Care Redesign

Integrating Social Needs with Care Delivery

Interview · January 11, 2016

Anna Roth and Amy Compton-Phillips

As CEO of Contra Costa Regional Medical Center and Health Centers, a large publicly funded health system in the San Francisco Bay Area, Anna Roth sees the challenges in shifting from volume-based to value-based care — but she also sees the opportunity.

Since June 2014, Contra Costa has partnered with Health Leads, a service provider aimed at integrating patients’ basic needs into care delivery. Through a Health Leads resource desk located in one of Contra Costa County’s health centers, providers now can direct patients to resources that have an impact on health, such as food and housing.

Roth sat down with Amy Compton-Phillips to talk about her health system’s innovative care model and the role of community partnership.

Amy Compton-Phillips: You have talked about how the social determinants of health can influence outcomes of care delivery. Programs such as Health Leads can help health systems provide for social needs, but they depend on external funding. How can we help make that funding sustainable?

Anna Roth: I think the answer begins with who pays for health care now. Patients, providers, employers, health plans, and taxpayers are all paying for the rework that is going on across U.S. health care. The goal is to go beyond producing health care and to produce better health. It may not be a simple process, but the money is already moving toward that end.

At the beginning of 2015, CMS set out goals to start to pay for value, not just volume. There are also many national demonstration projects, local programs, and initiatives at the system level, like in my own, that are happening across the country. Each has its own approach, but the important thing is that we are starting to think about smart investments that will ultimately result in a better patient experience, a healthier population, and affordable care.

Compton-Phillips: It sounds like you have already started on that journey. Have you figured out a way to incentivize physicians to focus on prevention?

Roth: Our health system is paid in two ways, and one is, like many other integrated systems, through our own self-funded health plan. We are monitored and paid using outcome measures such as HEDIS and other standardized scoring systems.

As a public hospital in California, the second way we are paid is through our Section 1115 Waiver. Over the last five years, we’ve had the Delivery System Reform Incentive Payment Program, which is an innovation incentive that has fueled initiatives such as PCMH transformation, our partnership with Health Leads, and alternative care offerings including telemedicine and telephone appointments.

In a fee-for-service environment, these programs would have no mechanism for payment. So, these federal demonstration projects, programs attached to federal waivers at the state level, and the innovative relationships we’re building are a promising way forward.

Compton-Phillips: Given these financing arrangements, have you been able to actually get your providers off fee-for-service reimbursement?

Roth: We are still somewhere in the middle of fee-for-service and capitation. We all dream of a fully reformed health care system and the payment reform that goes along with it, but that will take a while. Like everyone else, we have to think smart about how the health care spend is distributed within our population, how we can leverage the finite resources we have, and how to make our investments wisely.

For instance, does it make sense to pay for three or four extra primary care visits because a patient’s A1C is out of control? Or is it better to make a smart investment to ensure they have the resources they need for the refrigerator to be on, so that insulin can be stored properly and they can manage their diabetes?

Compton-Phillips: How do we get better at leveraging community assets in the health care system?

Roth: In health care, we often get tripped up trying to own and operate everything. We have not been world-class partners in reaching out to our community. We even hire navigators so members of our community can find their way through the complexity of our systems.

It is time we look beyond the four walls of our institutions and see how we can partner with those who have already mastered things like housing and employment. There are expert agencies, like the nationwide 211 program and other nonprofits, who are better at that than we’re probably ever going to be. We should learn how to work with them. If these networks and organizations are not as strong as we would like them to be, maybe the role we can play is to be strong partners for them so they can strengthen themselves.

Compton-Phillips: Do you have any advice for the physicians and caregivers in safety-net hospitals to maintain their resilience and avoid burnout?

Roth: I don’t know if I have advice, but I do recognize that it’s hard work. People inherently went into this profession because they want to help people. They want to ease suffering. We need to position providers to be able to do that, rather than face the daily frustration of generating interventions that only go so far.

