Building Healthy Communities: Building Healthy Communities Ron J. Anderson, MD, MACP, Paul J. Boumbulian, MPH, DPA, S. Sue Pickens, M.Ed. Rebecca Morrow, MS, MA Parkland Health & Hospital System Dallas, Texas USA Managing the In-Between as Servant Leaders


The health of the people is really the foundation upon which their happiness and all their powers as a state depend.: The health of the people is really the foundation upon which their happiness and all their powers as a state depend. Benjamin Disraeli


Managing the In-Between: Managing the In-Between Background Parkland Health & Hospital System Determinants of Health Managing the In-Between Complexity Tipping Point Tipping Point Management and Institute for Healthy People Servant Leadership


US Has a “Sick Care” System: US Has a “Sick Care” System Managing and treating the ill or injured


US System Is World’s Most Expensive: US System Is World’s Most Expensive Health expenditures: 14.1% of 2001 GDP $5,900 per person Expected to increase to 17.7% by 2012 Source: Centers for Medicare and Medicaid Services. http://cms.hhs.gov/statistics/nhe/projections-2002/highlights.asp Health Spending as a Percent of GDP in Selected High-Income OECD* Countries, 1997-99 Source: Bureau of Labor Education, University of Maine. Summer 2001. The U.S. Health Care System: Best in the World or Just the Most Expensive?http://dll.umaine.edu/ble/ U.S.%20HCweb.pdf *Organization for Economic Cooperation and Development


But Not the Most Effective: But Not the Most Effective U.S. ranks: 26th among industrialized countries for infant mortality rates, with the highest among high-income OECD countries Very low (24th) on disability-adjusted life expectancy among 29 OECD-member countries Source: Bureau of Labor Education, University of Maine. Summer 2001. The U.S. Health Care System: Best in the World or Just the Most Expensive?http://dll.umaine.edu/ble/U.S.%20HCweb.pdf


Nor the Most Efficient: Nor the Most Efficient Medicare Medicaid S-CHIP Titles 5, 19, 20 etc. 1011 funding for undocumented DSH UPL Trauma funding Tobacco litigation Crime Victim Compensation Commercial insurance Fee for service Managed Care Many others About 25% of the cost of health care in the US is administrative. Many of the programs below have significant structures for determining eligibility, making claims, making payments, auditing for fraud/abuse, etc.


Nor the Safest: Nor the Safest At least 44,000 people, perhaps as many as 98,000 people, die in hospitals each year as a result of preventable medical errors. Medical errors have been estimated to result in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. Errors also are costly in terms of loss of trust in the health care system by patients and diminished satisfaction by both patients and health professionals. Source: National Institute of Medicine. 1999. To Err Is Human: Building a Safer Health System. http://www.iom.edu/Object.File/Master/4/117/0.pdf Accessed 4/26/2007.


Nor the Most Equitable: Nor the Most Equitable Source: Commonwealth Fund Issue Brief: Equity in Health Care Across Five Nations, 2000. http://www.cmwf.org/programs/international/schoen_5nat_ib_388.asp Percentage of Respondents Who Say It Is Extremely, Very, or Somewhat Difficult to Get Care Percentage of Respondents Who Had Problems Paying Medical Bills in the Past Year


Inequities Are Related to Social and Economic Status: Inequities Are Related to Social and Economic Status Complex interplay among factors–age, gender, race, education, etc.—impact risk factors like poor housing, adverse working conditions, dangerous neighborhoods and the like Example: A boy who reaches the age of 15 in Central Park West has an 80% chance of living to age 65 while a 15-year-old boy in Central Harlem has only about a 37% chance of reaching 65. Source: Danse macabre: Poverty, social status and health. 2007. The Pharos. Winter 2007 pp. 4 9.


Lack of health insurance coverage is not a new problem and not just Texas’ problem.: Lack of health insurance coverage is not a new problem and not just Texas’ problem. Policy discussions about extending health insurance coverage to the uninsured have been conducted for over two decades, while the problem continues to grow. Source: US Census Bureau, Historical Health Insurance Tables.


