1. Changing What “Counts” as Healthcare
October 18, 2016 Texas Association of Community Health Centers Annual Conference
©2016 Health Leads Inc.

2. Mismatch Between Drivers of Health and Spending
Patients’ lives outside the clinic drive vast majority of health outcomes
Source: Healthy People/Healthy Economy: An Initiative to Make Massachusetts the National Leader in Health and Wellness Data from NEHI
©2016 Health Leads Inc.

3. Resource Connections at Work
©2016 Health Leads Inc.

4. Paradigm Shift
©2016 Health Leads Inc.

5. Change the Definitions
Sick?
…or Hungry?
©2016 Health Leads Inc.

6. Unmet Resource Needs  Poor Health, Inefficient Utilization
Patients with comorbidity X (%)
Patients without comorbidity X (%)
Source: Berkowitz, S.A. et al. 30 November 2015 British Medical Journal Quality and Safety: “Addressing Basic Resource Needs to Improve Primary Care Quality: A Community Collaboration Programme.”
©2016 Health Leads Inc.

7. “What is the role and responsibility of the healthcare system with respect to patients’ social needs?”
This central question – what “counts” as healthcare?
Recently, Ray Baxter, an SVP at Kaiser Permanente, one of HL’s partner integrated delivery systems, framed this dilemma: “There’s a spectrum from, at one extreme, simply pretending these issues don’t exist in our patients’ lives, and, at the other, just going ahead and building affordable housing. We know neither of these is the right answer, but what is the role and responsibility of the healthcare system with respect to patients’ social needs?”
Simple but powerful – not on either end of the extremes
Ray Baxter
Former Senior VP, Community Benefit, Research and Health Policy
Kaiser Permanente
©2016 Health Leads Inc.

8. Social Needs Intake
©2016 Health Leads Inc.

9. The Challenge of Execution
“In healthcare we have an inexplicably high tolerance for poor execution.”
Jim Yong Kim, President, The World Bank Group
Journal of Delivery Science and Innovation, 2013, vol. 1(1-2), pp. 1-3
©2016 Health Leads Inc.

10. Core Elements: Driver Diagram
Primary Drivers
Secondary Drivers
Systematic Screening Protocol
Screening tool
Clinical integration
Resource Referral
and/or Navigation Services
Scope of service
Community resource database
Case management protocol & tool
Quality patient interaction
Dedicated Workforce
Roles & Capacity
Training
Management
Data Systems & Performance Improvement
Technology platform
Database infrastructure
Reporting capability
Leadership & Stakeholder Engagement
Clinic & Administrative Champions
Physician, clinic staff engagement
Strategic & Financial Commitment
Community engagement
Patient engagement
©2016 Health Leads Inc.

11. Social Needs Dashboard
©2016 Health Leads Inc.

12. Rapid-Cycle Learning: Workforce and Resource Connections
©2016 Health Leads Inc.

13. Data Systems: Resource Landscape
Health Leads’ Community Resource Usage, FY15
©2016 Health Leads Inc.

14. “Historic” CMS Pilots: Powerful Market Signal
Accountable Health Communities (AHC):
Comprehensive Primary Care+ (CPC+):
Targeted implementation:
$157 million/5 years; up to 44 awardees
Fees for screening & navigation to social resources
Scaled implementation:
Up to 2,500 primary care practices
Alternative payment model incl. social needs screening & resource directory
3M+ patients screened annually
12M+ patients screened annually
©2016 Health Leads Inc.

15. “All you have to do is be the kind of physician your patient is hoping you will be.”
This central question – what “counts” as healthcare?
Recently, Ray Baxter, an SVP at Kaiser Permanente, one of HL’s partner integrated delivery systems, framed this dilemma: “There’s a spectrum from, at one extreme, simply pretending these issues don’t exist in our patients’ lives, and, at the other, just going ahead and building affordable housing. We know neither of these is the right answer, but what is the role and responsibility of the healthcare system with respect to patients’ social needs?”
Simple but powerful – not on either end of the extremes
Tom Lee, MD
Physician, Brigham and Women’s Hospital
Chief Medical Officer, Press Ganey
©2016 Health Leads Inc.

16. Shifting the Paradigm: Leadership
©2016 Health Leads Inc.

17. Shifting the Paradigm: Leadership
©2016 Health Leads Inc.

18. A New Paradigm
©2016 Health Leads Inc.

19. ©2016 Health Leads Inc.