What top five interventions
would you support to achieve
the triple aim of better care,
better health, lower cost?
Leveraging the Community Benefit Requirements of the
Affordable Care Act for Collective Impact: The Atlanta
Regional Collaborative for Health Improvement (ARCHI)
Presented to:
Grantmakers in Health
March 7, 2014
ARCH I
Changes in
Public
Coverage
Changes in
Private
Coverage
Improving
Health Care
Quality
Improving
Health
The CHNA Opportunity in the ACA
• Community health needs assessments (CHNA)
are now required every three years of
not-for-profit health entities in order to
maintain their tax-free status
• CHNA and implementation strategy required
for each facility
Atlanta Regional Collaborative for Health Improvement
The CHNA Opportunity in the ACA
• CHNA:
– A description of “community” and how it was
determined
– A description of process and methods, including
data used and information gaps
– A description of how input was gathered from
those with a broad interest in the community
– A prioritized list of community health needs,
including how the list was prioritized
Atlanta Regional Collaborative for Health Improvement
The CHNA Opportunity in the ACA
• Implementation plan:
– Must describe how each health need
identified in the CHNA will be met, or
– Describe identified needs that will not be met
by that hospital and why
– Must be approved by a governing body
– Collaboration is encouraged
Atlanta Regional Collaborative for Health Improvement
Led by United Way, ARC, and
Georgia Health Policy Center
Funders (CDC, Kaiser, St.
Joseph’s Healthcare, Grady,
and the Lead Organizations)
Public Health, Hospitals,
FQHCs, Physicians, Behavioral
and Other Providers
Solution
Business, Education, County
Commissioners, Faith Leaders,
Insurers, Philanthropy
Atlanta Regional Collaborative for Health Improvement
ARCHI Video
Atlanta Regional Collaborative for Health Improvement
Seeding Innovations in Health
ARCH I
Atlanta Regional Collaborative for Health Improvement
Rippel, ReThink Health, &
the RTH Dynamics Model
THE RIPPEL FOUNDATION
Seeding Innovations in Health
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Founded in 1953 as a charitable foundation
6 person Board of Directors
Home office Morristown, NJ; satellite location in Cambridge, MA
$85 million in assets; $6.4 million 2014 budget
30 full and part time staff and long term contractors… and growing
Legal Mandate: Women, Elderly, Cancer, Heart Disease, Hospitals
2007 Mission: “Seed Innovations in Health”
Primary program and investment: ReThink Health
• 75% of total Rippel budget; 95% of program budget
• Generated $2.5 million in grants and earned income to date
After 53 years of primarily making grants…
• Almost no grants, not operating foundation; work through DCA
Commitment to collaboration with like-minded partners
13
1959 – We have long known that health care facilities should be adapted to the
patients rather than the opposite.
1967 - To avoid becoming sick may be the greatest health and medical challenge
to contemporary society.
1968 - Sooner or later some group will find out how to build, organize and
operate a hospital which will be better and more flexible than at present, and
at a lower cost.
1968 - The greatest opportunity people have to achieve and maintain good
health and well-being, at the lowest possible cost, is by their own intelligent
methods of daily living habits.
1969 - We need to develop a health care system which will be recognized as
distinct from medical care. This is a real key to solving our “medical problem.”
1969 - We must have substantially new manners of thinking to enable mankind
to bridge the gap between the things that have been and the things which will
be.
Problem
Identification
Evidence,
Examples,
Ideas
Build & Sustain
System-Wide
Change
Measures
RETHINK HEALTH
A Collaborative Initiative of
the Rippel Foundation
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1.
Don Berwick | CMS, IHI
2.
Elliott Fisher | The Dartmouth Institute
3.
Marshall Ganz | Leading Change, Harvard
4.
Celinda Lake | Lake Research
5.
Laura Landy | Rippel Foundation
6.
Amory Lovins | Rocky Mountain Institute
7.
Jay Ogilvy | Global Business Network
8.
Elinor Ostrom | Nobel Laureate in Economics
9.
Peter Senge | MIT, Society for Org. Learning
10.
John Sterman | MIT System Dynamics Group
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4
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10
8
5
3
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… work with leaders to demonstrate that sustainable redesign of regional
health systems is possible and can improve health, care, costs, equity,
ownership, productivity, regional economies, and communities vitality.
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Better health, better care, lower costs and access for all
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Collaboration by leaders across boundaries (in and out of health)
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Whole system thinking
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Redesign to meet health and care needs
•
National purpose, local action
Action
Results
ReActing
Thinking
RETHINKING
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18
Active
Stewardship
Effective
Strategy
Sustainable
Financing
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Bring system stakeholders together in a way that builds trust, shared vision,
and collaborative action.
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Build purposeful and effective stewardship teams that can sustain efforts and
achieve measurable results over time.
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Assure that health resources are being spent to achieve the greatest impact.
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Align community priorities with health system priorities.
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Finance and sustain efforts long enough to see real results and avoid rebound
experiences.
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Support innovation, implementation, and system redesign in ways that
achieve high impact goals and build critical interdependencies.
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Educate leaders to have a whole system and collaborative perspective.
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Engage in action-research
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Develop and share lessons, tools, approaches
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Grant funding from the California HealthCare Foundation and the Robert
Wood Johnson Foundation plus increasing earned income
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Experience in more than 30 regions across the country
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Created and used the Dynamics Model in 50 settings, 9 academic
institutions, and thousands of users
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Successful distance learning course with 180 participants
•
Building a learning network and community
•
Extensive partnerships with motivated leaders, regions and organizations
•
Strong enterprise wide evaluation process
•
Impact on regional and national levels
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RETHINK HEALTH
DYNAMICS MODEL
U.S. National Health Expenditures (1998-2020)
$6,000
$5,000
Historical Data
Stewardship
Teams
Exploring
Simulated
Scenarios
in Strategy
Labs
$ in Billions
$4,000
$3,000
$2,000
$1,000
$0
1998
2004
2008
2011
2014
2017
2020
Keehan SP, Cuckler GA, Sisko AM, et al. National Health Expenditure Projections: Modest Annual Growth Until
Coverage Expands And Economic Growth Accelerates. Health Affairs 2012.
