Pathways to Population Health: An Overview

Transcription

1 1 Pathways to Population Health: An Overview Somava Stout, MD MS Vice President, Institute for Healthcare Improvement Special Interest Breakfast December 12 th 2018

2 Agenda 2 Introduction to Pathways to Population Health Case Studies: P2PH Framework In Action Network for Regional Healthcare Improvement Table Discussions Taking Action

3 3 Introduction to Pathways to Population Health Somava Stout MD MS Vice President, IHI Jay Bhatt SVP and Chief Medical Officer, AHA

4 100 Million Healthier Lives Learn more at: Identity: An unprecedented collaboration of change agents pursuing an unprecedented result: 100 million people living healthier lives by 2020 Vision: to fundamentally transform the way we think and act to improve health, wellbeing, and equity. Equity is the price of admission. Convened by the Institute for Healthcare Improvement as a partnership across organizations.

5 A growing movement: >1850 members in 30+ countries worldwide reaching >500 million people come join us!

6 Core strategies + equity 1. Create healthy, equitable communities People 2. Build bridges across sectors Places Health, wellbeing and equity Systems (society) 3. Create a health care system that is good at health AND good at care 4. Promote peer-to-peer approaches 5. Create enabling conditions 6. Develop new mindsets

7 Challenges on the Journey to the Triple Aim 20% by :1 7

8 A tale of two boys 8

9 Health and Social Inequity are Interconnected and Related to Place 9

10 Chronic place-based inequities are due to legacies of structural racism Countering the Production of Health Inequities Report from the Prevention Institute 10

11 How It Started 100 Million Healthier Lives (100MLives) Health Systems Transformation Hub: Formed to coordinate and align efforts across organizations that support health systems in transformation efforts who agree to align messaging and move the field forward together. Pathways to Population Health grew from this effort. #Pathways2PopHealth

12 Pathways to Population Health (P2PH) Five Partner Organizations 1. American Hospital Association/Health Research and Educational Trust 2. Institute for Healthcare Improvement 3. Network for Regional Healthcare Improvement 4. Public Health Institute 5. Stakeholder Health Have Come Together To Create and align messaging about what the journey to population health entails for health care organizations Build a pathway of support for health care organizations that: Helps them identify where they are and where to go next Puts tools and resources from the field together in one place Engage health care organizations on the journey to population health ~30 pioneer sponsors! P2PH@ihi.org #Pathways2PopHealth

13 Pathways to Population Health Framework 2. Compass 3. Oasis of resources 4. A support system to go on the journey

14 Six Foundational Concepts of Population Health Improvement

15 What can health systems do? Population Health 4 Interconnected Portfolios of Work Population Health Improving the health and wellbeing of people Patients and Employees Communities Improving the health and wellbeing of places Improving the systems of society

16 Portfolio 1: Physical and/or Mental Health Health care organizations are improving the physical and/or mental health of people they directly reach (patients or employees) Activities for this domain may include: Partnering with patients and families Advanced primary care: Patient empanelment, care management, proactive population management Focus on access, evidence-based practice and risk stratification; Mental health integration Engaging in performance improvement Data utilization Improvement #Pathways2PopHealth

17 Portfolio 2: Social and/or Spiritual Well-being Health care organizations consistently screen for and address the social and spiritual drivers of health and wellbeing with the people they directly reach together with community based organizations. #Pathways2PopHealth Activities for this domain may include: Screening and addressing the social determinants and spiritual drivers of health and well-being in partnership with social sector agencies and faith communities Tracking e-referrals to community based organizations with loop closure Integration of social and physical health data to proactively predict who might be at risk for poor outcomes

18 Portfolio 3: Community Health and Well-being Health care organizations work together with community partners to improve specific health and well-being outcomes for a place-based population. P2PH@ihi.org #Pathways2PopHealth Activities for this domain may include: Collaboratively performing a community health needs assessment CHNA s Setting goals and identify a collection of improvement projects together with community partners. Working together with community partners to achieve improvement. Co-investing in infrastructure that facilitates collaboration and the sharing of data, improvement methods, learning, and resources

19 Portfolio 4: Community of Solutions Health care organizations actively engage in addressing systemic, place-based inequity using all their levers and in full partnership with the communities that are most affected #Pathways2PopHealth Activities for this domain may include: Leveraging nontraditional anchor roles such as a purchaser, employer, investor, and an environmental steward to disrupt the underlying drivers of placebased inequity. Growing the leadership of people with lived experience of inequity. Addressing policy and system changes to promote long-term health, well-being, and equity

20 Equity Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J. Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; (Available at ihi.org) P2PH@ihi.org #Pathways2PopHealth 1. Make equity a strategic, missioncritical priority 2. Develop structures and processes to support equity 3. Address the multiple determinants of health 4. Eliminate structural racism and oppression by changing the way you do business inside and outside your walls 5. Partner with the community and those with lived experience of inequity as leaders

21 What can you do by next Tuesday? Visit to take action! Learn Act Improve Download the Framework Use the Compass to create an action plan with key stakeholders Use the Oasis to support your journey to population health and share your progress. #Pathways2PopHealth

22 Breakout Discussion Join our group discussion on P2PH s work in your organization OR share your story/bright spot OR learn more about 100MLives work!

