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Radical Redesign and the Door to Transformation By Jamie Harvie P.E.

I’m a believer in synchronicity. For that reason, I’ve been thinking about two recent Huffington Post blogs which appeared within the span of a couple weeks. The first was one by John Weeks, editor of the Integrator Blog entitled “Hooking Up: Don Berwick, Integrative Medicine and His Call for a Radical Shift to 'Health Creation'". The other was written by retired Bay Area Physician and Soda Tax Champion Jeff Ritterman, “Can a Hat Trick Reverse Obesity?” I was intrigued, because through my lens, these blog posts were intimately connected. At one level, Ritterman’s article highlighted the Commons Health Hospital Challenge, a project initiated by the Institute for a Sustainable Future, and strongly supported by integrative clinicians referenced in Weeks’ post.  More deeply, I was excited because together they begin to frame the necessary new narrative about health, connection and relationship.


Weeks’ wonderful article highlighted the important and foundational role of the integrative health community in health creation and captured how a huge door to the transformation of our health system is swinging open. This past November, another door of transformation opened at the 2013 ABIHM (American Board of Integrative Holistic Medicine) review course, when  ABIHM President Mimi Guarneri announced the formation of the new Academy of Integrative Health & Medicine.  The Academy will be an umbrella for licensed health practitioners who will be, according to Dr. Guarneri “standing together in the name of health, not only of people, but of communities and the planet”.


This united front of clinicians may be one piece of the “radical” Don Berwick was referring to in his remarks at the recent Institute for Healthcare Improvement Annual Conference  (and highlighted in Weeks’ blog) where he suggested that, "The pursuit of health, the creation of health, may require something even bolder. The redesign we need may be even more radical than we have imagined."


My guess is that for many in the highly specialized bio-medical model, the notion of physicians, nurses, naturopaths and other providers working together is radical. Moreover, the idea that the health of individuals, community and the planet are somehow connected is equally radical. However, this concept appropriately acknowledges that our health is influenced by factors outside of hospital walls. More importantly, implicit in this emerging model is the vital importance of “power within,” social relationships, connection, openness rather than hierarchy, control and power “over.”


I think this is really what Berwick was referring to when he referenced how the  redesign we need may need to be more radical—perhaps this is because we have built western medicine on a top-down hierarchical worldview.  It IS radical because instead of a redesign, we appear to be in need of a fundamental shift in operating principles with a narrative built upon a new consciousness.  And that consciousness is embedded within the truth of the interconnections between health, individuals, community, and the planet that most of us can intuitively recognize.


Among our major collective challenges then, is how we tell this new story together. This question was raised in the recent JAMA opinion, Finding the Role of Health Care in Population Health, in which authors Eggleston and Finkelstein remind us that “the increasing inclusion of a population perspective is not a natural evolution for the US healthcare system. In fact, it is counter culture in a society that values personal independence and is often mistrustful of the centralized efforts of large organizations, public or private.” This “truth” is reinforced daily through our culture’s promotion of material gratification and through pervasive advertisements that reinforce the notion that material goods bring us love, happiness and satisfaction.


Also prevalent in the popular culture is the primacy of the “quick fix” and the promise that technology and science (the false promise of GMO’s) hold the answers to humanity’s ongoing problems, rather than the equally important exploration into relationships, connection, intuition, and the arts. This concept is captured brilliantly in Annie Leonard’s Story of Stuff.


A strategic approach to support this radical redesign must then include the construction of an alternative public narrative. One that connects us in a vision that allows us to wake up, each day with purpose. This new narrative will necessarily highlight connections, networks, collaborations and the ability for each of us to affect change. Perhaps that is what I saw in Ritterman’s blog, which tells us that there are often interrelated solutions which offers success and hope when we become “agents of change” working together. 


