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Health Care Opportunities

Three of the presentations at the workshop addressed opportunities that health care providers and systems have to reduce disparities and build healthy communities. Opportunities occur within large integrated health care systems, within companies, or during the training of providers. Together, these kinds of opportunities can reinforce each other and have a greater effect than any would alone.

TRINITY HEALTH

Central to the mission of Trinity Health, which is one of the largest health care systems in the country, is the concept of transforming communities, said Bechara Choucair, senior vice president for safety net and community health at the organization and a former Chicago health commissioner. “When you look at our core values in the organization, it’s about reverence; it’s about commitment for those who are poor; it’s about justice, stewardship, and integrity,” Choucair said, adding “It’s really all about transforming communities and being transforming agents within the communities that we serve.”

Based in Michigan, Trinity Health has a presence in 21 states, including Illinois. It has a network of 88 hospitals and is active in continuing care, with 51 home care and hospice locations. It operates 14 PACE (Program of All-inclusive Care for the Elderly) center locations and 61 senior living facilities. It employs 3,900 physicians and has 23,900 affiliated physicians. According to Choucair, 1.7 percent of all the babies born in America are delivered at Trinity Health facilities.

In recent years, Trinity Health has been increasing its population health management infrastructure, Choucair noted. As such, it has three affiliated health insurance plans across the country and 18 accountable care organizations in almost every one of its ministries. The system is responsible for the total cost of health care for about 1.8 million people through 61 risk- or value-based reimbursement programs.

About a year and a half before the workshop, the board of the system adopted a people-centered health system strategy that emphasizes episodic health care management for individuals, population health management, and community health and well-being. “My role within the system is taking the community health and well-being space and seeing how it interfaces with population health management and episodic health care so we can continue to be a transforming agent within our communities,” said Choucair.

Creating community health and well-being requires three things, he continued. The first is efficient and effective care delivery through Trinity’s safety net system. The second is efficient and effective wraparound services focused on the vulnerable and the poor. The third is community building focused on the built environment, economic revitalization, housing, and other social determinants of health. “We are an entity that’s not just treating illness. We’re also creating health within the communities that we’re in,” he said. That requires devoting attention to transportation, workforce development, and other aspects of community development. Achieving these goals, in turn, requires innovation in care delivery, technology, and financing to meet the triple aim of better health, better care, and lower costs, Choucair stated.

As an example of transforming safety net care, Choucair focused on the more than 10 million people in the United States who are eligible for both Medicaid and Medicare—the so-called dual-eligibles. These are seniors or people with disabilities who are living in poverty. This group constitutes one of the sickest and most vulnerable populations in communities, with most having multiple conditions and nearly half having significant mental illness. Almost all of these patients need social support services to optimize their care. “As part of our commitment to serving those who are poor, this is a population where we really need to be able to make a difference,” he explained.

Choucair explained that the nation spends almost 2 percent of its gross domestic product delivering health care services for the dual-eligible patient population—the equivalent of $30,000 per person per year, and $100,000 per person per year for the many patients who have end-stage renal disease. Furthermore, minorities are overrepresented in this population, he said, with the percentage of minorities among dual-eligibles three times larger than for the population that is not dual-eligible. This population has high

levels of utilization for hospitals, outpatient settings, home care, skilled nursing facilities, and other settings, he added.

The Centers for Medicare & Medicaid Services has launched multiple efforts, including 13 demonstration projects across the country, to blend Medicare and Medicaid and partner with health plans to optimize care for this population. For its part, Trinity Health has put together an interprofessional, multidisciplinary team to understand more about this population, how they interface with the system, and how their care can be optimized. In Boise, Idaho, Trinity Health has developed wraparound services to address the social determinants of health. In Muskegon, Michigan, Trinity Health is expanding its community health worker model with a specific focus on “frail elders.” In Camden, New Jersey, and Philadelphia, Trinity Health is launching a primary care model focused on dual-eligibles and high Medicaid users.

In the past, a harmonized data source for dual-eligibles has not been available. More recently, sophisticated analytics and ad hoc reporting are leading to better analyses, ease of use, and a deeper understanding of this population, Choucair said, adding that “To make a difference in this population, we need to be able to segregate the data and understand the population so we can target interventions in a culturally confident way.”

