Transcript Population Health Part 3

Inpatient & Transitional Care Coordination
Transitional Care
Complex Specialty-Based
Chronic Disease Management
Specialty Care
Primary Care
Primary Care
Well-Care
Chronic Disease Management
“Cross-Sectional” Approach
Importance of
Transitional Care
Coordination
Health Affairs 2015;34:1312-1319
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Housing
Health literacy
Transportation
Employment
Communication
“Universal” Approach
Impact of the Social Determinants of Health
County Health Rankings and Roadmap - http://www.countyhealthrankings.org/
UMMC Community Health Needs Assessment 2014
West Baltimore population survey identify transportation
as
a major healthcare barrier.
Social Determinants of Health: Priorities and Partners
Ability to Dialogue
Living Wage
High School Diploma
Good parenting
Fair Housing
Trauma-Free
Drug-Free Home
Access to Nature
Safe Neighborhood
Tobacco Free Home
Communication/Internet
Educational Success
Developmental Milestones
Fruits & Vegetables
30 Million Words
Preschool
Reading
Play
0-3 Programs
Immunizations
Well-child visits
Secure Attachment
Relaxation
Good Sleep
Healthy Weight
Health Literacy
Marital Support
Aerobic Exercise
Parenting Mentors
EtOH in Moderation
Health and Well-Being
Reproductive Health Rest
To love and be loved…
Equal Opportunities
The Chance to Serve
Vocational Training
Healthcare Access
Financial Acumen
Adequate Income
Higher-Education
Meaningful Work
Employment
Civic-Sense
Vocation
Emotional Intelligence
Problem Solving Skills
Video Moderation
Good Body Image
Self-Discipline
True Friends
Study Skills
Literacy
Hobbies
Sport
Music
Integrity
Honor
Faith
Hope
Culture
Justice
Prenatal
Violence Prevention
Healthy Delivery
Community Good Public Policy
Nutritious Food
Environmental Safety Fresh Food
Safety
Parenting Classes
Water
…longitudinal approach
Smoking Cessation
Housing
Vitamins
Support Systems Greenspace
Visits
Transportation
Baltimore
Family
Basic assumptions::
Population health
is a strategic problem.
Basic assumptions::
Population health is a
strategic problem:
Solution requires:
Operational synchronization
Tactical execution
…coordinated care, one person at a time.
Basic questions::
…So how?
Wanted 2016:
Healthcare Leadership
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Collaboration and Cooperation
Strong listening / communication skills
Skills in “horizontal” shared leadership
Self-confidence and mental resilience
Humility: “the absence of arrogance”
Recognition and appreciation of others
Mentoring
Life-balance
Vision
ForCe
from Latin “fortis” strength
A Call for Medical Leadership
Google: henry V 4.3
http://henryV43.wordpress.com/
henryV43/
“We few,
we happy few,
we band of brothers…”
ForCe Leadership Model
• Character “Lead Self”
– Know who you are and what you’re doing
• Competence
“Lead Others”
– Know who you’re dealing with and what they need.
• Context
“Lead work”
– Know what needs to be done and why you’re doing it.
• Communication
“Lead the Story”
– Narrative & Rhetoric
– Stories we tell ourselves & find ourselves in.
Callahan, Grunberg 2016
ForCe Leadership Model
• Character – “Virtus” “Lead Self”
– Know who you are and what you’re doing.
– Talent
– Temperament
– Timber
– Trajectory
– “Trim” Balance & Belief
5T
henryV43
ForCe Leadership Model
• Competence – “Lead Others”
– Know who you’re dealing with and what they need.
– Sensitivity
– Styles
– Skills
– “Seens”
4S
henryV43
ForCe Leadership Model
• Context – “Pietas” “Lead Work”
– Know what needs to be done and why you’re doing it.
– Culture
– Climate
– Change
3C
henryV43/
ForCe Leadership Model
• Communication “Narrative & Rhetoric”
– Stories we tell ourselves & “stories we find ourselves in.”
–Narrative
–Rhetoric
NR
henryV43
ForCe Leadership Model
• Character “Lead Self”
– Know who you are and what you’re doing
• Competence
• Context
“Lead Others”
“Lead work”
• Communication
“Narrative & Rhetoric”
Callahan, Grunberg 2016
ForCe Leadership Model
• Character – “Virtus” “Lead Self”
– Know who you are and what you’re doing.
– Talent
– Temperament
– Timber
– Trajectory
– “Trim” Balance & Belief
5T
henryV43
Four “B’s” of Leadership: Foundation
• Read the Basics.
• Leadership reading list
• Read Biography
• In literature and in life
• Read your “Bible”
• Get “meta” every day
• Faith or philosophy
• Visit the Balcony
• Two deck chairs on the balcony…
Four “Be’s” of Leadership: Outcomes
• “Be the man or ma‘am.”
• “Be the one.”
• John Wesley
• “Be there.”
• Gunther Gabel-Williams
• “Be the change.”
• Gandhi
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No definite formula
No stopping rule
Many players
Solutions “good or bad”
not “true or false”
Unpredictable
Unique
Problem symptom of
another problem
Complex
Ambiguous
Uncertain
Horst Rittel, 1973
3000
Intal
Flovent
Azmacort
Beclovent
LTRA
Albuterol Neb
Albuterol Liq
2500
2000
1500
1000
500
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1998
success?
1999
Number Scripts Schofield Barracks
Number Scripts TAMC
3500
900
800
700
600
2000
500
Intal
Flovent
Azmacort
Beclovent
LTRA
Albuterol Neb
Albuterol Liq
2001
400
300
200
100
0
1998
1999
2000
2001
“…to leave the world a better place,
whether by a healthy child,
a garden patch or a redeemed social condition;
to know even one life has breathed easier
because you have lived,
this is to have succeeded.”
Ralph Waldo Emerson
“If you have built castles in the air,
your work need not be lost;
that is where they should be…
…Now put the foundations under them.”
Henry David Thoreau
UMMC’s Overarching Population Health Vision
“To dramatically improve the health and wellbeing of the West Baltimore population and our other
patient groups, beginning with our most complex and
vulnerable patients through a high-quality, delivery
system of advanced primary care homes in an
integrated “medical neighborhood” that improves
outcomes, reduces cost and enhances the patient
experience.”
Aligning the UMMC Population Health Strategic Plan
with the “Three Block” Medical Neighborhood model
G3♦S4,S5
Health Promotion
G4♦S6,S7,S8
Health Equity
G2♦S3
Complx Ch Dz Mgmnt
G1♦S1,S2
PAU Reduction
Reduce Potentially Avoidable Utilization
Inpatient Initiatives:
• Hospitalists
• ED / Urgent Care
• Case Management
“Transitional Care Coordination”
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Complex Chronic Disease Management
“The Patient-Centered Specialty Practice"
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Specialty Care
Chronic Disease Management
Promotion of Health and Well-Being
“The Patient-Centered
Primary Care Medical Home”
“Accountable Primary Care”
Transitional Care
G5♦S9
3.
Primary Care
“Accountable” Primary Care
Population Health: Lines of Effort and
Engagement
Lines of Effort:
• Program Execution
o Reduce Avoidable Utilization, Optimize Chronic Disease Care
• Strategic Communication
o Develop and communicate models linking population health w/ practice
• Community Collaboration
o Coordinate with West Baltimore University and Community efforts
Lines of Engagement: (“The Three-Block Medical Neighborhood”)
• Transitional Care Coordination
o Effective Hospital Care (Hospitalists / ED / Urgent Care, Case Mgmt)
• Specialty - Based Complex Chronic Disease Management
• Patient-Centered Medical Home