Threads of this narrative are elsewhere. Consider the increasing coverage and appreciation for the benefit of health care teams in media such as the Wall Street Journal. Or  the idea of teams and collaborations though a different, but equally important lens. The Evergreen Cooperatives, a partnership of the Democracy Collaborative and Cleveland anchor institutions including the Cleveland Clinic and University Hospitals, have together helped create a laundry, solar panel business and one of the largest urban green houses in the country, all new worker-owned collaboratives, in one of the poorest zip codes in the country. These are all exciting, successful health creation models. Finally, we see other threads through the partnerships and collaborations of labor, environment and clinicians providing necessary transparency to support safer chemical policies, through clinically relevant data bases such as  ChemHat, the Pharos Project  and the Collaborative on Health and Environment Toxics Database.


We are at an exhilarating moment when opportunities allow us to strategically seize and advance a culture of health creation. Issues such as climate change, toxic chemical and body burden and food systems inform us about the connection between human activity and the resultant influence on people, the planet, and health. Similarly, rising inequity, health disparities and adverse childhood experiences have invigorated a focus on the social determinants of health. These offer us both a reminder that health is created in community and an opportunity to acknowledge and address the role of race, class and gender hierarchies and institutional racism in health inequities.   


If we are wise, we should think about how to weave and embed these strands together and cultivate an alternative narrative in our collective work, allowing a new consciousness to arise. It will have to reinforce how we succeed through cooperation, connection, collaboration and relationship. It will include transparency, the power of agency, and the ability to affect change. Finally, it will embody humility and importance of loving and valuing everyone equally.   


At a local level, this movement will require community organizations--those working on issues such as affordable housing, food access, and livable jobs--to tell the story of their vital work through the lens of health creation, rather than charity and service. It will support inclusion of health affected communities as partners in decision making through Community Health Needs Assessments and development of  Accountable Communities. And finally, it will require us to invite our local hospitals to collaborate, rather than compete. As Dr. Guarneri astutely stated in the Academy announcement, “We don’t need more pretty green buildings competing against one another.”


The principles upon which the integrative health community are built are ideally aligned with this broadly focused narrative. I’m eager to explore how the many allies in this work connect with this wisdom as we co-evolve a shared new consciousness and open the door to transformation. I’m equally excited to hear what ideas you might have for this 'radical redesign'.


(Originally posted here on the American Board of Integrative Holistic Medicine website on March 10, 2014).


Jamie Harvie P.E. is the Executive Director of the Institute for a Sustainable Future and co-creator of the Commons Health Network

 

Hospitals As Anchor Institutions: Linking Community Health and Wealth

“Anchor institutions” are foundational to the Commons Health Care framework as they exemplify the concept of healthcare in community. Moreover, they allow for the development of health “agency” and highlight the linkages between individual and community health and resilience. David Zuckerman gives us a preview of what we might expect from his upcoming landmark report “Hospitals Building Healthier Communities.”

  

Hospitals As Anchor Institutions: Linking Community Health and Wealth
By David Zuckerman

 

Since the passage of the Affordable Care Act, discussions of healthcare policy in national politics and the mainstream media have overwhelmingly focused on the law’s impact on health insurance rather than public health. For example, the 2 percent of the population that will be affected by the individual mandate provision have received an inordinate level of attention. But a separate ACA provision should receive at least as much attention and energy, as it will have a significantly greater impact on the country, and open up new possibilities for how health systems and communities can work together to target pressing economic and health challenges.


I’m referring to Section 9007, a little-known provision which has not caught the public’s attention yet and whose opportunities are only starting to be fully understood by the public health and healthcare communities. In brief, this ACA section requires every not-for-profit hospital to complete a community health needs assessment (CHNA) at least every three years. This means that the nearly 3,000 not-for-profit hospitals in this country now have to address the health needs of more than just those within their walls. (Some of the more than 1,000 state and local government hospitals will also be subject to this requirement.)


For public health and community advocates, this provision is a significant victory, and forces hospitals to seek input from their communities. For most hospital administrators, this provision compels them to rethink the historical focus of the hospital as (merely) an acute-care institution. For organizations such as my own, The Democracy Collaborative, that focus on helping economically marginalized communities, the requirement helps strengthen our argument that hospitals need to embrace an “anchor institution mission” to lift up the impoverished neighborhoods in which many of these institutions reside.