If market reforms could have solved the problem...: If market reforms could have solved the problem... of the uninsured and underinsured, they would have likely done so in over a decade of low inflation and unemployment. Source: US Department of Labor Bureau of Labor Statistics


But the problem remains... : But the problem remains... Source: US Census Bureau Number of uninsured Americans increased until in 1999, when, for the first time in 12 years, it decreased slightly. In 2001, number jumped upward again, a trend that has continued.


In 2003, an Additional 17 Million Americans Were Under-insured.: In 2003, an Additional 17 Million Americans Were Under-insured. Underinsured have insurance but still do not have "adequate financial protection from high out-of-pocket health care costs" In this study, that meant those under 65 who have insurance but still spend more than 10% of their tax-adjusted family income on health care, excluding insurance premiums. About 9 million of these had insurance through employers; the other 8 million had public or private coverage not affiliated with a group Source: Banthin, J. The Journal of the American Medical Association, Dec 13, 2006; vol 296: pp 2712-2719. Jessica Banthin, PhD, Agency for Healthcare Research and Quality. News release, JAMA/Archives. http://www.webmd.com/news/20061212/out-of-pocket-health-care-costs-up Accessed on 2/12/2007.


Slide15: You cannot escape the responsibility of tomorrow by evading it today. Abraham Lincoln


Dallas County Is a Microcosm of the Challenges Facing Health Care: Dallas County Is a Microcosm of the Challenges Facing Health Care Increasing costs Decreasing funding Higher demand for services Aging population More uninsured Shortage of health care providers


Dallas County Continues to Grow, but More Slowly than Contiguous Counties: Dallas County Continues to Grow, but More Slowly than Contiguous Counties Dallas County’s 2007 population = 2.4 million North Central Texas added 135,350 persons during 2006 for a total population of 6,406,500 Region has now averaged over 150,000 new persons per year since 2000 and this marks the 11th consecutive year to add more than 100,000 persons


In 2000, Dallas County Became More Diverse with No Clear Ethnic Majority: In 2000, Dallas County Became More Diverse with No Clear Ethnic Majority Source: US Census Bureau and Steve Murdock, Ph.D. Texas State Data Center (scenario .5)


Dallas County Continues to Become More Ethnically Diverse: Hispanic Dallas County Continues to Become More Ethnically Diverse White African American Other Population Estimates for 2005


Over 43% of Low-income Texans Are without Insurance: Over 43% of Low-income Texans Are without Insurance * defined as 40% (2 states) 36-40% (10 states) 31-35% (8 states) 26-30% (15 states) 18-25% (15 states) Percentage of Low-income* Population Without Health Insurance, 1999-2000 US Overall = 31%


Parkland Fills the Gaps for Dallas County: Parkland Fills the Gaps for Dallas County 1 in 4 trauma cases go here 4 in 10 for major trauma More than 1 in 4 residents lack insurance and are likely to seek care here 3 of 10 babies born here Nearly half of county’s doctors train here 4 of 10 HIV/AIDS patients treated here 3/07


Parkland Remains Area’s Busiest Hospital System: Parkland Remains Area’s Busiest Hospital System *Observation days increased due to chest pain and abdominal trauma protocols, reducing admissions by over 2,000. Source: PHHS Annual Reports


Parkland’s Trauma Volume Is Twice Regional and National Averages, 2006: Parkland’s Trauma Volume Is Twice Regional and National Averages, 2006 Source: PHHS Trauma Registry, CY 2006 Source: National Trauma Data Bank, Report 2007 National Average is a 5 year average 2002-2006.


Ambulatory Surgery Center Has Decreased OR Volume: Ambulatory Surgery Center Has Decreased OR Volume


Parkland Gets Patients from All Over Texas: Parkland Gets Patients from All Over Texas But most—84.33% or 18,741 patients—come from 18 nearby counties


Parkland’s Out-of-County Trauma Patient Mix by County (CY 2006): Parkland’s Out-of-County Trauma Patient Mix by County (CY 2006) 60% come from contiguous counties 14% come from next tier contiguous counties (Hunt, Henderson, Navarro, Cooke, Fannin, Grayson, 25% come from Texas counties, out of state or outside the US 1% are unidentified