23 Discussion 1. Share your name, organization, and: How have you used the P2PH tools in your work so far OR What are your initial reactions to the tools and framework? 2. What advice do you have for people who haven t started this journey? 3. What are some questions you have for individuals who have already begun this work?

24 We would love to feature your work on IHI s Blog and in the 100MLives Change Library! 26 We incorporated the P2PH framework into our care management assessment process over this past year, and it was really helpful! More broadly, aspects of the four portfolios are woven into our combined population health and community investment work in our Integrated Strategic and Financial Plan/Health for a Better World roadmaps for the next 5 years. We are actively developing/building community relationships with other partners aimed at improving specific outcomes related to social determinants of health, with particular focus on housing, food insecurity and social isolation. We are looking at which efforts on which we should function as leaders, which as participants and which as supporters.

25 Next Steps

26 Actions to take to get started: Give us your feedback through the pulse check survey handout Read the Framework and take the Compass to catalogue your current activities and create an action plan at Sign up for the newsletter on the Join tab to learn about P2PH events and engagement opportunities Register for the P2PH Virtual Expedition starting April 2019 more information will be available at

27 Join the Movement 29 Population Health Activator (individual) Pioneer Sponsor (organization)

28 Population Health Activators 30 If you are an individual, consider joining fellow health care change agents from across the country in committing to the P2PH movement as a Population Health Activator (PHA). Population Health Activators will be the first to know about Pathways to Population Health virtual and in-person opportunities to share with and learn from one another, and accelerate their progress. As a Population Health Activator, you will commit to: Downloading the Pathways to Population Health Framework; Utilizing the Compass to assess your organization s balance of activities across portfolios, and submitting your assessment score; Developing an Action Plan; Assessing your progress over time by using the Compass quarterly and updating your Action Plan accordingly; and Celebrating and sharing your progress with others in the P2PH movement. Sign up here. All materials are available online at: pathways2pophealth.org

29 What is a pioneer sponsor? Champion the movement by using and sharing P2PH tools and resources Support health care organizations within your network on their journey Share progress and learnings with us and one another We invite Pioneer Sponsors to: Champion the movement by sharing P2PH tools and resources within their organizations and networks

30 What is a pioneer sponsor? Champion the movement by using and sharing P2PH tools and resources Support health care organizations within your network on their journey Share progress and learnings with us and one another We invite Pioneer Sponsors to: Engage your Health Care Organization (HCO) or Support a group of HCOs on the Population Health Journey in Learning to use the P2PH tools, framework and methodology Taking the Compass to assess current portfolio of work Developing an action plan Utilizing tools and resources to support progress Assessing progress quarterly and celebrate

31 What is a pioneer sponsor? Champion the movement by using and sharing P2PH tools and resources Support health care organizations within your network on their journey Share progress and learnings with us and one another We invite Pioneer Sponsors to: Share progress with us: We will ask that you help support the P2PH measurement collection quarterly by distributing a survey to your cohorts as well as sharing any other evidence of progress that you are able to.

32 Our Current Pioneer Sponsors 34 Health Care Organizations (HCOs) Organizations that Support HCOs Current Pioneer Sponsors San Diego/Imperial Henry Ford Health System The University of Vermont Medical Center Association of State and Territorial Health Officials (ASTHO) Novant Health Prevention Institute The University of Arkansas for Medical Sciences Providence St Joseph Health Healthcare Collaborative of Greater Columbus Trinity Health Of New England Southern Illinois University School of Medicine Office of Population Science and Policy New Jersey Health Care Quality Institute Charter Oak Communities Gold Coast Health Plan Way to WellVille Health Care Improvement Foundation American College of Preventive Medicine Public Health Foundation Roberts Health Solutions Loma Linda University Institute for Health Policy and Leadership Michigan Health Improvement Alliance (MiHIA) Louisiana Public Health Institute Creo Wellness National Center for Complex Health and Social Needs Governance Institute American Association of Diabetes Educators National Association of County and City Health Officials (NACCHO) Indiana Rural Health Association Greater Detroit Area Health Council

33 Thank You! Good luck on the journey to improved population health. We look forward to working alongside you! If you have any questions please reach out to us at #Pathways2PopHealth