Not-for-profit hospitals are anchor institutions because, once established, they rarely move location. Their mission, their invested capital, and their customer relationships tend to tether them to their communities. When other more mobile capital, like for-profit corporations, abandon communities — an occurrence most dramatic in Rustbelt cities but not unique to them — the remaining nonprofit and public institutions often become the largest employers and economic engines. To give you a sense of the scale here, not-for-profit hospitals as a sector had reported revenues of more than $650 billion and assets of $875 billion as of August 2012. By embracing their anchor mission, hospitals can strategically deploy their financial and human resources to benefit the local economy and build community wealth, specifically in low-income communities.


So how does all this work in practice? There are a variety of community building strategies that hospitals can undertake to begin to move in this direction. Here are just a few examples from health systems across the nation:

 

In Cleveland, University Hospitals and Cleveland Clinic, along with other partners, have helped finance the Evergreen Cooperatives, a network of employee-owned, “greenest-in-class” businesses that hire from target neighborhoods, providing low-income individuals the opportunity to own part of a business and build wealth. A long-term goal is to create a new type of nonprofit community anchor to connect anchor institutions, local government officials, and employee owners, spurring revitalization in a coordinated and sustainable manner. And Cleveland’s anchors are not just limiting their community development work to support of Evergreen: In 2012, University Hospitals reconfirmed its commitment to address these root causes of poor health in its CHNA, and has dramatically shifted its procurement locally through its $1.2 billion Vision 2010 initiative, with the intent to integrate similar changes into all supply chain purchasing going forward.

 

Mayo Clinic in Rochester, Minnesota, helped finance the community land trust, First Homes, which aims to permanently preserve affordable housing for community members as well as employees. To date, it has constructed more than 875 units of housing and represents the state’s largest-ever community-based assisted-housing program. In Baltimore, Bon Secours Health System engaged the community as part of a neighborhood revitalization effort in the late 1990s. After learning that housing, trash, and rats were top community priorities, it has developed more than 650 units of affordable housing, and has worked with residents to clean up and convert more than 640 vacant lots into green spaces.

 

Another example is Gundersen Lutheran in La Crosse, Wisconsin. Often known for its environmental initiatives, Gundersen set a goal to purchase 20 percent of its food locally and was a critical partner in establishing Fifth Season Cooperative, an innovative, multi-stakeholder cooperative that is one of the first of its kind in the nation with six member classes working together: producers, producer groups, food processors, distributors, buyers, and cooperative workers. Fifth Season helps bridge the scale divide by serving as an aggregator between the capacity of local producers and the needs of larger purchasers, while combining the principles of a sustainable economy, local ownership, and building community.

 

Hospitals can leverage their assets in other ways to maximize impact. Since 1992, Catholic Healthcare West (now Dignity Health), based in San Francisco, California, has provided below market rate loans to nonprofit organizations. As the fifth-largest health system in the nation, it allocated $80 million for loans and $10 million for loan guarantees in fiscal year 2012, helping finance efforts to develop affordable housing, provide job training, assist neighborhood revitalization, offer needed medical services, and build wealth in underserved communities.

 

Local hiring is another strategy hospitals can adopt to strengthen local communities. Partners HealthCare in Boston, Massachusetts, which includes the two academic medical centers Massachusetts General Hospital and Brigham and Women’s Hospital, created a program that aims to hire and promote entry-level workers from surrounding neighborhoods. As of 2011, more than 400 people had participated in the program.

 

A final powerful example is St. Joseph Health System of Sonoma County in Northern California. Since 2002, it has actively worked to build community capacity by focusing on community organizing, leadership development, and partnership and coalition building in surrounding neighborhoods.