Parkland’s Payer Mix for Out-of-County Trauma Patients, 2006: Parkland’s Payer Mix for Out-of-County Trauma Patients, 2006 Inpatients Outpatients Source: TII, download 2006 from Robyn Manning


Ongoing Regional Efforts: Ongoing Regional Efforts Air quality Water quality/availability Disaster preparedness/Homeland security Pandemics/Bioterrorism Natural disasters Man-made disasters/Terrorism Transportation


Regional Funding for Safety Net Services: Regional Funding for Safety Net Services Why not: Trauma Burn Tertiary care


Parkland’s Challenges: Parkland’s Challenges Facing increasing demands for services through both patient growth and the inability of its facilities to meet this growing demand Strain on current facilities limits access to all populations, including Medicare and other paying patients Poverty population has increasingly spread to the suburbs Source: Dr. Paul Jargowsky, University of Texas at Dallas, Dallas Morning News, Sunday, May 18, 2003 Section B, page 1.


Slide31: The future is not something we enter. The future is something we create. Leonard I. Sweet Theologian, Author, Futurist


Possible New Facilities: Possible New Facilities Women’s & Infants’ Hospital Medical/Surgical Hospital Trauma Institute Rehabilitation & Spinal Cord Injury Treatment Center Potential for 1-2 satellite hospitals in addition to Parkland replacement facility Psychiatry & Alcohol/Substance Abuse Treatment Center and Community-based Psychiatry Jail Health Opportunity to improve public health and chronic disease treatment in otherwise difficult-to-reach population


From Hospital to Health System: 1989 to Today: From Hospital to Health System: 1989 to Today Parkland saw the need to move from sick care to health care Moved to provide more primary care: COPC Health Centers, Youth & Family Clinics located at DISD schools Co-located public health and related programs: dental health, WIC, etc. HMO: Parkland Community Health Plan


Community Oriented Primary Care: Community Oriented Primary Care


Community Prioritization of Healthcare Issues: Community Prioritization of Healthcare Issues Focuses services on health issues that most concern the residents of targeted communities Issues that have direct bearing on health status but little to do with the medical care system Health Care Leadership Forum made up of elected officials and community opinion leaders Establish priorities Develop action plans for 1-3 years


Parkland COPC Health Centers & Clinics Located in Areas of High Need and Extend into Non-traditional Settings.: Parkland COPC Health Centers & Clinics Located in Areas of High Need and Extend into Non-traditional Settings. de Haro Saldivar Health Center Integrated health system for multi-specialty care/hospitalization/ discharge/follow-up 760-bed hospital 10 Health Centers 8 Women’s Clinics 11 Youth/Family Centers 4 mobile vans Senior Outreach Program


Areas of Unmet Need: Areas of Unmet Need Next tier to address: Mesquite Grand Prairie Seagoville-Balch Springs-South Mesquite Northwest Dallas-Love Field, Stemmons, Farmers Branch area Spring Valley-Coit area Need 1-2 subspecialty clinics, according to new strategic plan Stemmons Love Field Source: Parkland Health & Hospital System, 2006 data Central Irving


HOMES: Homeless Outreach Medical Services: HOMES: Homeless Outreach Medical Services Joint program of Parkland and city of Dallas Provides pediatric and adult medical services and social work services Texas Hospital Association’s Excellence in Community Service Award in 2001 & 2005


HOMES: Homeless Outreach Medical Services: HOMES: Homeless Outreach Medical Services 4 mobile medical units equipped with clerical and nursing stations, two exam rooms, class D pharmacy, restroom Deliver care to 38 homeless shelters, transitional housing sites, selected schools Mobile medical record Visits: 16,594 in 2006 15,231 in 2007


Dallas Healthy Start: Dallas Healthy Start Infant mortality for 2 target areas, Southeast and West Dallas, declined from 11.9% per 1,000 births in 1990 to 6.7% in 1996


Parkland’s Neonatal Mortality Rate Does Not Follow Texas and US Trends: Parkland’s Neonatal Mortality Rate Does Not Follow Texas and US Trends Source: PHHS data, 1999-2001; Texas Bureau of Vital Statistics, 2001; US Bureau of Vital Statistics 2000. Latest available for all. * * When adjusted for severity, Parkland’s rate for white women is better than the national average. PHHS gets many referrals of high-risk women.


