|By the Innovations Exchange Team|
"Our approach to community partnerships is to combine aligning services for people in a holistic way, and aligning advocacy for the entire neighborhood." —Eric T. Baumgartner, MD, MPH
The local health care system in Louisiana was devastated by Hurricane Katrina in 2005. A collaboration of local community clinics, the Louisiana Public Health Institute (LPHI), and other partners decided to work on rebuilding the primary care capacity and building the foundation for a high performing, sustainable, community-based approach to health care and population health. These efforts are increasingly being integrated with approaches of healthy communities to population health, and providing a new outlook for how the Greater New Orleans area will create measurable improvement in its population health outcomes. The resources for these activities are drawn from the community itself with significant contributions from Federal, State, and philanthropic funders.
Innovations Exchange: Why is important to focus on linkages between clinical, community, and public health providers to improve chronic disease care?
Dr. Baumgartner: When a person has a chronic condition, we need to address all influences on their personal health including their behavior in their environment, which goes beyond the scope of what a clinical provider typically does. These linkages need to be done thoughtfully and deliberately across the continuum of care (prevention, primary care, the spectrum of specialty and diagnostic services, and acute care) and address those behavioral and environmental influences on a person's behavior such as nutrition, physical activity, socialization, and access to social services.
These linkages are also important because environmental influences on a person's behavior are driven by community-level norms, policies, and market-place practices. Communities that create healthy environments and positive community norms improve the likelihood of preventing and managing chronic health problems in the population. Community norms, for example, may emphasize receiving regular primary and preventive care, having healthy nutritional habits, or engaging in a safe physically active lifestyle.
What gaps exist in this population's clinical care and how are they being addressed?
Before Hurricane Katrina, there weren't enough primary care clinics that were accessible and affordable to the poor and uninsured. This resulted in delayed care, an overuse of emergency departments for basic primary care, and ultimately poor health outcomes. Hurricane Katrina caused a major disruption and further reduction in capacity of the major public hospital and its adjacent ambulatory care sites.
To help meet the post-Katrina goal of creating high quality, affordable, and accessible community-based primary care and behavioral health services, the Centers for Medicare and Medicaid Services (CMS) awarded a $100 million grant to the Louisiana Department of Health and Hospitals in 2007. The Department partnered with the Louisiana Public Health Institute (LPHI) to stabilize and expand access to primary care and behavioral health services in the region. Twenty-five primary and behavioral health care organizations participated in the 4-year grant program. By the end of the program, these organizations operated 85 sites (an increase from 67 sites), which could demonstrate higher quality and more accessible services for the area's uninsured population.
These community efforts to ensure access to quality care for residents in post-Katrina New Orleans have been nationally recognized. Forty community clinic sites have been recognized by the National Committee for Quality Assurance (NCQA) for achieving Patient-Centered Medical Home status. Additional indicators of the success of community efforts are found in the 2009 survey by The Commonwealth Fund.1
Eighty-eight percent of patients reported that they had easy access to care.
Seventy-nine percent of patients reported excellent patient–clinician communications.
- Eighty-two percent of chronically ill adults with an excellent patient experience indicated that clinicians had helped them manage their conditions compared with 65 percent of adults with a suboptimal patient experience who felt clinicians had helped them manage their conditions.
Seventy-five percent of patients said they were very confident in their ability to get high-quality and safe medical care if they became seriously ill. In contrast, 39 percent of adults elsewhere in the United States were very confident that they could get high quality and safe care.
Building upon these successful efforts to establish high-performing community clinics, many former CMS grantee clinics and an additional large regional hospital partner are engaged in the Crescent City Beacon Community (CCBC) collaborative as one of the 17 national Beacon initiatives sponsored by the Office of the National Coordinator for Health Information Technology (ONC). Now into the third year of CCBC, many of these clinics are advancing their culture and capacity for population health management by coordinating care internally in a more robust, high-quality manner, while building relationships and the informational infrastructure for transitions of care with regional providers of the full continuum of care.
What gaps exist in the primary care referral network?