 

CHNA requirements provide a promising opening that allows and encourages hospitals to move in this direction, by requiring a more collaborative process for identifying health needs. (And, in an ideal world, they would also mandate a more collaborative process to address those needs.) In combination with the ability to count community building activities (or elements thereof) as part of a hospital’s community benefit, these new requirements provide an important additional reason for adopting an anchor mission. These kinds of anchor strategies also align with a hospital’s core mission to promote health and well being; create economic returns to the institution by reducing the need for uncompensated care; and help strengthen relationships with local government by offsetting the impacts of their tax exemptions with increased revenue from a healthier local economy.


It won’t be easy to fully realize the opportunities created by this new requirement. Many hospitals will do the bare minimum to solicit community input. Others will target the more surface-level health needs or continue to prioritize charity care — in effect, continuing to reapply a band-aid to a gaping wound. But to truly address the staggering health needs facing so many of our communities­ ­­— needs caused by unemployment, poor housing, lack of assets, and environmental hazards — a combination of enlightened hospital executives; buy-in from doctors, nurses, and other employees; and communities sufficiently organized and demanding a seat at the table will be necessary.


On March 5th, The Democracy Collaborative will release a report entitled Hospitals Building Healthier Communities that explores in detail the new community benefit and CHNA requirements, along with other incentives to embrace an anchor mission. In addition, it features five case studies of six health systems and highlights numerous other best practices from across the country, some summarized here. Although a small percentage of the total hospital sector, these examples of hospitals engaging the community and building community wealth to more effectively promote health are inspiring and deserve to be studied and emulated. Our report challenges hospitals to rethink how they deploy their resources, and provides a guide for everyone trying to expand the conversation on how to better address the socioeconomic and environmental causes of poverty and health.

 

 

Commons Health Care - Connecting Individual, Community and Planetary Health and Resilience

After fifteen years of working at the intersection of healthcare and the ecological health movement, I had begun to question whether “we” were really going to be able to figure out some of the challenging issues facing our planet. I believe in the sobering science of climate change and of the UN Millennium Assessment, yet I also believe in love and the wisdom and compassion of individuals. While not overtly optimistic, I am still hopeful. That said, in the context of a global economic crisis, an overwhelming global burden of chronic disease and interrelated climate change crisis I have wondered if there might be a new way to consider the role of healthcare and its relationship to health and community that would provide an opportunity to imagine new language, new relationships, and new models for change. The following are some of my ideas, in hope that they will initiate a conversation that may ultimately lead to a paradigm shift, a place that famed environmental thinker, Donnella Meadows, has identified as “the most important places to intervene in a system.” Let me know what you think……

 

About fifteen years ago, the EPA released a report documenting that the healthcare industry was one of the largest sources of dioxin and mercury--two known persistent, bioaccumulative, toxic compounds--discharge to the environment. Ironically, healthcare itself was making people and the planet sick! When the Center for Disease Control identified that 1 in 8 women were at risk of having learning disabilities as a result of mercury burden within her body, and that mercury contamination was limiting our intake of certain species of fish, it seemed obvious that we should eliminate mercury from commerce and find safer materials.

 

Since that time, I have worked with like minded colleagues to shift to a model that could make healthcare more environmentally responsible. Inherent in this idea was the recognition of the intimate link between the health of people, their communities, and the environment, and the belief in the benefits of prevention orientated approaches rather than downstream treatment. The idea is that through a systems approach to thinking, we might create multiple benefit solutions.

 

More recently, we applied this approach to food served within healthcare, based on the obvious relationship of food to health. Through a variety of lenses--environmental, social, nutritional and others-- it seemed intuitive that the healthcare sector would recognize these connections and model preventive action. For example, in light of our current obesity crisis, it seemed obvious that hospitals would want to model healthy behaviours by reducing or eliminating the sale of sugar sweetened beverages, which are linked to a host of human health and environmental problems. Similarly, it seemed apparent that administrators across the country struggling with the costs and consequences of multidrug resistance infections would link the fact that every major public health, nursing and medical association has called for the elimination of non-therapeutic antibiotics in livestock (because of their promotion of drug resistant organisms) and would work to purchase meat produced without antibiotics or support legislation which would regulate their use.