Human Consequences of Prenatal Care, 1998-2002: Human Consequences of Prenatal Care, 1998-2002 Parkland Birth Outcomes With and Without Prenatal Care, per 1,000 live births


Slide43: Under this model, patients: Remain in the same health plan Keep the same primary care doctor Receive services at the same COPC Health Center or primary care area Retain the same Medical Record Have their information retained in the same data base Have their cost of care funded by a combination of Medicaid, Disproportionate Share, or Ad Valorem Taxes Parkland HEALTHplus MEDICAID CHIP


Parkland HMOParkland Community Health Plan, Inc.: Parkland HEALTHplus Indigent and Other Parkland HMO Parkland Community Health Plan, Inc. Parkland HEALTHfirst Medicaid Three Products Under One Umbrella Parkland KIDSfirst CHIP Platform for insurance for the working poor Under this model, patients remain in the same health plan, keep the same primary care doctor, get services at the same place, and have their cost of care funded by a combination of Medicaid, Disproportionate Share, or Ad Valorem Taxes


Enrollment in PCHP & Healthplus ProgramsSeptember, 2007: 77,000 116,230 18,940 5,653 Healthfirst KIDSfirst Healthplus Children 0-18 Perinate Enrollment in PCHP & Healthplus Programs September, 2007 (40% market share w/o perinate, 52% market share with perinate) (51% market share) Source: Parkland Community Health Plan, September, 2007. 24,593


PCHP Outcomes: PCHP Outcomes Improved emergency room utilization through he establishment of a medical home and through management of outliers. Lower percentage of low birth weight births than the community average.This has extended to beyond the Parkland system to the community based providers. Asthma disease management program has 2,000 children enrolled is a public/private partnership for disease management. The private company is at 100% risk for improved outcomes.


Parkland Serves a Predominately Minority Population: Parkland Serves a Predominately Minority Population Inpatients Outpatients Source: DCHD, 2002


Future Improvements in Community Health Depend on Addressing the Determinants of Health: Future Improvements in Community Health Depend on Addressing the Determinants of Health Health care can moderate the effects of these factors, but its contribution to prevention of premature death is much smaller. Source: Evans, R.G. and G.L. Stoddart, Producing Health, Consuming Health Care. Soc Sci Med, 31(12), 1247-1363, 1990.


Physical and Social Environments: Physical and Social Environments Account for 70% of the impact of the determinants of health on premature death Are influenced by a complex array of factors, including education, economics, housing, transportation, security, etc. Example: given that basic public health needs are met in the U. S., education is most highly correlated to health status improvement. This does not hold true in areas where basic public health needs are lacking. Can best be changed when all influencing factors are considered together, which rarely happens


Each Area Operates in Its Own Sphere of Influence, Sometimes Causing Unexpected and Unwanted Outcomes in Other Areas: Each Area Operates in Its Own Sphere of Influence, Sometimes Causing Unexpected and Unwanted Outcomes in Other Areas


We Must Manage the In-Between, or the Common Ground, that Benefits the Whole Infra-structure But Is Not Managed by Any One Part: We Must Manage the In-Between, or the Common Ground, that Benefits the Whole Infra-structure But Is Not Managed by Any One Part


Why Is Managing the In-Between Important?: Why Is Managing the In-Between Important?


Managing the In-Between Promotes Synergism: One Success Builds on Another: Managing the In-Between Promotes Synergism: One Success Builds on Another


Where We Came From: Where We Came From For the last 200 years, Newtonian science and Cartesian philosophy have held that the universe is: a linear place where simple rules of cause and effect apply. made up of a series of components or “machines.” When one part is made to work better, the whole automatically improved.


Where It Got Us: Where It Got Us Industrialization with tremendous innovation Production of huge quantities of uniform goods, services and knowledge


But That’s Not the Whole Story: But That’s Not the Whole Story While this model worked fairly well in physics at large scale and in manufacturing, it doesn’t work as well in the micro world, nor with biological systems. No matter how we try, we cannot make these systems work as predictable “machines.”


