On the stump for bet­ter health

Grass-roots ap­peal aims to boost S.C. town’s health

Modern Healthcare - - FRONT PAGE - Lola Butcher

Can the com­mu­nity or­ga­niz­ing tac­tics that em­pow­ered mi­grant farm work­ers in the 1970s and helped elect Pres­i­dent Barack Obama in 2008 empty out Amer­ica’s over­loaded emer­gency de­part­ments?

Six physi­cians-turned-or­ga­niz­ers are work­ing in Columbia, S.C., to find out.

They are us­ing or­ga­niz­ing tac­tics—cold calls, house meet­ings, com­mu­nity as­sem­blies and ral­lies—to jump-start a cam­paign in ZIP code 29203, one of the un­health­i­est ar­eas in the coun­try. The cam­paign goal: to em­power res­i­dents to take re­spon­si­bil­ity for the health of their com­mu­nity.

The Healthy Columbia cam­paign had its of­fi­cial kick­off in March, but it has been build­ing steam for more than a year. Dur­ing that time, many ideas have bub­bled forth—from ex­pand­ing hours at pri­mary-care clin­ics and build­ing walk­ing trails to train­ing church mem­bers how to do blood pres­sure checks and re­cruit­ing driv­ers to take peo­ple to med­i­cal ap­point­ments.

The cam­paign has en­listed the help of the area’s ma­jor health­care providers, Pal­metto Health and Prov­i­dence Hos­pi­tals, along with the city of Columbia, the South Carolina Hospi­tal As­so­ci­a­tion, the South Carolina Depart­ment of Health and En­vi­ron­men­tal Con­trol, Blue Cross and Blue Shield of South Carolina and Eau Claire Co­op­er­a­tive Health Cen­ters, which op­er­ate fed­er­ally qual­i­fied health cen­ters in the 29803 area.

The core com­po­nent of the cam­paign is a com­mu­nity covenant, in which peo­ple who live and work in 29203 sign a pledge to take care of their own health and the health of their neigh­bors. That may mean mon­i­tor­ing their blood sugar level or start­ing an ex­er­cise pro­gram, but it also may mean vol­un­teer­ing to be on a health watch team that checks on frail el­derly neigh­bors or ad­vis­ing a hospi­tal CEO about what time the pri­mary-care clinic should open.

If the cam­paign works as en­vi­sioned, one mea­sure of its suc­cess will be that res­i­dents stop us­ing emer­gency de­part­ments for pri­mary care or emer­gency care that could have been avoided. But that in­di­ca­tor would have more im­pact on res­i­dents than it would on the hospi­tal, said Dr. Michael “Shawn” Stin­son, one of the cam­paign’s physi­cian or­ga­niz­ers and vice pres­i­dent of clin­i­cal qual­ity and pa­tient safety at Pal­metto Health, a three-hospi­tal sys­tem based in Columbia.

“That will un­clog our emer­gency rooms so that we’re not pro­vid­ing emer­gent care to a di­a­betic that could have been dealt eas­ily in the am­bu­la­tory set­ting three weeks ear­lier,” he said. “Or could have been dealt with three years be­fore with bet­ter diet and ex­er­cise. Or could have been dealt with 30 years be­fore with ed­u­ca­tion about a health­ier life­style.”

Be­cause this ap­proach has never been tried in health­care be­fore, the po­ten­tial out­comes are hard to pre­dict. Dr. Laura Long, vice pres­i­dent for clin­i­cal qual­ity and health man­age­ment, Blue Cross and Blue Shield of South Carolina, said the cam­paign must keep go­ing un­til res­i­dents’ health sta­tus—and health­care costs—are brought un­der con­trol.

“We must suc­ceed,” she said. “It’s not a choice any more. We must suc­ceed.”

Ag­i­tat­ing for change

Long and Stin­son are two of six physi­cian-ex­ec­u­tives re­cruited to serve on the “vi­sion team” of Or­ga­niz­ing for Health’s first-ever com­mu­nity cam­paign. The six were re­cruited in part be­cause of their lead­er­ship po­si­tions in area or­ga­ni­za­tions, and work­ing on the Healthy Columbia cam­paign is now a part of their jobs.