Heffler S, Smith S, Keehan S, Borger C, Clemens MK, Truffer C. U.S. health spending projections for 2004-2014.
Health Affairs 2005:hlthaff.w5.74.
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Unsustainable program financing
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Spreading resources over too many initiatives
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Lopsided investments downstream or upstream
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Triggering “supply push” responses to declining
utilization
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Exacerbating capacity bottlenecks
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Perpetuating inequity
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Neglecting or focusing only on disadvantaged, children,
or seniors
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Pursuing narrow goals and short-term impacts
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Concentrating only on small sub-systems
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Hard to see the bigger system and where things/we fit
Stakeholders see different problems and solutions
Stakeholders speak different languages
Don’t recognize that not all solutions are equal – good / bad
Real conversations about money, priorities, strategy, etc. are difficult
Alignment from the community to policy levels is challenging
Pressure for short term results with limited evidence for better planning
System is complex and hard to predict
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Consider
Many
Pathways
Engage
in Deeper
Dialogue
Anticipate
Consequences
and Plausible
Futures
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Realistic yet simplified portrait of a local health system (N=8 to date)
Anchored to evidence from dozens of datasets
A common, testable framework and tool for open, experiential learning
Designed with and for diverse stakeholders
Not a prediction, but a way to see and feel how local health system can
change
ReThink Health. Summary of the ReThink Health Dynamics model.
Available at http://rippelfoundation.org/docs/RTH-Dynamics-Model-Summary.pdf 27
Selected Geographic Focus
Productivity & Equity
Aging
Risk
Health
Care
Cost
Capacity
Other Trends
Initiatives
Payment
Scheme
Innovation
Funds
Captured
Savings
• Insurance eligibility
• Economic conditions
• Health care inflation
• Primary care slots
Population tracked separately in 10 segments
by age, insurance, and income
28
SYSTEM CONNECTIONS
Capture Cost Savings
(as negotiated with
payers)
Innovation Fund for
Early Investments
Reduce Crime
Reduce
Environmental
Hazards
Per-capita (vs.
fee-for-service)
payment scheme
Provider Support
for Initiatives
Funds Available
for Initiatives
Improve Hospital
Efficiency
Prevent
Hospital-Acquired
Infections
Environmental
Hazards
Health Status
(physical, mental)
Poverty
Coordinate Care
Health Care Costs
Mortality
Crime
Share captured
savings with
providers
Acute
Episodes
Risky
Behaviors
Malpractice
Reform
Post-Discharge Care
(to reduce
readmission)
Specialist &
Hospital Net
Income
Cost per Acute
Episode
More Use of
Hospice
<Poverty>
'Supply-Push'
Responses to
Reduced Income
Use of ER for
minor episodes
Medical Home
Pathways to
Advantage
Healthier
Behaviors
(Ability to work &
support family)
Control Mental
Illness
Support Patient
Adherence
Routine Physician
& Self-Care
<Adequacy of
Primary Care
Capacity>
Improve Provider
Compliance with Routine
Care Guidelines
Cost of Routine
Care
Use of Specialists
for Routine Care
Insurance
Coverage
Insurance expansion
due to federal
mandate
<Health Status
(physical, mental)>
Adequacy of
Primary Care
Capacity
Redesign Practices
for Efficiency
Recruit FQHC
PCPs
Recruit
General PCPs
30
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Savings O
Initial
Innovation Fund
R
Capture &Reinvest Health Care
Savings
Costs
O
Funds Available
for Investment
O
B
Fund
Depletion
Spending on
Programs
Program
Investments
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www.ReThinkHealth.org
Philanthropy can invest in aligning a
community around strategies to
improve health
ARCH I
Atlanta Regional Collaborative for Health Improvement
Philanthropy
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Convener
Neutral voice
Demonstrate patience and perseverance
Exhibit and encourage collaboration for
collective impact
• Invest
• Work behind scenes
Atlanta Regional Collaborative for Health Improvement
Kaiser Permanente
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Funded research that identified need/opportunity
Key influencer behind the scenes
Shared value of collective impact
Continuous engagement
Patient capital investment
Aligned CHNA requirement/grant making to
support ARCHI
Atlanta Regional Collaborative for Health Improvement
Philanthropic Collaborative Healthy Georgia
• 20 foundations sought to improve primary care through
collaboration, data sharing and joint planning
• Grady Health System & Four Federally Qualified Health Centers
(FQHCs)
• Collaborations on Patient Navigator Program, Accountable Care
Organization application & Mobile Phone App
• Aligned with ARCHI – Care Coordination
• Grady allows staff privileges for FQHC physicians
Atlanta Regional Collaborative for Health Improvement
United Way of Metro Atlanta
• Aligned major $3.5 M Grant “Forget the Box”
• Grantees must
 Demonstrate at least two ARCHI priorities
 Collaborate
 Participate in Rethink Health learning agenda
• Selected grantee may become ARCHI pilot
Atlanta Regional Collaborative for Health Improvement
Discussion:
Share opportunities for
investment in your community
Atlanta Regional Collaborative for Health Improvement
Thank You!
www.archicollaborative.org
ARCH I
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Leveraging the Community Benefit Requirements of