Public Health–Health System Coordination: Upending the Siloed Status Quo

Article · June 13, 2018

It is widely acknowledged that the health problems our nation faces cannot be solved with the traditional — and often siloed — ways of approaching care and prevention. Unsustainable and rising health care costs continue to outpace gross domestic product growth and prevent other crucial investments; and yet, our costly health care system produces poor health outcomes with troubling inequities and trends in infant mortality, life expectancy, chronic illness, obesity, etc.

To solve these problems, we must build strong cross-sector partnerships and coordinate our efforts and resources. There are real challenges to doing this, which explains why successful coordination between public health and health care systems is rare.

The Public Health Leadership Forum is a diverse group of public health leaders addressing opportunities for transformation in the field of public health, and the Health Care Transformation Task Force is an industry consortium of payers, providers, purchasers, and patients committed to accelerating the pace of delivery system transformation. Together, our groups convened expert roundtable meetings over the course of a year to develop a framework for driving successful partnership between the health care industry and public health, validated by case studies and lessons learned from prior experience.

This consensus effort culminated in defining an overarching shared aim to promote a comprehensive community wellness vision that supports all people achieving their highest possible levels of health by simultaneously addressing all determinants of health. This aim envisions public health, the health care delivery system, community-based organizations, and social/human services working together more seamlessly to address both acute and chronic illness and the upstream environmental conditions and barriers to care that contribute to poor health outcomes in the first place.

Our comprehensive community wellness vision is explained in greater detail in a comprehensive framework and accompanying white paper, Partnering to Catalyze Comprehensive Community Wellness: An Actionable Framework for Health Care and Public Health Collaboration. This framework will help jump-start partnerships, but health policymakers, purchasers, and payers should also recognize the need to help finance cross-sector collaborative models and remove barriers in current payment models that prevent collaboration.

Framework for Comprehensive Community Wellness

  Click To Enlarge.

Moving toward a comprehensive community wellness vision requires a fundamental transformation of how health care and public health engage with one another. Previously siloed organizations may find they have duplicative efforts that are ripe to be streamlined. For example, we reviewed cases where local health department funding to address certain public health objectives was made dependent on performing a certain service (e.g., reproductive health counseling), even if the local health care system was already efficiently and effectively providing that service for the same population. Rather than reject the funding from the state or federal government, local public health was compelled to implement a duplicative service. A structured partnership that arranges consolidation of these repeat programs could free limited resources within a community to be redirected to other health needs.

As this example demonstrates, the needs and assets of each community are unique; therefore, the overarching goals and priorities will vary. For this reason, the framework is intended to be used as a guide rather than a blueprint.

The framework for Comprehensive Community Wellness highlights five essential elements for public health and health care leaders to consider as they build their partnerships, based on the best practice strategies we identified in the successful case examples described below. Our subject matter experts emphasized that the need to prioritize health equity, person-centeredness, and sustainability should be addressed within all elements.

Governance Structure

Successful collaborations hinge on a clear governance and decision-making structure, and ideally utilize local leadership to champion and sustain the effort. One best practice example of localized leadership was evident in Idaho’s implementation of a State Healthcare Innovation Plan (SHIP), catalyzed by State Innovation Model (SIM) funding from the CMS Innovation Center. The grant supported the creation and maintenance of seven regional collaboratives across the state in each of its seven Public Health Districts. Each regional collaborative is led by the local Public Health Director and two primary care physicians from nearby health systems. Local cross-sector leadership has been an effective strategy to drive group buy-in among various stakeholders, including behavioral health clinicians, dental/eye doctors, food banks, transportation, and schools.

The Idaho model is currently in its 2nd year of operation, and the interim evaluation from CMS highlighted that the participating community stakeholders expressed a sense of ownership in the regional collaborative and, in turn, were satisfied with the structure and the ability to better coordinate on addressing key social determinants of health. The regional collaboratives have effected change among the diverse stakeholders through establishing formal charters with specific local goals informed by a joint Community Needs Assessment. For example, each region has established formal referral and feedback protocols to better link local medical and social services, which health care providers and public health adhere to. Stakeholders shared with the evaluators that one lesson learned from this experience was the need to bring commercial payers to the table earlier in the process — ideally, during the initial planning stages — to ensure their buy-in.

Financing Plan

Many of the partnership case studies we reviewed were catalyzed by grant funding or other sources of time-limited capital and, though successful, are still working to ensure long-term sustainability. In Jackson County, Michigan, the Health Improvement Organization (HIO) represents a successful collaboration continuously running since 2000. Recognizing that the rising health care costs were not sustainable, the local health system allocated community benefit funds to support prevention and community health initiatives to address the upstream health behaviors and determinants that lead to higher utilization of services. The organization continues to pool resources from the local health system, a Federally Qualified Health Center, and the public health department to complete their Community Needs Assessment. HIO also created a shared FTE Health Officer position dedicated to both the health care system and the public health department. This shared resource oversees optimal deployment of infrastructure to address community wellness, such a shared electronic health record system.