Or­ga­niz­ing for Health is a project of Re­think Health, an ini­tia­tive of the Fan­nie E. Rip­pel Foun­da­tion that brings to­gether top thinkers in health­care and other fields to con­sider how a sus­tain­able health­care sys­tem might be cre­ated. Dr. Don­ald Ber­wick, for­mer ad­min­is­tra­tor of the CMS, and Dr. El­liott Fisher, di­rec­tor for Pop­u­la­tion Health and Pol­icy at the Dart­mouth In­sti­tute for Health Care Pol­icy and Clin­i­cal Prac­tice, are found­ing mem­bers of Re­think Health, along with Peter Senge, di­rec­tor of the Cen­ter for Or­ga­ni­za­tional Learn­ing at the MIT Sloan School of Man­age­ment, and oth­ers.

Since July 2011, the Rip­pel Foun­da­tion has given $250,000 to sup­port the Or­ga­niz­ing for Health or­ga­niz­ers and con­sul­tants in the Healthy Columbia cam­paign. The grant pays for one full-time worker and four part-timers.

While Healthy Columbia is the first cam­paign, its pro­po­nents think the con­cept will spread as the or­ga­niz­ing model proves it­self.

“Any com­mu­nity that said we’re go­ing to just go out and to­tally change the health of an

en­tire city or metro area would find that is over­whelm­ing,” said Dr. Richard Foster, se­nior vice pres­i­dent of qual­ity and pa­tient safety at the South Carolina Hospi­tal As­so­ci­a­tion. “So we are start­ing small, but the work we are do­ing should be able to be repli­cated in the larger com­mu­nity or across an en­tire state.”

Terri Jow­ers, Or­ga­niz­ing for Health’s lead or­ga­nizer in Columbia, said the task is to change the bal­ance of power be­tween health­care providers and the peo­ple they seek to serve. She sees the cur­rent bal­ance as physi­cians and other providers hav­ing “power over” pa­tients. “It’s the med­i­cal pro­fes­sion up here and the peo­ple down there,” she said. “We hope to build a sys­tem so it is ‘power with’—in­di­vid­u­als tak­ing per­sonal re­spon­si­bil­ity for their own health, mak­ing a com­mit­ment to sup­port each other’s health, and ask­ing key stake­hold­ers like providers and pay­ers to sup­port them in their ef­forts.”

Ac­cord­ing to or­ga­ni­za­tional the­ory, that model will in­crease the like­li­hood that res­i­dents know about and use health­care re­sources that can im­prove their health sta­tus.

“In the past, we would put a lot of money into a project and then be frus­trated when the com­mu­nity didn’t em­brace it, didn’t show up, or didn’t make a change,” Stin­son said. “Now I’m re­ally start­ing to un­der­stand why.”

Kate Hil­ton, the di­rec­tor of Or­ga­niz­ing for Health, is a prin­ci­pal in prac­tice for the Lead­ing Change Project at Har­vard Univer­sity. Dur­ing the site-se­lec­tion phase of the project, Hil­ton honed in on Columbia’s largest ZIP code—29203, known as Eau Claire/north Main area—in part be­cause it has more than 40 neigh­bor­hood as­so­ci­a­tions.

“So there is this power struc­ture, and lots of peo­ple who are ac­tively in­volved in neigh­bor­hoods and safety is­sues and a num­ber of things,” Jow­ers said.

The en­tire state of South Carolina has health chal­lenges—more than 60% of the pop­u­la­tion is over­weight, one-third has high blood pres­sure and 11% suf­fer from di­a­betes—but the picture in ZIP code 29203 is even worse. Stin­son said 29203 has one of the high­est rates of am­pu­ta­tion in the coun­try due to di­a­betes.