Turning to Trinity Health’s work on community engagement, Choucair noted that the quality of care drives only about 10 percent of health outcomes. An estimated 40 percent comes from social and economic factors, 30 percent from health behaviors, and 10 percent from the physical environment. To address these other factors, Trinity Health has developed integrated delivery networks and other models that bring together a variety of services. For example, in Muskegon, community health workers are placed within social service agencies. A coordinator gets phone calls and referrals not only from the hospital system and doctors’ offices but from the police departments, the fire department, and other agencies. “We’re seeing a lot of success stories,” said Choucair.

Finally, Choucair talked about community transformation, which arises in part from focusing on policy systems and environmental changes. “This is kind of new for health systems,” he said. “I lived and breathed this in my role in the health department, but to get a major health system like ours to say, ‘We need to partner with organizations and the community around this work’ is really important.” For example, Trinity Health has targeted smoking and obesity as the biggest threats to healthy communities. The system has been vocal on raising the minimum age for buying tobacco products from 18 to 21 in the communities where it has presence, especially given the recent findings that doing so would lead to a 10 percent reduction in smoking-related deaths, a 12 percent decline in premature births, and a 16 percent drop in cases of sudden infant death syndrome. In the area of

obesity, it has strengthened its hospitals’ breastfeeding policies, established standards for day care centers and Head Start programs, and has advocated for healthy food and physical activity policies in schools.

Community transformation is part of a broader effort to establish a health equity road map to raise awareness about the issue within the system and more broadly, with the goal of developing equitable care throughout the system. “How do we hire people? How do we recruit people to our board? How do we procure services? We’re developing a 5-year road map for that,” Choucair said. To that end, Trinity Health has contributed to an $80 million, 5-year investment in community health interventions with an emphasis on community engagement and transformation. Already Trinity Health has been engaged in housing development in nearby communities, job training for health care services, and other forms of community integration. In many such areas, “We just have to be sitting at the table with the community partners,” he said, adding “They’re already doing a lot of this work.” In addition, the system’s hospitals conduct community health needs assessments on a regular basis. These assessments have contributed, for example, to the focus on tobacco and obesity. “Every one of our hospitals will be working with community partners on addressing the social, policy, and environmental changes we’d like to see within those communities on tobacco and obesity,” he concluded.

MARRIOTT INTERNATIONAL

Marriott International is a global hospitality company with more than 4,000 hotels and 140,000 employees worldwide. The company’s core values, said Rebecca Spencer, director of benefits for Marriott International, Inc., are to put people first, pursue excellence, embrace change, act with integrity, and serve the world.

About 70,000 employees are enrolled in the company’s U.S.-based medical program (representing more than 80 percent of the benefits-eligible population), with about 140,000 people covered altogether. The company offers a national self-insured dual-option program consisting of a health maintenance organization and a preferred provider organization plan, with the Kaiser health plan offered as an option in eight markets. Employees come from many different cultural and language backgrounds and speak more than 100 languages. “We always are thinking about cultural relevance and appropriateness with everything we do related to health and wellness,” said Spencer.

The company’s TakeCare Wellbeing program is available to all employees regardless of whether they participate in a medical plan. As in other large companies, many of the employees suffer from chronic conditions, including high rates of heart disease, diabetes, and asthma. They need help with when and how to access the right care at the right time. The TakeCare

Wellbeing program has created a network of wellness champions, with at least one at each of the company’s 800-plus properties in the United States. These champions help employees learn about how to make healthy choices through health and fitness challenges, exercise tips, nutrition recommendations, healthy recipes, stress management, financial well-being, and more. Since the program began in 2010, it has rolled out eight national well-being challenges: Get Moving at Marriott, Choose Health Every Day, Gear Up for Gold, World Cup Challenge, Maintain Don’t Gain, Race the Globe, New Year New You, and Renew, Refresh, Recharge. For example, in one challenge, employees picked a healthy activity to do every day for 30 days, and if they completed 25 or more of the 30 healthy activities in 1 month, they were entered to a raffle to win prizes. “We had over 10,000 associates participate in this first challenge,” said Spencer. “Even now, 5 years later, I still hear feedback from employees telling me how they’ve stopped drinking soda because of this challenge—because they learned how much sugar is in soda—or they now take the stairs instead of the elevator. . . . The small changes really do add up and become healthy habits.”