In our effort to help these community clinics establish referral relationships across the continuum of care, we have unfortunately not yet made meaningful breakthroughs. There is still a shortage of many specialties and subspecialties, including in gastroenterology, orthopedics, and dermatology in our community. Also, many specialists are responding to market forces and trying to manage the payer mix to optimize revenue.
Moreover, patient health information doesn't flow between primary care providers and specialists, leading to an inefficient use of the specialist's time when the right information isn't received. Conversely, primary care providers don't receive information from the specialists about test results, procedures, and any required patient followup or aftercare. The community is addressing this issue through the CCBC.
Another barrier is long wait times for some specialty procedures such as colonoscopies or some orthopedic surgeries because many of these outpatient procedures must still be performed in hospital settings with expensive specialized equipment. There is limited capacity compared to the demand.
Can you provide some examples of innovative linkages?
There are several community clinic operators in metropolitan New Orleans who have shown in their mission statement and, to some extent, in their operational practices, that they provide adjunctive services beyond the traditional scope of clinical services or link their patients to them. For example, we have a few clinics, such as the NO/AIDS Task Force clinic and the Daughters of Charity, which have offered or currently offer exercise space on their campus. Structured exercise activities are offered to patients in their neighborhoods, which promotes safe active living as both as a primary prevention and chronic disease adjunct.
The Daughters of Charity and the St. Thomas Community Health Clinic, which offer specialty services in addition to primary care services, have worked with the Interim Louisiana State University Hospital to facilitate direct case consultations between clinic primary care providers and specialists.
Another example of innovative linkages is the new Mahalia Jackson Center in Central City, New Orleans. The center has co-located several government social service agencies, a library, an elementary school, nonprofits, a clinic, and a neighborhood civic engagement organization. It has become the neighborhood hub for relationships with public or nonprofit family services, and a model of a holistic patient/family-centered approach to health for other neighborhoods.
There is also a citywide nonprofit in New Orleans called The Neighborhoods Partnership Network (NPN). Its mission is to conduct leadership development for New Orleans residents and help them form effective civic engagement organizations in their neighborhoods. NPN helps these neighborhood associations be more effective by having a consensus, evidence-based set of priorities, and the ability to implement their priorities by influencing community stakeholders through direct action or information sharing.
LPHI has partnered with NPN to promote civic engagement at the neighborhood level using an evidenced-based approach to creating healthy communities. The first strategy is to provide a wealth of information across the broad determinants of health as well as model practices, tools, and helpful organizations via an open Web platform. The second strategy is to engage salaried LPHI "Neighborhood 'Health' Liaisons" to coach and work with residents in creating neighborhood associations. Growing and building on these complimentary strategies will help New Orleans become the most informed community in the nation, and one that is aligned with health services and social services and the broader determinants of health.
What role is LPHI playing to facilitate clinical and community linkages?
LPHI is a nonprofit organization established in 1997 to improve community health. The Institute has an annual budget of $30 million and 80 employees from multiple disciplines, including informatics, systems development, research and evaluation, and social marketing. Through a series of Federal and State-funded programs as well as philanthropic grants, we have built relationships with clinics over the last decade, and helped infuse millions of operational dollars into community clinics for electronic medical record adoption, quality and business cycle improvement, and referral relationships. These efforts are related to applying the Beacon grant toward building clinical quality in population health management and support for systems of care through a community health information exchange.
LPHI also helps clinics develop relationships with community partners and understand the neighborhoods in which they reside. We recently developed a project concept that will support, among other strategies, clinics building neighborhood partnerships to support healthy lifestyles for their patients. For example, in the plan, clinics will write "prescriptions" for food items for patients to have "filled" at a farmer's market in their neighborhood at a discount or "prescribe" family activity in the nearby park that would be refurbished to make it safer for people in the neighborhood to engage in safe active living.
LPHI is facilitating informed linkages by preparing and providing data down to the neighborhood level for the broad determinants of health, and natural and manmade attributes of each of the 72 New Orleans neighborhoods. In addition, we are building neighborhood maps and profiles on the demographics, housing, economics, and health metrics of the neighborhoods surrounding some of the community clinics committed to being in more effective partnerships with their respective neighborhoods.
