A New Way of Thinking About Health: Changing How We Change Bruce - - PowerPoint PPT Presentation

A New Way of Thinking About Health: Changing How We Change

Bruce Behringer, MPH June 1, 2017 Deputy Commissioner for Continuous Improvement and Training Tennessee Department of Health (Retired)

Initial comments

• Your regional challenge
• Your selected priorities
• The wording you choose

• Advantages and disadvantages of being

Tri-State

• Strength of sense of regional

community

• Different policies, people, priorities and

portions

• Ability to feed ideas across lines

Your regional challenge

Your selected priorities are troubling issues that require:

• Continuing and continuous care
• Coordination of effort between patients

and providers and among providers

• Focus on risk reduction
• Really hard behavior change
• Broader more comprehensive public

interventions

Clarify your language: Differentiate between health problems and solution

• Regional health

issues

– Behavioral and substance abuse – Chronic Disease

• Strategies address

issues

– Access to care – Data and technology

• Learn from lack of clarity in nation health care reform

debate  Health, health care, or health insurance?  Which essential benefits?

• Access to what?

 Treatment, coordinated care, preventive services, knowledge and skills to adopt healthy behaviors

Five ideas for your consideration

• Units of practice to expand who could be

involved with regional population health improvement

• Working together strategies to reconsider

steps in process toward change and success

• Give-Get Grid to identify and value

contributions and benefits of the many

• Aspects of community health to record,

track and evaluate regional population health issues

• Strategic maps to display visible outcomes of

effort

Units of practice, Units of solution

• Helps to consider “who

else” contributes to health?

• What is your
• rganization’s

traditional unit of practice?

• How could

effectiveness be improved with broader units of solution?

• Engages and involves

more in the solution

From: Stewart G. (1993). Social and Behavioral Change

• Theory. Health Education Quarterly. Supplement 1:

S113‐S135.

TOOL 1

Working Together Strategies

• Networking: Exchanging information for mutual

benefit

• Coordinating: Exchanging information for mutual

benefit and altering activities for a common purpose

• Cooperating: Exchanging information for mutual

benefit, and altering activities, and sharing resources for a common purpose

• Collaborating: Exchanging information for mutual

benefit, and altering activities, sharing resources, and enhancing each other’s capacity for a common purpose

Arthur Turovh Himmelman. 2007 CDC Cancer conference.

TOOL 2

Working Together Strategies

• Provides framework for planning
• Classify each opportunity for working together
• Consider requirements to move to next step
• Cooperating becomes a regional goal for

change

• Incidents of collaborating should be identified,

documented, evaluated, and awarded

• Important to recognize common purpose and

how organizations increase each other’s capacity

Behringer, 1992 (multiple references)

TOOL 3

Explanation of cells in model

• Each partner to defines own “Give” and

“Get” cells

• Cell contents

– Gives – promised contributions – Gets – expected benefits

• Negotiate relationship together to …

– Learn each other’s missions, values and resources (and limitations) – Discover value of own resources (not necessarily money) as contributions – State expected benefits to hold partners publicly accountable to process and shared

• utcomes

What the Give‐Get Grid is not

• “Giver and receiver” relationship

between those of greater and lesser power and resources

• Set of short‐term promises just to get a

grant or express support for a program

• Traditional “win‐lose” approach or even

“win‐win” thinking

What the Give-Get Grid is

• Focuses on development of long term,

continuing relationship

• Provides framework for dual and shared

and benefits

• Promotes a sense of accountability among

partners

• Framework to share new external sources

support that address community-identified issues and open doors to community

• Used for formative evaluation of a planned

collaborative program

Background beliefs

• Partnerships defined as redistributed

power brought about through negotiations (Arnstein)

• Equality of partners achieved through

recognizing assets, not just needs (Kretzman and McNight)

• Value participation and development of

relationships based upon contributions seen as meaningful, challenging (Depree)

• Define own and others’ interests leading to

stating expectations of benefits (Fisher and Ury)

Give‐Get Grid Example 1992:

Community Partnerships for Health Professions Education

University gave:

• New curriculum
• Student time in community
• Faculty expertise
• New health service site

University got:

• Rural training location
• Expanded service area
• National rural reputation
• Recruit new faculty/students

Community got:

• More doctors and nurses
• New preventive services
• Strengthen health

system

• Their children in college

Community gave:

• Permission, time and energy
• Use of practice and services
• Space, homes
• Teaching “Small Town 101”

Example 2007: Appalachian Communities and Comprehensive Cancer Control Coalitions

Communities gave:

• Volunteer community time
• Local knowledge of cancer
• Ally for advocacy
• Local credibility and leaders

Communities got:

• State recognition of local

needs and accomplishments

• Connection for cancer

information and resources

• More programs and services
• Address cancer problems

CCCs got:

• Help to complete and

implement state plan

• New partners and members
• Local evidences of success
• Reduce state burden of cancer
• Statewide interconnectedness

CCCs gave:

• Appreciation and recognition
• Materials, services, paid field

staff to support local efforts

• State cancer plans, data and

coalition infrastructure

• Support health policy change

U Pittsburgh-Oakland Get Give

Center for Rural Health as a regional collaborative group project

Get Give Give Get U Pittsburgh-Bradford Bradford community

• rganizations

Example 2009: Bradford (PA) Center for Rural Health with multiple partners

Value of the Give-Get Grid

• For planning across multiple parties

– Level of participation – Time commitment – Expertise

• For evaluation of cooperative efforts

– Repeat use of grid every year and compare promises with reality – Count number of contributions and benefits cumulatively over time

How to address typical frustrating dilemma

Patients and community

Health care providers and systems

These common attitudes just do not serve a region well

• r promote cooperation to improve region’s health.

