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Changing the Conversation from Health Care to Health

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I was excited to hear Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention (CDC), speak at this year's Centers for Medicare & Medicaid Services (CMS) Quality Conference about the importance of moving "upstream" and strengthening the relationship between community-based prevention services and health care. This is a topic near and dear to my heart, as I started my career working in public health to help communities improve the systems that support community health and prevention. Now that I work in health care quality improvement, I see daily the health care community's challenges and opportunities in not only providing good health care, but helping people achieve health.

Most of us who work in health have learned that there are significant limitations to what the health care system can achieve alone. Our systems of care must change to meet the growing burden of chronic disease.

Cardiovascular diseases, pre-diabetes and diabetes are at a record high. According to the CDC, cardiovascular diseases are the leading cause of death in the United States. Nearly one in 10 Americans has diabetes, and without intervention, this number will likely continue to grow. More than one-third of American adults have pre-diabetes, an estimated nine out of 10 of don't know they have it. The good news is many risk factors for these conditions can be prevented or managed with lifestyle changes between visits to the doctor. Success, in many cases, depends as much on lifestyle as it does on quality care.

Throughout my career, I've worked with community-based partners across Oregon to increase access to self-management education (which is proven to help patients better manage their chronic conditions) and improve systems that support patient activation. Although these models are evidence-based, they often rely on tenuous grant-based funding and volunteer commitment. These community programs are doing amazing work and they are changing lives. They are also laying a foundation that ultimately could bend the cost curve for the health care system.

Three exciting models in Oregon rely on community-clinical partnership, using traditional health workers to help patients navigate the health system and access appropriate self-management education and needed social services. Through a partnership with Kaiser Permanente Northwest, Familias en Accion employs community health workers and health navigators using a Pathways to Health model to help ensure that patients receive culturally sensitive support and the tools they need to become activated partners in their care. Their newly released implementation guide has details on how to replicate this program.

Asian Health & Service Center's (AHSC) Asian Wellness Connection program, a three-year pilot, is a partnership of AHSC, two Portland area federally qualified health centers and Portland State University. Together they're building an integrated medical home model in which patients receive culturally specific assistance with care coordination, navigating wraparound services and chronic disease prevention and management education.

A third promising model in rural eastern Oregon is Good Shepherd Medical Center's ConneXions program. Using community health workers, ConneXions is helping bridge geographic and cultural divides by helping patients navigate the health care system and by providing support and education in the communities where they live.

In January, CMS began reimbursing for Medicare beneficiaries to complete the Diabetes Prevention Program (DPP), marking the first time Medicare has paid for preventive services for beneficiaries with pre-diabetes. Since many organizations that provide the DPP are nonclinical, this shift will likely open the door for other new and innovative clinical-community partnerships. CMS also incorporated direct incentives for providers in the new Quality Payment Program to reward referrals to community-based education and other support services. HealthInsight can also help organizations navigate these opportunities and test new ways of improving care.

Similarly, Oregon's Medicaid program is beginning to test payment models using flex funds to facilitate member access to Stanford University's evidence-based self-management education programs and the DPP. These value-based payment reforms will help to drive much-needed conversations about how to invest long-term in population health and how to scale up and spread the most promising models.

Emerging models that move upstream from treatment to community-based prevention and patient activation are the key to improving health and driving down costs in the future. It is our charge as a quality organization to continue to foster an environment in which lifestyle-focused programs that nurture activated patients can grow and thrive. The conversation is changing in health care, and timing could not be more important. Our health depends on it.

What do you think about improving partnerships between community organizations and the health care community? What role should these programs play in care coordination, and how should they be included in payment reform? What other innovative clinical-community partnerships are you familiar with? Please share your comments!

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