One-third of the 45,000 res­i­dents are unin­sured, and the av­er­age res­i­dent makes two emer­gency depart­ment vis­its each year. That trans­lates into 90,000 ED vis­its a year, in­clud­ing 30,000 from res­i­dents with no abil­ity to pay.

The ZIP code is home to two hos­pi­tals, in­clud­ing Pal­metto Health Rich­land, a 647bed teach­ing hospi­tal as­so­ci­ated with the Univer­sity of South Carolina.

“A few years ago, we were rec­og­nized as hav­ing the great­est im­prove­ment in mor­tal­ity of any health sys­tem in Amer­ica,” Stin­son said. “And we sit in one of the least healthy com­mu­ni­ties in the na­tion. So we know the dis­con­nect there.”

Re­cruit­ing the lead­ers

Af­ter con­duct­ing about 40 one-to-one meet­ings in Columbia to learn about lead­ers, re­la­tion­ships and his­tory of the com­mu­nity, Hil­ton re­cruited the vi­sion team. In ad­di­tion to Foster, Stin­son and Long, it in­cluded Dr. Lisa Wad­dell, South Carolina’s state deputy com­mis­sioner for health ser­vices; Dr. Casey Fitts, a sur­geon and med­i­cal di­rec­tor of Tri-county Project Care; and Dr. Stu­art Hamil­ton, CEO of Eau Claire Co­op­er­a­tive Health Cen­ters.

Although their po­si­tions in the health­care com­mu­nity were a fac­tor in their se­lec­tion, Hil­ton sought out team mem­bers with spe­cific qual­i­ties, in­clud­ing tenac­ity and a will­ing­ness to try dif­fer­ent ap­proaches when some­thing does not work as planned.

“We were look­ing for who felt re­ally pas­sion­ate about change and have a sin­cere ur­gency for change,” she said. “Peo­ple who are learn­ers. Peo­ple who have a his­tory of col­lab­o­rat­ing with one an­other. Peo­ple who had been in the sys­tem at dif­fer­ent places.”

Pick­ing the ‘bad guy’

Team mem­bers went to Bos­ton to be trained in or­ga­niz­ing prin­ci­ples by Mar­shall Ganz, a key fig­ure in or­ga­niz­ing for the United Farm Work­ers and the man cred­ited with map­ping out the grass-roots cam­paign that elected Obama. He told them to fig­ure out what they were or­ga­niz­ing against. “We learned that we needed a bad guy,” Stin­son said.

Brain­storm­ing yielded the stan­dard re­sponses. Pay­ers were pro­posed as the bad guy, then providers and then politi­cians.

“When­ever we came up with a ‘bad guy’ that was one of these en­ti­ties, the fear was that we would end up on op­po­site sides,” he said. “We fi­nally came up with chronic dis­ease as the bad guy, and well­ness as the good guy, and we ac­tu­ally could all work to­gether to sup­port it.”

Ganz and Hil­ton also taught the physi­cians some­thing no one learns in med­i­cal school: how to re­cruit peo­ple to be ac­tive par­tic­i­pants in a ma­jor change.

“We watched the Obama speech back in 2004 at the Demo­cratic Na­tional Con­ven­tion to learn the power of nar­ra­tive,” Stin­son said. “We spent a long time learn­ing how to tell sto­ries, how to evoke emo­tions to get peo­ple in­volved, and then how to fol­low that up with the ‘ask.’ It’s not just telling a story for the story’s sake, but you’re try­ing to ac­com­plish some­thing with it.”

Re­turn­ing to Columbia, mem­bers of the vi­sion team started prac­tic­ing their new­found skills. They called peo­ple they had never met to ask for one-to-one meet­ings. They so­licited spe­cific things the cam­paign needed. And they started see­ing their own roles dif­fer­ently.

“Although there is def­i­nitely a tran­si­tion tak­ing place in health­care to em­power the pa­tient to be on equal foot­ing with the doc­tor, that is not the way we were trained, and it’s cer­tainly not the model that most of us have prac­ticed,” he said.