Model of Health Care Access, Anderson and Aday (1981)

Measured by consumer satisfaction Population Needs Measured by Utilization of services Health Policy Financing and Organization Structural Availability of care

Aspects of Community Health Model

Characteristics

• f population

and community Characteristic s of health services and systems

Behringer Adapted from: Model of Health Care Access, Aday and Anderson (1981)

Population Health Outcomes

TOOL 4

Aspects of Community Health Model

Characteristics of population and community Characteristics

• f health

services and systems

Providers  Patients

Interactions

System  Community

Population Health Outcomes

One successful use 2014: TDH Focused Community Assessment Model Variables

Health Status and Outcomes

• Risk
• Morbidity
• Mortality

Characteristics of the Population and Community

• Demographics
• Cultural
• Environmental

Interaction

• Satisfaction
• Evaluation

findings

Characteristics of Health Services and System

• Use of services
• Cost
• Workforce

Assessment process identified eleven variables

Part of Community Health Assessment and Improvement Plan process

Aspects of Community Health Model Data Collection Tool

Health issue problem statements Health services and system factors Population and community factors

Interaction factors

Use of Aspects model - HOW

• Use sheets to collect data and ideas for

topic problem statements, population and systems factors.

• Create central visible repository to accept

and integrate input

• Key questions

– Who will collect data? – How will it be shared in a timely manner? – What participatory processes can interpret it? – Who will be responsible for acting on findings?

Use of Aspects model - WHY

• “No numbers without stories, nor stories

without numbers”

• Root solution in community’s lived experience

and collective impact

• Data is valuable regional asset IF collected,

shared and interpreted together

• Repository as regional asset to:

– Explain reasons why the problem exists and factors that contribute to problem change theory – Guide development of interventions from assessment to concepts to strategies to evaluation

Taken together, a framework of regional leadership without authority

• Most regions have no continuing public forum

for communication, debate and accountability

• Engage without finger pointing
• Partnering, not ownership, as the key

principle

• Focus cooperative energy on agreed upon

changeable issues

• Build in accountability with understandable
• utcome measures
• Collaboration = combined investments with

shared benefits

• Give it time to work

The Strategic Map

• One-page “map” that documents actions and

efforts

– “The relationship between the drivers and the desired

• utcomes constitute the hypotheses that define the

strategy“ – Kaplan and Norton – CDC adaptation is an excellent tool for public consumption – “We are doing something!”

• Promotes inclusive thinking

– Focus on regional cooperative actions – Include adoption of individual organization’s best practices

TOOL 5

Public Health Approach to the Opioid Abuse Epidemic Tennessee Department of Health Strategic Map, 2016

Expand efforts to reduce NAS Actively support community coalitions Expand use of optimal prescribing guidelines Provide prescriber/ dispenser education on regulation & enforcement

Improve collaboration with law enforcement

Expedite investigations supporting Board oversight

• f prescribers

Adopted 1/11/16

Expand treatment alternatives to incarceration Partner with Mental Health to expand treatment

• ptions for opioid misuse

Optimize use of the CSMD Improve the high risk patient model Link other data sources to the CSMD Destigmatize & approach addiction as a treatable chronic illness Eliminate “Pill Mills” Develop a high risk prescriber model for individuals and practices Improve legislation to allow proactive regulation

Reduce Opioid Misuse, Abuse & Overdose

Improve Primary Prevention Improve Regulation and Enforcement Increase Utilization

• f Treatment

(2º Prevention) Improve Monitoring and Surveillance A B D C

Secure/Realign Resources and Infrastructure to Implement Comprehensive Approaches

Facilitate community interventions, including safe disposal of drugs Expand appropriate use of MAT Expand SBIRT training and use Advocate for Prescription for Success including treatment and care

Expand and Strengthen Key Partnerships and Collaborative Infrastructure Use Data, Evaluation and Research to Inform Interventions and Continuous Improvement

Improve education for consumers, families & HCWs Develop a high risk dispenser model Reduce harm from needle use

1 2 3 4 5 6

Improve proactive use of clinical monitoring tools Work with academic partners to improve training of prescribers Describe how patient care is impacted by sudden clinic closure Require pain management clinic physicians to have specialty certification

Increase Access to Appropriate Pain Management E

Increase access for uninsured Develop a model for desirable integrated pain practices Expand the availability and use of Naloxone

Some generic strategies to consider

• Customer Services
• Operational and process improvement
• Legislation/regulation/enforcement
• Advocacy
• Surveillance, research and response
• Initiative development, including strong evaluation
• Individual, group and community education, including

involvement of public media

• Staff development/training (professional and public)
• Working together projects: network, cooperate,

coordinate

• Shared financing with public: collaboration

Do the ideas fit?

• Units of practice and solution: who else to

invite to the regional table?

• Working together strategies: adopt as way

to challenge regional efforts to move to next step!

• Give-Get Grid: tool for getting started after

identifying focused proprieties and issues

• Aspects of community health: consider a

regional repository of diverse inputs on regional population health issues

• Strategic maps: consider the good that is

being done now

Final comments, 1

• Can’t do everything

– Focus – Do it well – Document it and celebrate success

• Find what is going right and learn from it
• Promote creativity and inclusivity in

cooperative ventures

• Form follows function

Final comments, 2

• Pay attention to process of cooperation as well as
• utcomes
• Reinforce positive employee behaviors of working

together

– Coordinate among health organizations – Cooperate with community groups and agencies

• Make participation in regional effort seen as

Meaningful Work

– Personal satisfaction of acknowledgement for effort and effectiveness – Ability to document and see of discretionary results – Perseverance in meeting community expectations for regional health improvement