The intangible benefit of this approach has been improved trust and camaraderie between the health care system and local public health department as they seek to integrate efforts and create a set of key population health measures. Funding from a SIM grant to the state of Michigan was also utilized to build a social service navigation platform that allows partners to track progress through an electronic closed loop referral system. HIO has demonstrated improved health outcomes including reductions in smoking usage and increases in the percentage of adults meeting recommendations for both physical activity and fruit/vegetable consumption. Like other partially publicly funded initiatives, HIO faces long-term sustainability challenges as funding streams can be volatile and uncertain depending on changes in political and legislative priorities.

Cross-Sector Prevention Models

Collaboratives must also clearly define the clinical and community health interventions that will be pursued by the partner organization. We found again that reducing duplicative efforts is paramount so that limited resources can be optimally allocated and used most effectively. A particularly successful example of a cross-sector prevention model is North Carolina’s Pregnancy Medical Home Initiative (PMHI). This partnership integrates the North Carolina Community Care Networks’ (N3CN) regional providers, the Department of Health and Human Services, and the Division of Public Health to provide holistic and high-quality maternity care to Medicaid beneficiaries across the state to improve birth outcomes. The team utilizes a pregnancy medical home program, modeled on N3CN’s successful primary care medical home program.

This partnership clearly delineates roles and responsibilities with the local health departments responsible for employing pregnancy care managers to coordinate prenatal care and the physician practices agreeing to reduce elective deliveries before 39 weeks, reduce primary C-section rates, use a standardized initial risk screening, and prevent recurrent preterm births. Since launching in April 2011, the program has scaled to include most maternity care providers across the state. In its first 3 years, PMHI produced promising results reducing the rate of low birth weight by 7.2% and narrowing the racial disparity of low birth weight between African American and white Medicaid populations, according to a 2015 program analysis.

Data-Sharing Strategy

A solid data-sharing strategy is needed to support the clinical and community-based intervention and allow for both interim and long-term evaluation. As mentioned above, Michigan’s HIO has driven closer collaboration between clinicians and public health by expanding electronic health record access to community health workers. In the absence of shared data platforms, many other cross-sector partnerships have found data-sharing to be a vexing and complicated legal issue.

Sharing protected health information (PHI) with community partners can be challenging, since addressing an individual’s social needs is typically not considered “treatment” under HIPAA, thereby limiting a clinician’s ability to share that information with partners. Providers at our roundtable described how their organizations worked closely with their legal teams to streamline data-sharing agreements when working with local government and community agencies, such as creating universal authorization for disclosure forms that will allow multiple entities to share PHI. In the meantime, providers can seek verbal agreement from individuals to share certain data with community partners.

Performance Measurement and Evaluation

Long-term sustainability of effective collaborative models depends on robust evaluation and continual improvement, which starts with aligning measurement approaches. Public health measures typically assess population health trends and outcomes at the macro level, whereas the health care system measures health care performance and individual clinical outcomes for a set of patients. For example, if a partnership goal is to reduce tobacco use, a hospital’s process measure of tracking referrals to a tobacco quit line would not be sufficient; to evaluate actual smoking cessation rates, an outcome measure that tracks the patient’s engagement with that program and sends the data back to the physician for follow-up and documentation provides a more effective evaluation of the intervention.

Partners should engage stakeholders and collaboratively hone their measure set to ensure measurement accurately reflects program goals. Idaho’s SHIP stakeholders have done this successfully by utilizing a consensus process to create initial performance measures that include detailed definitions of the numerator, denominator, and data source of each measure.

Taking Action

Local, state, and federal policymakers can learn from examples of effective cross-sector collaboration. In particular, SIM funding has proven to be a powerful and effective catalyst of these partnerships. As CMMI considers a “New Direction,” we urge CMS to continue investment in state innovation. Furthermore, as it continues to build out new models for testing, CMMI should heed the lessons learned from successful partnerships and incorporate the key elements of collaborations detailed above.

Ensuring long-term viability of these collaborations requires support and initial funding, but it also requires a fundamental restructuring of health financing and operations to advance the comprehensive community wellness vision. Rather than only considering reinvestment strategies once savings are earned, stakeholders must take the more challenging step of reworking the current financing and reimbursement structures such that population health efforts and interventions are reimbursed fairly and sustainably.

In striving for a true comprehensive community wellness vision, public health and the health care delivery system are just two of the many players needed to transform our system to a more equitable and sustainable one. However, these sectors are in a good position to jump-start and lead this work. Improving health outcomes and reducing disparities requires investment, policy change, and cross-sector collaboration and partnership. The inequities, poor health outcomes, and unsustainable costs in our current health care system demand new action from our fellow leaders in public health and health care, and we offer this framework as a guide to upending the siloed status quo.

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