The program has created a TakeCare Healthy Hotel Certification that awards and recognizes properties that have generated a healthy environment. Hotels are evaluated on the basis of property leadership, wellness champions, wellness challenges, healthy nutrition, physical activity, stress management and sleep, and health education, with properties meeting certain criteria certified at the silver, gold, or platinum level.

Spencer outlined what a healthy hotel looks like. It

• Has executive support and an active wellness champion;
• Participates in TakeCare challenges;
• Makes an effort to improve nutrition;
• Provides time and, in many cases, a fitness center for physical activity
• Offers information on stress management or a room dedicated to relaxation and meditation; and
• Reports associate success stories and overall excitement around wellness.

The program has had tremendous success, said Spencer, in helping employees change their behaviors and lead healthier lives. “Your environment shapes your behaviors, as well as the choices you make in health and wellness,” Spencer concluded. “We know there’s a lot of opportunity here.”

EQUITY AND THE ACCREDITATION OF MEDICAL EDUCATION

The Accreditation Council for Graduate Medical Education (ACGME) is a private, nonprofit organization that reviews and accredits graduate

medical education programs and the institutions that sponsor them. It oversees 9,600 programs in the United States and 121,600 residents and fellows, from beginning medical students to fellows in advanced training. The training they receive has a big effect on health equity, for better or worse, said Joanne Schwartzberg, scholar in residence at ACGME and clinical assistant professor of preventative medicine and community health at the University of Illinois in Chicago’s College of Medicine. The question then becomes, “What do we have in the educational programs that will sensitize them to these issues and help them provide better care?” she asked.

ACGME has recently developed a set of strategic priorities that has resulted in a new accreditation system. These priorities include

• Increase the accreditation emphasis on educational outcomes.
• Provide a structured approach to evaluating the competency of all residents and fellows.
• Foster innovation and improvement in the learning environment.
• Conduct clinical learning environment reviews (CLERs).

In the past, accreditation has been based largely on time spent on an activity, whether 3 hours of lectures or 4 weeks of rotations. The new priorities emphasize competencies, with the training institution having the freedom to figure out how to develop these competencies so long as they can be demonstrated for accreditation purposes. For example, the goals of the CLERs are to enhance the safety and quality of clinical care and remove health disparities, both in today’s teaching environment and in the future practice of graduates, and to continually assess and improve the environment in which the U.S. physician workforce is educated. Reviews are designed to provide onsite review and feedback on the learning environment, as well as opportunities for sponsoring institutions to demonstrate leadership in patient safety, quality improvement, and reduction in health care disparities. “You tell us what you think is going to work in your community and how you are organizing it,” Schwartzberg said. “We are not telling you how to do that.”

CLER pathways to excellence are designed as expectations, not requirements, she said. They promote discussions and actions that will optimize the clinical learning environment. Each pathway has a series of key properties that can be assessed for engagement of residents, fellows, or faculty members. “To change, the faculty are going to have to be educated as well as the residents and fellows,” she said. As an example, she cited a quality pathway involving resident/fellow and faculty member education on reducing health care disparities. This pathway requires formal educational activities that create a shared mental model with regard to quality-related goals, tools, and techniques that are necessary for health care professionals

to consistently work in a well-coordinated manner to achieve a true patient-centered approach. “How do you get everybody working together, and what’s necessary to make change?” she asked.

The properties of this pathway have three categories:

1. To identify and reduce health care disparities relevant to the patient populations served by the clinical site
2. To develop cultural competencies relevant to the patient population served by the clinical site
3. To know a clinical site’s priorities for addressing health care disparities

Another pathway involves resident/fellow engagement in clinical site initiatives to address health care disparities. Experiential learning is essential to developing the ability to identify and institute sustainable systems-based changes to address health care disparities, Schwartzberg observed. The properties for this pathway are that residents/fellows are engaged in quality improvement activities addressing health care disparities for the vulnerable populations served by the clinical site, and residents/fellows are engaged in defining priorities and strategies to address health care disparities specific to the site’s patient populations.

