Care Redesign
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We Owe Our Nation Something Different (13:20)

“I got a phone call that nobody wants a few years ago,” begins Amy Compton-Phillips, MD, Executive Vice President and Chief Clinical Officer for Providence St. Joseph Health and Theme Leader for NEJM Catalyst. Her cousin’s stepson, who was a product of divorce and a former drug user who ultimately got clean, returned home from Afghanistan and shot himself in his parents’ bedroom.

“It’s not just him — it’s 22 veterans a day. It’s the second leading cause of death in adolescents. It’s 69,000 people last year who died of overdoses. It’s not just suicide, it’s depression, being the number one cause of morbidity in days lost from work. It’s national trauma — we have so much morbidity from mental health and illness, and yet it’s the system we’ve designed. That’s the results we’re getting,” says Compton-Phillips.

“I was trained back in the era when we were going to have science cure everything and a pill for every problem. But the bulk of what influences ultimate health outcomes is really behavioral, social, environmental — which makes complete intuitive sense.”

If you grow up in an environment where you have parks and fresh food and opportunities for education, says Compton-Phillips, of course you’re going to have higher odds of turning out with a healthy future than if you grow up in violence and chaos. She offers an example: when working in Oakland, California, she’d take BART to the 12th Street station, where the average life expectancy was 73 years. Then she’d get on the train and ride out four stops to Lafayette / Walnut Creek, and the average life expectancy there was 84 years. “There was no difference in people on the train. The difference was in the context of life in people who didn’t have access to the things that future a healthy life.”

If people live at the federal poverty level or below, their risk of suffering from depression is 4 times as high as people from higher incomes, Compton-Phillips says. And a really frightening fact for the future is that as of last year, 49% of children born in the U.S. had their birth paid for by Medicaid. “That means half of our children are being born into poverty.”

Poverty isn’t only associated with depression, it’s also associated with adverse childhood experience, adds Compton-Phillips. “Children who live in an environment where they’re more likely to experience abuse, neglect, or family dysfunction are 10 times more likely to become alcoholic, 20 times more likely to attempt suicide, and 150 times more likely to use IV drugs. As I think back to my cousin’s stepson, that was his environment — he wasn’t able to create the resilience, grit, and drive to make it past all the hardship in his life, so his solution was like so many that experience adverse childhood experiences,” she says.

Compton-Phillips believes we need to — and can — address this. She recalls the example of fluoride in the 1970s. “Rather than focusing on the teeth, we focused on what would prevent bad teeth. Right now we have 90% less diseased, missing, or filled teeth than we had in 1970.”

Compton-Phillips says that there are three things that seem to be a theme in terms of what we can change:

  1. Organizations and systems spend a lot of time focusing on what they’re trying to solve. If they spend time asking what the fundamental driver of the problem is, they’ll get much further. For example, the Southcentral Foundation Nuka System of Care was developed when the Native Alaskan population in Anchorage decided they wanted to take over their own care from the Indian Health Service. To do it, they went out to their community and found out that what the community wanted from the health system was to address child neglect, child abuse, and alcohol use. The health system then broke itself apart and reconfigured so that it could address these needs. Now, they have one clinician partnered directly with one behavioral health person and a nurse, as a primary care team. When patients come in, they talk about their stress, sleep habits, and relationships, in addition to vitals. They’ve recently won their second Baldrige Award for quality for outstanding care, despite the fact that their community is very high in depression and morbidity.
  2. Aligned voices from multidisciplinary groups for designing solutions. Compton-Phillips provides NHS Scotland as an example. When they set a goal to make Scotland the best place to grow up, they had educators, caregivers, parents, and business people come together to figure out how. A fundamental issue, they realized, was that they had parents raising children who didn’t know how to be parents, so they focused on breaking that cycle. They developed a system where they gave every young child a bear and a book, and told the children that they needed to read to the bear before bed every night. It significantly increased the number of parents reading to their children before bed, which made a real dent in enhanced relationships between parents and children.
  3. Making sure we have the wherewithal to connect the dots. In San Antonio, Texas, the instigator was actually the police, because they realized they had more mentally ill people in jail than in treatment. When they looked at the bottom line and saw what the substance abuse system, the prisons, and the health care system were each spending, they said, we need a place to bring them other than an ED and jail. So they built a restoration center that has substance abuse treatment, crisis intervention treatment, and homelessness services. Today, they treat 18,000 people a year, they have capacity in their jails and EDs, and all of the organizations that have invested in this are saving over $10 million a year. “They’re getting better outcomes at lower cost, just by getting everyone on the same page with how to execute on the problem,” says Compton-Phillips.

“Everybody knows we spend more than any other rich westernized country on health care. But if you add health spend, to health care spend, we’re actually fairly on par with other countries, but it’s the ratio that’s different — they spend a little over 2:1, we spend a little more like 1:1,” says Compton-Phillips. Providence St. Joseph, she says, decided to make a $100 million investment to begin hosting the conversation around how we can change this. “I don’t want anyone else to get a phone call like we got, to raise children we know are at risk for the future. We owe it to our families, our patients, our communities, and our nation to change the course of the stream and deliver something very different.”

From the NEJM Catalyst event Expanding the Bounds of Care Delivery: Integrating Mental, Social, and Physical Health, held at Vanderbilt University Medical Center, January 25, 2018.

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