We also profile entities residing in neighborhoods that are known to be effective partners with residents in creating healthier neighborhood circumstances. The goal is to give clinic operators a sense of confidence and competence on how they can have more conversations with civically engaged people that live around them, and develop a common agenda of linking clinical care to other aspects of people's daily behavior in their environment. The New Orleans neighborhood health information and maps are available at http://www.healthynola.org.
What is the public health professional's role in these linkages?
The New Orleans City Health Department is the only local health dept in the state. All other parishes and communities have their public health administered by the Louisiana Office of Public Health. The New Orleans City Health Department, in previous administrations, was trying to maintain direct health care services with an underfunded budget. When the current administration came in 2 years ago, there was a commitment to have the health department be a leader in this community based on a deep understanding of the drivers of community health. The health department began reducing legacy direct clinical health services to develop and committing more staff resources to population health, community assessment, leadership, and linkages. They are well into this transformation.
Health Commissioner Dr. Karen DeSalvo has created a new atmosphere for the government's role in local health. Her administration is working with the general health services community, nonprofits, and local foundations to bring a more unified approach to health. The health department has been bringing together different community sectors to align assets to create sustainable circumstances for health.
What are the major challenges for health professionals who want to develop clinical and community linkages for this population?
A challenge is to find and connect people in organizations who are inclined to build linkages, which by definition means engaging in nontraditional activities and collaborative relationships, that organizations don't entirely control. My observation is that every community already has these professionals in various sectors. The challenge is to create the space and the call to action, and to find the early champions in organizations who can take the lead.
There is an ocean of missed opportunities for alignment of services for both primary prevention as well as managing chronic conditions. In this age of payment reform, organizations and provider networks must consider a new world order whereby reimbursement will be tied to measurable changes in the patient population, rather than to volume of covered services rendered. The more that organizations can reach a threshold of spending time, energy, and resources on building relationships where evidence shows that the more patients with diabetes or congestive heart failure, for example, receive better management, there will be a measurable increase in health.
There is also a general challenge of collaboration, which requires leadership, not just organizational or heroic leadership, but cross-sector leadership. But such innovative collaborative leadership is not as evident or amplified as the traditional organizational management style.
One of LPHI's overarching strategic goals for a healthy New Orleans is to see the creation of a formal community health charter, which codifies a strategic community health vision and a cross-sectoral leadership or advisory structure that would deepen, broaden, and sustain these collaborative, cross-sector community linkages. Our neighbor city, Baton Rouge, has created such a charter, which gives us confidence that we will achieve a similar structure. But, a challenge we face is that people have their usual priorities and traditional domains of what they manage and influence. The nature of collaboration is for them to spend time on creating a new agenda with other organizations, while being comfortable with changing how they let others overlap with what they see as their mission. It takes patience and leadership to help each of those organizations/sectors see opportunities to mutually support their respective missions and common interests. This will foster strategic change across communities as well as policy and environmental changes and social norms.
How are you evaluating community linkages?
The evaluation approach and framework for the Healthy New Orleans Initiative mimics a participatory evaluation method, in which participants move along a scale of engagement with a tool or system, from passive to active. Ultimately, we plan to track changes in neighborhood assets and health status. However, due to budget constraints, most of the measures have not been tracked or implemented to this point. However, we are building a chronicle of what we are doing, and still have an opportunity to build a retrospective evaluation plan.
The figure in the Healthy New Orleans Initiative Evaluation Framework2 describes the types of possible engagement, and suggested related measures. Success is measured as moving from passive to active engagement.
Neighborhood associations are encouraged to use the public information on the Web platform (http://www.healthynola.org) to inform their consensus priorities and act upon them. There is a built-in baseline of metrics in the neighborhood profiles that the neighborhood associations can use as benchmarks to see what changes occurred over time. Of course, the CCBC Beacon programs as well as related activities with clinics have formal evaluation plans in play also.
