In the final discussion, roundtable members and attendees reflected broadly on how to successfully spread and scale to achieve meaningful population health outcomes.1 Moderator Jacqueline Martinez Garcel of the New York State Health Foundation prompted participants to consider what they had learned from the discussions; what questions were raised for them by the discussions; and what, if anything, was missing from the discussions.
Martinez Garcel opened the discussion with a summary of what she heard as common themes throughout the day.
- Collaboration. A basic ingredient of spread and scale is collaboration, she said. This includes finding a common language and sharing joint responsibility and ownership for the issue and the solutions.
- Community engagement. Collaboration requires identifying common beliefs and value systems and building from them. Creating programs and then imposing them on people is a failure in public health, Martinez Garcel said. It is good to translate
1 Use of the terms “spread” and “scale” should be understood in the context of the comments offered by each speaker.
research into practice, she said, but the research needs to take into account what the community wants and needs. To grow to scale, build programs based on the beliefs, values, wants, and needs of community, she said.
- Data. Data that are local and relevant are essential to defining targets, planning, and going to scale. Understand the needs of the community, and scale to meet that need.
- Infrastructure and resources. Infrastructure and resources are needed to support the collaboration, community engagement, and data collection and use.
- Leadership and vision. Leadership and vision are what bring everything together. Leadership is not necessarily one leader, but more likely champions from all different sectors, from politicians to people from the community, Martinez Garcel said. Leaders need to be allowed the flexibility to lead, she added, and leaders cannot be expected to take something to scale that they do not believe in.
The following additional topics were then highlighted by roundtable members and participants as important takeaway messages from the presentations they heard.
Many participants mentioned getting started and then learning by doing as being an effective approach. Concerning how to get started in a large, complex system, M. Rashad Massoud of the U.S. Agency for International Development Applying Science to Strengthen and Improve Systems Project provided an analogy from maternal mortality reduction (a target of the Millennium Development Goals). Trying to deal with maternal mortality can be overwhelming for a country. The primary causes of maternal mortality are known (e.g., postpartum hemorrhage, preeclampsia, sepsis). There are interventions that work for each of these conditions individually, and it is possible to approach the larger issue by starting with these. Another aspect of maternal mortality is the “three delays”: delay in recognizing the need for care, delay in getting to a care facility, and delay in treatment at the facility. An effective approach is to start by setting aims and very specific actions for each area. Once good progress has been made in these areas, one can go onto more difficult issues, such as complications during delivery. It is very difficult to take on all things at once, Massoud said. Start with the easiest, and build up in terms of complexity.
Pamela Russo of the Robert Wood Johnson Foundation expressed concern about taking a “winnable battles” approach that focuses on a sub-
set of concrete outcomes because of the complexity of population health improvement. The focus should be on the best way to make the change for the outcome to be improved, she said. She referred the workshop participants to an article by Kania and colleagues on an emergent strategy for philanthropy to address complex problems (Kania et al., 2014).
A participant observed that many communities have already started working on population health in one form or another. They are at different stages of activation. Part of the challenge is to determine how to take them from where they are at the beginning of a movement to the next level of scale.
Debbie Chang of Nemours suggested that there is a need to build a shared sense of urgency. This might come from an explicit, time-bound aim, but people have to agree on that time-bound aim. Another participant noted that urgency often stems from an emotional connection to an issue. Jean McGuire from Northeastern University also reiterated the need to take into account the goals and objectives that matter to people.
Mary Pittman of the Public Health Institute noted that she was encouraged that the discussion is finally moving from defining the problem to developing concrete steps for taking action.
Planning for Scale
Neal Kaufman of the University of California, Los Angeles, suggested thinking about scale in a business context, in the sense that something that cannot be sustained should not be built. Scale should be considered at the research level when creating the effective evidence-based programs. The Diabetes Prevention Program, for example, was highly effective but unaffordable and unscalable because of personnel costs and other issues. If the original researchers had considered reaching 50 million people instead of 3,000, they might have done things very differently at the beginning. A second element is working with the agents of sustainability (individuals, communities, foundations, governments, and others) to maintain those relationships and ensure that they receive value. In some cases, these agents are interested in outcomes such as health care improvement and cost savings, but there are many other reasons (customer loyalty, member retention, public relations) to participate.
Based on his experience with foundations, nonprofit organizations, health departments, and governments, Paul Jellinek of Isaacs/Jellinek said that one of the biggest challenges is that people do not recognize the importance of getting to scale in population health. How can people be helped to understand the importance of getting to scale in the first place? David Kindig of the University of Wisconsin suggested that another barrier is the public perception that medical care equals health. Sally Herndon
of the North Carolina Division of Public Health Tobacco Prevention and Control Branch reiterated the importance of resources, both human and financial.
In scaling up population health there are three interacting levels to be considered, Massoud said: the individual adoption level, the care delivery level (e.g., facility or community), and the policy level. Chang said that payers will be key accelerators of spread and that they need to be brought to the table.
In reference to the discussion of people not in true need taking advantage of programs (e.g., free housing for homeless people), Lourdes Rodriguez with the New York State Health Foundation said that the fear of being taken advantage of should not stop people from taking action or scaling. At the population level, the number of people who may take unfair advantage of a program will be very small relative to the number of people who have a true need and will benefit.
Six Drivers of Population Health Improvement
Kindig reminded the workshop participants that part of the roundtable’s mission is to “catalyze urgently needed action.” He repeated the six drivers that shape population health improvement and that the roundtable hopes to influence—metrics, resources, policy, research, relationships, and communication—and he observed that, based on the discussions, there is much work to do on catalyzing action.
George Isham of HealthPartners said there is a need for multi-faceted metrics in spread and scale.2 For example, what kind of infrastructure and daily metrics are needed to monitor the effects of efforts at a community level? What kind of robust system of measurement is needed to meet the purposes of government or private payers? Isham raised a concern about the use of resources (e.g., finances) to oppose change, as illustrated in some of the tobacco case examples discussed. How does economic power affect overall strategy? Addressing the subject of relationships, Isham noted that the experts on the panels are assets and resources who are part of the relationship circle. Isham said that the discussions raised questions for him about how siloed or fragmented the body of research may be and about how to bring it together for population health improvement and scale. He said that he was inspired by some of the examples of overcoming state-level policy barriers and by what has been achieved in spite of policy barriers. Finally, with regard to communication, Isham emphasized the power of consumerism in health care delivery and the
2 The roundtable held a workshop, “Metrics That Matter for Population Health Action,” on July 30, 2015.
need to pay much more attention to communication in connection with population health and addressing the social determinants of health.
Avoiding Opposition to Scale
Participants discussed further the idea of resistance to the scale up of population health improvement. Isham stressed the need for a strategy to improve population health in all states, not just some states, and to have all of industry support the change, not just some of it. Population health should be bipartisan, he continued, not liberal versus conservative, and it should engage all cultures and races. There are lessons to be learned from movements such as tobacco control about the challenges of facing a strong opposition to social change. The next iteration of large social policy and strategy must learn from these lessons.
Jeannette Noltenius of the National Latino Tobacco Control Network pointed out that there is a cost associated with not scaling up when there is the possibility to do so. When people work with a community and the community becomes excited about an initiative and that initiative is not scaled, it discourages the community, and it becomes a barrier for future scale up possibilities.