The problem is never how to get new, innovative thoughts into your mind, but how to get the old ones out. Dee Hock (VISA): The problem is never how to get new, innovative thoughts into your mind, but how to get the old ones out. Dee Hock (VISA)


Insight at the Intersection: Insight at the Intersection Creating intersections Cultures Communities Disciplines Quantum breakthroughs versus incremental gain


It’s a Complex World: It’s a Complex World Complexity theory offers an answer: the universe is full of systems, and these systems are complex and constantly adapting to the environment. In complex, adaptive systems, relationships are important. Inter-relatedness and interdependence become more evident. We can move from the mindset of “those people” to one of “our neighbors.” Source: http://www.trojanmice.com/articles/complexadaptivesystems.htm


Comparing the Theories: Comparing the Theories Newtonian/Cartesian Theory Linear System Reductionistic Mechanistic model Denominator driven Centralized authority Routinized practices Enforced conformity Subspecialization Complexity Theory Non-linear Community Inclusive Biological model Numerator driven Decentralized Individualized More general


Complexity Theory Recognizes Bi-directionality: Complexity Theory Recognizes Bi-directionality Complexity provides a perspective that recognizes the bi-directional influences that is present in most relationship a influence B and at the same time B influence A. Causality is bi-directional rather than unidirectional, and this changes everything. Amplification of small differences can lead to big changes - “The Butterfly Effect” References: Suchman, Tony. “Linearity, Complexity and Well-Being.” Medical Encounter 2002; 16(4):17-19. & Hock, Dee. Understanding the Industrial Age. CommUnity of Minds. Friday, September 28, 20001. http://solutions.synearth.net/2001/09/28. Retrieved Sept 2, 2003.


What Does It Mean?: What Does It Mean? Life is non-linear. Patients (people) are greater than the sum of their parts. Communities are made up of people who are constantly adapting to changing conditions. They act and are acted upon. Communities are living organisms, complex adaptive systems that are not easily predictable. Recognizing trends and responding to them by becoming learning organizations may allow us to make midcourse corrections to affect change toward a desired outcome.


3 Important Principles Can Be Applied to Complex Adaptive Systems: 3 Important Principles Can Be Applied to Complex Adaptive Systems Self-organization Amplification of small differences Inverse power law


Self-organization: Self-organization Non-linear, complexity-based relationships lead to development of bi-directional relationships, which allow the creation of self-organizing groups of non-related individuals and organizations


Amplification of Small Differences: Amplification of Small Differences Minute changes have the potential to be amplified through self-reinforcing feedback loops, which can culminate in changes to the entire system


Inverse Power Law: Inverse Power Law Small events can come together to create a “tipping point” that leads to large change. The last small change may get the credit, but generally, it is the sum of all the changes over time that matters.


Tipping Point: Little Changes Matter A Lot : Tipping Point: Little Changes Matter A Lot Things can happen all at once, and little changes can make a huge difference. As human beings, we always expect everyday change to happen slowly and steadily, and for there to be some relationship between cause and effect. When there isn't--when crime drops sharply in New York for no apparent reason, or when a movie made on a shoestring budget ends up making hundreds of millions of dollars -- we're surprised. This is the way social epidemics work. References: Gladwell, M. The Tipping Point: How Little Things Can Make a Big Difference. Little Brown, Boston. January 2002. & Kim, W. C. & R. Mauborgne. “Tipping Point Leadership.” Harvard Business Review, April 2003. pp 61-69.


Where to from Here?: Where to from Here? Focus on the In-Between Look at all areas that contribute to creating, and therefore, alleviating a particular health issue Create community partnerships that extend to areas beyond health care


How Can We Do This?: How Can We Do This? “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed it’s the only thing that ever has.” –Margaret Mead


How Can We Do This?: How Can We Do This? Act in the spirit of servant- leadership “A servant-leader is a person who begins with a natural feeling of wanting to serve first—to help, support, encourage, and lift up others. And because of their noble role model, others begin to lead by serving.” Robert K. Greenleaf


What Does Servant-Leadership Look Like?: What Does Servant-Leadership Look Like? Servant-leaders: Work cooperatively. Build consensus. Listen deeply. Share information. Seek others’ welfare as their own. Recognize inter-dependence. Respect and value individual differences, opinions, insights


When Servant-Leaders Go Into Communities, They:: When Servant-Leaders Go Into Communities, They: Realize they are guests rather than experts. The experts on any community are those who live in it. Ask questions. The answers they already have may be to questions nobody cares about. Respect the values and traditions of the community, even when they don’t agree. Work with the community rather than working on it. Acknowledge the strengths of the community and tap them to multiply the effects of interventions.