This really hit home with me when we sat down recently with providers in one of our larger clinics and shared data from our Health Leads resource desk. We showed them that the number one need met by our Health Leads advocates was food. Some of our providers choked up. Many have worked for decades in the center of this safety net with no way to meet that kind of need. In the past, the best they could do was make a blind referral, close the office door, and live with not really knowing what happened.

Now we can tell them that their patients were connected to food. That is how you build resilience: by surrounding providers with tools that help them meet the needs of people they’ve dedicated their lives to serving.

Call for submissions:

Now inviting expert articles, longform articles, and case studies for peer review

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

More From Care Redesign
Community Resource Referral Type

Assessing and Addressing Social Needs in Primary Care

Lincoln Community Health Center improved care quality by measuring and responding to upstream social and economic risk factors disproportionately affecting low-income households.

Time Driven Activity Based Costing for ECMO

Achieving Value in Highly Complex Acute Care: Lessons from the Delivery of Extra Corporeal Life Support

To improve both the value and outcomes of ECLS, Cedars-Sinai Medical Center created guidelines for ECLS delivery and explored opportunities for more efficient care.

ARISE and SFHN BHVS Collaboration

The “Behavioral Health Vital Signs” Initiative

A safety net system’s trauma-informed approach to integrating interpersonal violence into behavioral health programs in primary care.

OpenNotes Epic Patient Email Cascade Chart February 1, 2018 - August 14, 2018

Measuring Performance of OpenNotes Initiatives to Target Improvement Efforts

How a New York safety-net health system used data science to identify obstacles to OpenNotes use, address technical barriers, and develop strategies for improving clinical note sharing by providers and viewing by patients.

Mapping a Technology Strategy for Bundled Payment Care Using a Value-Driven Framework

Harnessing Emerging Information Technology for Bundled Payment Care Using a Value-Driven Framework

A four-part framework developed by physicians at Partners HealthCare provides a stepwise process for assessing and integrating technologies to effectively use data through a continuous patient experience.

UCLA Health CKD Risk Stratification and Management

Proactively Catching the Declining Patient

A coordinated effort by UCLA leaders to identify a high-cost population with chronic kidney disease and to modify care processes and personnel has led to improved health and reduced utilization.

Telehealth and remote monitoring are little used and ineffective for chronic disease care

Survey Snapshot: Treating Chronic Disease Proactively

Though survey respondents don’t indicate strong use of telehealth and remote monitoring, NEJM Catalyst Insights Council members discuss the ways they’re using these tools to monitor chronic disease, with good results.

Platforming Health Care Operations - Consumer-Driven Health Care - Business-Minded Optimizations

Platforming Health Care to Transform Care Delivery

Health care leaders need to focus less on ownership and control of the delivery process, and more on outcomes, cost efficiency, and customer experience.

Shah05_ integrated systems innovation pullquote

Build vs. Buy: What Should Health Systems Do?

The consolidation craze continues, but vertical integration has yet to demonstrate real progress toward the Triple Aim. Health care leaders would do well to consider innovative approaches that are working in other industries, including the tech-enabled full stack model.

Diagram Illustrating the COPD Care Pathway at Allegheny General Hospital

End-to-End Care for COPD Patients that Improves Outcomes and Lowers Costs

Allegheny General Hospital created a comprehensive solution for patients with chronic obstructive pulmonary disease (COPD) that led to improved clinical outcomes, reduced hospital admissions and readmissions, and a resultant decrease in the total cost of care.

Connect

A weekly email newsletter featuring the latest actionable ideas and practical innovations from NEJM Catalyst.

Learn More »

Topics

Design Thinking

20 Articles

Taxonomy of the Patient Voice

While health care pursues the important trend of putting patients at the center of care,…

Measuring Performance of OpenNotes Initiatives to…

How a New York safety-net health system used data science to identify obstacles to OpenNotes…

Proactively Catching the Declining Patient

A coordinated effort by UCLA leaders to identify a high-cost population with chronic kidney disease…

Insights Council

Have a voice. Join other health care leaders effecting change, shaping tomorrow.

Apply Now