waste and all non-value-added requirements

and activities for patients, families, and clinicians

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Move Knowledge, Not People – Exploit all helpful capacities of modern digital care and continually

substitute better alternatives for visits and institutional stays. Meet people where they are, literally.

Collaborate/Cooperate – Recognize that the health care system is embedded in a network

that extends beyond traditional walls. Eliminate siloes and tear down self-protective institutional or professional boundaries that impede flow and responsiveness.

Assume Abundance – Use all the assets that can help to optimize the social, economic,

and physical environment, especially those brought by patients, families, and communities

Return the Money – Return the money from health care savings to other public and

private purposes

5. Shared Leadership

Boss vs Leader

Some keys for the new mental models Shared leadership Embracing complexity Shaping culture Curiosity

A spectrum of shared leadership

Doing More with More: Putting Shared Leadership into Practice Written by Michael Allison, Susan Misra, and Elissa Perry

Accepting complexity – Doug Eby, SCF

Culture eats strategy for breakfast

“The only thing of real importance that leaders do is to create and manage culture.”

- Edgar Schein

Curiosity, of course “I have no special talents. I am only passionately curious.” Albert Einstein

High CQ = Ambiguity + Acquisition

Some Leadership Fundamentals (n=1) Comfortable with complexity and generous with power Heroism is out – humility is in Leaders need to figure out how to partner – co-design and co-produce Leaders need to get the whole team connected to the purpose and to the mission

5 keys to population health 1. Deeply understand your population 2. Assets not Deficits 3. Collaborate for the Early Years 4. Radical redesign of health care 5. Shared Leadership

100 MILLION HEALTHIER LIVES Vision: Fundamentally transform the way the world thinks and acts to improve health and well-being

Identity: An unprecedented collaboration of change agents pursuing an unprecedented result: 100 million people living healthier lives by 2020 Supports: A culture of health and wellbeing

Unprecedented collaboration Innovative improvement System transformation

100 Million People Living Healthier Lives by 2020

JUST START