Tipping Point Management: Tipping Point Management Four-step process described by Kim and Maugorgne in “Tipping Point Leadership” Steps require overcoming hurdles: Cognitive Resources Motivational Political


Cognitive Hurdle: Cognitive Hurdle Puts servant leader face to face with community problems and those who live with them on a daily basis Become convinced of the problem and that they can help solve the issue Ultimate success of project requires active, ongoing participation by the affected community


Resources Hurdles: Resources Hurdles Communities generally have more resources than they are aware of Servant Leaders must become master chefs in creating “stone soup” Inventorying available assets and getting agreement to redirect those assets is essential. Servant Leaders must learn to trade resources that aren’t needed for those that are


Slide76: We must reclaim our sense of community and become again a caring society. Becoming a community resource is a beginning.


Motivational Hurdles: Motivational Hurdles If a new strategy is to be “community owned,” community members and institutions must recognize what needs to be done and want to participate in creating solutions Servant Leaders concentrates on bringing “key influencers” to the table. These are people and organizations with disproportionate power due to connections, ability to persuade, ability to open up or block access to resources. Servant Leaders put “key influencers” in the spot light, allowing them to become the champions


Political Hurdles: Political Hurdles Any change will be met with resistance by those happy with the status quo Servant Leaders must recognize this reality and be politically astute when pushing through change


“People who choose to do nothing still affect public policy—but their silence supports the way things are rather than helping make things better.”: “People who choose to do nothing still affect public policy— but their silence supports the way things are rather than helping make things better.” Helen J. Farabee


Community Forum: Community Forum Managing the in-between requires constant input from the communities involved An umbrella organization that can bring together various community leaders, organizations and residents with representatives of government and organizations outside the community is needed


Formation : Formation Defining a “circle of trust” as “a space between us that honors the soul,” shows how people in settings ranging from friendship to organizational life can support each other on the journey toward living “divided no more.” Circles of Trust: Ground rules: "no fixing, no saving, no advising, no setting each other straight.” Reference: Palmer, Parker, “A Hidden Wholeness : The Journey Toward an Undivided Life.” ...“circles of trust" are not management tools that organizations can force on employees for some grand motive, such as crisis control or increased productivity. They are the opposite of quick fixes—places where we sit and wait for our souls to tell the truth..


What We Must Understand: What We Must Understand Change requires vulnerability; we may not always be seen as we see ourselves We are part of the experiment, not just observers Complex problems did not arise overnight and will not be solved overnight either. Believe in incremental change.


Why We Must Act: The cost of not working together is a higher price than any of us can afford to pay, both in dollars, public health effects and the cost of human suffering. Carolyn Boone Lewis, American Hospital Association Why We Must Act


Other Community Outreach Initiatives: Other Community Outreach Initiatives Institute for Community Medicine and Health Research, Professional Education (professional), community health promotion and improvement, outcomes Regional Health Information Organization Community Health Improvement, Measurement and Evaluation System (CHIMES)


CHIMES: CHIMES Provide ongoing assessment of the community, including development of a community assessment of needs and assets and dialogues with community to determine perceptions on health issues and solutions. Develop, maintain information systems and other infrastructure to support interventions and research. Measure improvements in health, quality of life through study of determinants of health and burden of illness. Measure the outcomes of community-based interventions and inpatient and outpatient clinical outcome studies.


CHIMES : CHIMES Also conduct policy studies on relevant issues within the community, such as: health disparities among minorities, the cost to the community of tobacco-related illness, Childhood obesity and early-onset diabetes Excess cost of lack of parity for mental illness and substance abuse Etc.


“We must become the change we seek in the world.”Mohandas Ghandi: “We must become the change we seek in the world.” Mohandas Ghandi