In 1998 the ACGME’s board of medical specialists agreed that the knowledge physicians needed to learn could be divided into six code competencies:

1. Medical knowledge
2. Patient care
3. Interpersonal and communication skills
4. Professionalism
5. Problem-based learning and improvement
6. System-based practice

While the first two are straightforward, the last four are more difficult to evaluate, Schwartzberg acknowledged. How can communications skills, professionalism, quality improvement, and self-reflection be measured? In response to such questions, ACGME has developed a set of milestones as a road map to competency. The milestones describe performance levels residents are expected to demonstrate for skills, knowledge, and behaviors in the six competency domains. The milestones lay out a framework of observable behaviors and other attributes associated with residents’ development as physicians. The milestones have five levels, with no prescribed speed at which residents must progress. Level 4 is the target for graduation, with the program director deciding when a resident is ready to graduate and

take on an independent practice. Level 5 recognizes lifetime progression. “You don’t end up just at level 4, even though you are out in practice and you are a good doctor. You can always improve,” Schwartzberg explained.

As an example, Schwartzberg cited several of the competency milestones in the field of urology. They include the following:

• Communicates effectively with patients and families with diverse socioeconomic and cultural backgrounds.
• Demonstrates sensitivity to differences in patients, including race, culture, gender, sexual orientation, socioeconomic status, literacy, and religious belief.

At level 1, students know the importance of the milestones, while at level 4 they exhibit them consistently and capably.

For family medicine, a level-1 milestone in the area of professionalism is “Recognizing impact of culture on health and health behaviors,” while a level-3 milestone is “Identifying health inequities and social determinants of health and their impact on individual and family health.” For physical medicine and rehabilitation, a level-2 milestone is “Utilizing effective verbal and nonverbal communication strategies (including active listening, augmentative communication devices, interpreters, etc.)” and a level-3 milestone is “Effectively educating and counseling patients and families, utilizing strategies to ensure understanding (e.g., ‘teach back’).” In particular, this last milestone was designed to address low levels of health literacy in the United States, where only about 13 percent of the population can read health care information and understand it, according to Schwartzberg, adding that “We have a big problem in communicating the knowledge that we know in health care to patients who need to have this to take care of themselves.”

Developing these milestones involved hundreds of volunteer physicians, and each specialty developed its own milestones through a long consensus process. Together, the new process reflects the ACGME’s commitment to improving health care and population health through reducing health disparities, Schwartzberg said.

In response to a question during the discussion session, Schwartzberg pointed out that medical students can be $200,000 in debt before they even start a residency program. Some students are opting instead for other positions, such as physical therapist or physician’s assistant, so they can work in health care without putting themselves in such a financial bind. “We need to look at the cost and what that has done to the health professions and health equity,” she said. “I don’t have an answer. I’m just saying it’s the gorilla in the room that we have to pay attention to.”

Responding to another question about students coming to the United

States to pursue medical degrees, she noted that when the ACGME implemented clinical skill exams in 2007, the number of international medical graduates dropped, perhaps because their English was not good enough to pass the exam. However, the numbers have increased since then. These students tend to be well prepared and motivated, she noted, and they tend to report less depression and overwork than U.S. students. “Some of the hospitals and others go out of their way to make it easier for the foreign grads to feel comfortable and give them a lot of support in the beginning; others don’t. It’s an individual thing,” she concluded.

DEFINING COMMUNITY

A crosscutting issue that arose in the discussion session was how to define community. Choucair pointed to the importance of letting Trinity Health’s partners define the communities with which they want to work. These communities occur at different levels. Trinity Health has developed wellness programs for its more than 120,000 employees. It also is looking at internal policies that can improve health for employees and patients, such as having farmers markets on campuses. “We’re going to be looking at those types of models to be able to replicate across the system,” Choucair said.

At Marriott International, as with Trinity Health, the employees decide how to define their communities. For example, some live close to the hotels where they work while others live some distance away, which influences their ideas of community. Marriott also designates a day in May specifically to serve the communities in which their hotels are located, with similar outreach occurring throughout the year.

In response to this question, Schwartzberg emphasized the different populations with whom residents interact. Residents take care of patients every day, and their education is reinforced by going on rounds, presenting cases, and thinking about their practice. Many residency programs have rotations into community health centers, where residents can learn more about the equity issues embodied in the competencies, adding that they have “many opportunities where they can see and experience the situation directly.” Residents get feedback on a regular basis from faculty members, nurses, family members, patients, and others. “You have much more of a sense of how you are doing and what you need to work on,” she concluded.

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