Though changing slowly, the business of healthcare remains siloed and fundamentally geared toward illness rather than prevention, while perverse incentives continue to reward healthcare for increased demand. Healthcare now represents 17% of the GDP and, without changes in law and policy, will reach nearly 50% of GDP by 2080 if current trends continue. Imagine the difficulty for both healthcare CFO’s and clinicians overwhelmed by the burden of chronic disease. In my community of Duluth, MN, a program was able to cut the readmission rate for patients with congestive heart failure to 7 percent compared with the national average of a 40 percent readmission rate. Ironically, though, succeeding in keeping patients out of the hospital wasn’t rewarding financially. “Every time somebody hit the hospital with heart failure, everybody got paid for taking care of that patient,” shared one of the providers. Clearly, our healthcare model is in transition, but the business of healthcare cannot maintain or increase much further without negatively affecting the economic health of individuals, communities and our nation. Moreover, reports from the Millenium Assessement and IPCC remind us that from an ecological perspective rapid change is essential.

 

Fortunately, many wise people have been thinking about this. The Institute for Healthcare Improvement is recognized as a national leader in this work and developed what they describe as “The TripleAim of Healthcare”.

 

Triple Aim

 

Not long ago, a colleague shared with me a link to a 2009 speech titled Squirrel”. After reading this now somewhat famous talk by Donald Berwick, M.D., then president and CEO at IHI, I had one of those “a ha’ moments. It was his metaphor of a Turkish fishing fleet that he used to explain important ideas on how to limit the “over-fishing” of health care resources that helped connect the dots. This fleet had somehow figured out rules to share their resources. Though “Squirrel” was focused on the triple aims of “experience of care” and “per capita cost,” I saw the connection to the third triple aim of “health of populations”.

 

Just weeks earlier, I’d had a conversation with friend and colleague, Diane Imrie, R.D, MBA , Food Service Director and thought leader behind Fletcher Allen Health Care’s nationally recognized healthcare food service model. She had developed a comprehensive sustainable seafood initiative for their hospital. She was helping their facility think about and put into practice the linkage between preserving fish stocks and the health of New England populations. Fletcher Allen was thinking about the Triple Aim.

Berwick went on to describe a seven-step process for containing healthcare costs across communities, applying rules developed by economist Nobel Laureate Elinor Ostrom a leading scholars in the study of common pool resources and human–ecosystem interactions. This reminded me of the work of Council of Canadians and their report Our Water Commons, and also of our local hospital, St. Lukes, that had worked to phase out bottled water so as to reduce the environmental health impacts and promote the public water system.

He further reminded us that ultimately it is the communities that are going to need to take responsibility to define their commons, set goals, develop metrics, and establish a healthcare solution. Though Berwick’s discussion was explicitly about cost containment and healthcare utilization, it suggested to me how we might incorporate an integrated commons approach to food, environment, climate and healthcare. Moreover, there were many parallels to the community driven healthcare model contained within the Sustainable Road Map (see below) developed by United Kingdom’s National Health Service.

Sustainable route map

 

I now see linkages and the importance of defining our commons, with the efforts of the ecological design leadership of the Cascadia Green Building Council working in the Cascadia commons and to the work of locally based food councils and networks.

 

On the Commons is an important effort working to draw attention to the importance of the commons in the modern world and to advance commons-based solutions.

 

I’m excited to follow Rethink Health, an effort involving Ostrom, Berwick and others, in which the focus appears to be thinking through a commons approach, with an emphasis on cost and quality of care, two of the three triple aims.

 

Commons healthcare is used to emphasize a commons framework to the population health triple aim and thereby distinguish, yet connect it, to a commons framework for cost containment and quality of care. Recently, I began to share these ideas through a presentation Commons Health Care. Many have responded favorably to the recent healthcare policy piece “The Case for Commons Health Care”. I’m curious about your reaction, similar work, and your ideas. Please send them along.

Jamie Harvie, January 2012