Through the Neighborhood Health Liaisons and representatives from a host of community organizations, we also provide coaching to help neighborhood associations create their own profile or dashboard on the platform with their priorities. They can also import information about model practices, relevant guides and tools and contact information to support their strategies. The platform can also be used also to describe their neighborhood objectives and set a deadline. An example of such an objective is two groceries or three parks that are clean and safe with structured programming for children and families. We want them to be specific in their neighborhood level health charter so they can track changes over time, and input information. For example, if they say we want no blocks where street lights are out, they can produce a detailed map of current street light functionality, which they can upload into their Web page and track the changes over time.
Health disparities in New Orleans reside at the neighborhood level. A foundational part of our work is to get information closer to the ecology of where people live daily. If we want to have measurable change in New Orleaneans' health and health equity statistics, those changes will only occur in neighborhoods with disparate health and equity burdens. We will also continue to have relationships with these neighborhoods and be aware of what they are doing, including setting goals and using and adding information. Through the HealthyNOLA.org Web platform, we will be able to see shared interests or patterns of what's working or not, and ways to improve Web site functions and content to better meet what people and organizations really need to make more informed decisions.
Neighborhood clinics, acting as partners with community residents, can assure delivery of continuous primary care and health information, and can increasingly become that "Community Centered Health Home" that deliberately augments neighborhood health assessment, informs evidenced-based health prioritization, and acts as an effective advocacy partner for the community health agenda. A growing number of neighborhood clinics are engaging in such activities. In this way, they can be part of the whole person/whole community approach to linking medicine, prevention, and promotion of the public's health.
What lessons have you learned from your own experience developing/evaluating clinical and community linkages?
We also encourage neighborhoods to think about the policy change that they consider to be important—there are a lot of challenges in New Orleans, including those relating to housing practices, transportation, infrastructure, and public safety. We think that that the environmental and policy change priorities of one neighborhood are generally shared by other neighborhoods. Having a collective approach to building a community health agenda enables civically engaged people to create an evidence basis for prioritizing changes in their communities that can be distilled into policy statements. We and our partners can bring in the evidence, and to the extent that these become shared policy priorities, there will be a known constituency behind it due to neighborhood relationships. We think that a huge mobilized constituency and built-in, evidenced-based community stories will help accelerate policy changes rather than relying on single voices and leaving communities to fight their own struggles.
We are working to secure local ownership of this work to assure its sustainability after the grants end. We understand that no program should be sustained if it is not perceived as valuable. We will continue to work with sector leaders, including civically engaged residents, to better understand how we can produce value across this community so that the community will own it and sustain it in the future. Then, we can grow the adjunctive strategies that could help this community be the most informed in the nation, and aligned around health and social services and broader determinants of health. A challenge is to get strategic ownership and sustainability for the HealthyNOLA.org Web platform and neighborhood health liaisons.
The value is that this community will have as a permanent attribute, an approach to alignment to related health and social services that are the broader drivers of health and health equity. There are numerous strategies we think are complementary to this that we hope would be part of our community capacity going forward and part of a broader strategy and ownership.
About Eric T. Baumgartner, MD, MPH
Dr. Baumgartner is a career public health physician committed to the mission of creating population health and access to care. He currently serves as Director of Policy and Program Planning for the Louisiana Public Health Institute (LPHI), a Technical Assistance Team Leader for the Georgia Health Policy Center's Rural Health Network Technical Assistance Program, and a national coach for communities in action around health and health care.
Disclosure Statement: Dr. Baumgartner reported that his salary has been supported from grants awarded to LPHI including the CMS Primary Care Stabilization and Access Grant, the Kresge Foundation, CDC's REACH Core Cooperative Agreement, and ONC's Beacon Cooperative Agreement. Dr. Baumgartner also worked as a consultant for the Georgia Health Policy Institute, and provided technical assistance to the Health Resources and Services Administration and the Office of Rural Health Policy.
1 Coming Out of Crisis: Patient Experiences in Primary Care in New Orleans, Four Years Post-Katrina, The Commonwealth Fund. January 2010.
2 Healthy New Orleans Initiative Evaluation Framework. Adapted from the Key Performance Indicators Framework drafted by the International Institute for Sustainable Development (IISD).