The plan­ning stage of the cam­paign be­gan in July 2011, with eight months of work that in­cluded 130 one-to-one meet­ings, a town hall meet­ing that at­tracted more than 90 neigh­bor­hood res­i­dents, 45 house meet­ings at­tended by 750 com­mu­nity mem­bers and train­ing for nearly 300 res­i­dents on how to be com­mu­nity or­ga­niz­ers.

Or­ga­niz­ers an­a­lyzed state health data to iden­tify which blocks within 29203 have the high­est rates of in­ap­pro­pri­ate ED vis­its, hospi­tal read­mis­sions, di­a­betes, heart dis­ease and other in­di­ca­tors of poor health sta­tus. They used that in­for­ma­tion to map three “turfs”— ge­o­graphic ar­eas home to about 3,000 res­i­dents each—to start the real work of the cam­paign.

“While 1 in 3 are unin­sured in the en­tire ZIP code, the three ar­eas that we have tar­geted have about 50% of res­i­dents unin­sured,” Jow­ers said.

The of­fi­cial kick­off in March drew more than 500 res­i­dents to hear a gospel choir, a speech by the mayor and a com­mit­ment cer­e­mony in which res­i­dents, health­care providers, church mem­bers and oth­ers pub- licly stated their com­mit­ment to im­prov­ing health­care in 29203.

Jow­ers said the cam­paign has no end date. As res­i­dents as­sume a greater role in im­prov­ing the health of their com­mu­nity, Or­ga­niz­ing for Health per­son­nel will grad­u­ally re­duce their in­volve­ment.

“It’s a par­a­digm shift with the com­mu­nity be­com­ing equal part­ners in their health and health­care,” she said. “The cit­i­zens of this com­mu­nity and of this state have to own the cam­paign. It is theirs. When there are needs for com­mu­nity or­ga­niz­ers, then the folks who are in­volved will find a way to make that hap­pen.”

The physi­cian an­gle

Spe­cific goals such as a cer­tain per­cent­age of re­duc­tion in ER vis­its have not yet been es­tab­lished, but the big-picture goals are set: to in­crease ac­cess to pri­mary care, re­duce the cost of health­care for cit­i­zens and providers, and rein­vest money saved into com­mu­nity ini­tia­tives, such as build­ing satel­lite care cen­ters and train­ing health coaches.

Sev­eral strate­gies for im­prove­ment have al­ready emerged. One is to re­cruit vol­un­teers who will work un­der su­per­vi­sion of a nurse prac­ti­tioner or nurse to pro­vide care in peo­ple’s homes. “These are peo­ple who have a lit­tle bit of train­ing that can ac­tu­ally go out and check peo­ple’s blood pres­sures, check their blood sugar, make sure they are tak­ing their med­i­ca­tion,” Jow­ers said. “If it looks like there is a prob­lem, they can let some­body know, so that the pa­tient is get­ting sup­port im­me­di­ately.”

Also, health coaches will be as­signed to keep an eye on peo­ple who have just been re­leased from the hospi­tal and are at high risk for read­mis­sion or help preg­nant women take good care of them­selves.

As the com­mu­nity or­ga­nizes it­self, health sys­tems and in­sur­ers have pledged to sup­port their ef­forts. As part of their com­mit­ment to Healthy Columbia, Pal­metto Health is adopt­ing the pa­tient-cen­tered med­i­cal home model, and Blue Cross and Blue Shield of South Carolina will pay physi­cians for im­proved man­age­ment of chronic dis­eases.

“Blue Cross would want to pay physi­cians dif­fer­ently and per­haps pay health coaches to do door-to-door ser­vices,” Long said. “We will be look­ing at all kinds of things that get cre­ated in that com­mu­nity if they are shown to re­duce ER uti­liza­tion and hos­pi­tal­iza­tions.”

More than 90 res­i­dents of ZIP code 29203 gath­ered for an Or­ga­niz­ing for Health town hall meet­ing last sum­mer.

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