By Lola Butcher
In a novel pilot in South Carolina, hospital leaders are working with insurance executives, church volunteers, Medicaid officials, and others to learn if a grassroots campaign can improve the health of residents in ZIP code 29203, one of the poorest areas of the state. Using principles of community activism that have proven successful in organizing farm workers and electing government officials, the South Carolina Organizing for Health project is engaging community leaders and citizens to identify unique approaches to improving population health.
"We healthcare leaders tend to think that we know how to best provide care to the community," says George A. Zara, president and CEO of Providence Hospitals in Columbia, S.C. "I see this initiative as a real opportunity for us hospital CEOs to create a dialogue with different stakeholders in the community about new ways to keep our citizens healthy."
While community organizing might be outside the scope of a typical hospital CEO's responsibilities, Zara sees it as an essential component of positioning Providence Hospitals for the future. As payers increasingly move toward value-based payment structures, Providence is eager to test new population health models that can keep patients healthy-and costs in check.
ZIP code 29203 covers a section of Columbia, the state capital, where the 2010 median household income was $31,141. Healthy 29203 focuses specifically on the neighborhood of Eau Claire, which is home to 45,000 residents, many of whom have no access to primary care and low health literacy.
That makes the neighborhood a good laboratory for figuring out how to manage population health. On average, each resident visits a hospital emergency department (ED) twice a year. About 30,000 uninsured ED visits from that single ZIP code rack up $20 million in unreimbursed costs each year.
Zara thinks the information gleaned from the South Carolina Organizing for Health effort will influence how care is provided and paid for across the state. "This is an opportunity to be part of the experience from the ground up-learning, participating, contributing, and trying to develop a model that is transferrable across the state."
The South Carolina Organizing for Health campaign was launched in early 2011 by Organizing for Health, an initiative funded by the Fannie E. Rippel Foundation. The campaign aims to use community activism approaches to improve access to primary care, reduce inappropriate ED use, and improve the health of the 29203 populace by partnering with residents.
The campaign will officially kick off on March 3. The overarching goal is to create a process for upending the traditional healthcare delivery model-and replacing it with a more effective approach that can replicated in other communities.
"A number of neighborhood organizations, churches, and businesses have stepped up to help," says Richard Foster, MD, senior vice president of quality and patient safety at the South Carolina Hospital Association. "Our aim is to get the community engaged with those who have power to change things-and together, we will come up with solutions."
Foster is one of five physicians who was recruited by Organizing for Health to launch the South Carolina initiative. The other physicians are Laura Long, MD, vice president for clinical quality and health management, BlueCross BlueShield of South Carolina; Lisa F. Waddell, MD, South Carolina's state deputy commissioner for health services; Michael S. Stinson, MD, vice president for quality at Palmetto Health; and Stuart Hamilton, MD, CEO of Eau Claire Cooperative Health Centers.
After receiving training on the principles of community organizing, the five physicians were tasked to design a campaign that would engage the entire 29203 community. "We spent the last year organizing groups of people in the community to see how they wanted to transform their community to improve their health," says Long.
During a six-week period last fall, organizers convened 45 house meetings attended by 750 people, and 180 citizens attended a community assembly to discuss the campaign strategy. By this spring, at least 300 volunteer organizers will be trained to work in the community, helping individuals, groups, and neighborhoods develop wellness programs and other health-oriented initiatives. Organizing for Health first trained a group of master trainers who are now training the rest of the community volunteers.
A core leadership team was also recruited for the campaign, which includes top officials from Palmetto Health and Providence Hospitals, community clinics, federally-qualified health centers, the state Medicaid office, Columbia city government, the University of South Carolina, and citizens who are connected to churches, schools, and neighborhoods.
Exactly what impact the initiative will have on 29203 residents remains to be seen, but Foster and Long like what they have seen so far. Organizers have met with city officials to explore building a new community health center, and they have identified property owners who may be willing to donate land for walking trails.
Beyond that, four primary strategies have emerged as initial priorities.
Recruiting as many individuals as possible to sign a community covenant. By signing the agreement, individuals commit to work to improve their own health and to help improve the health of their community. "This includes everybody from the CEO of Blue Cross Blue Shield and the mayor of the city to individual church members and others living in the neighborhood," says Foster.
Increasing access to primary care services. Stakeholders will work together to make this happen. For example, the city is identifying abandoned houses and money that could be used to renovate these buildings to accommodate clinics staffed by nurse practitioners who would be hired by one of the local health systems. The hospitals will also expand the hours of their primary care clinics in the area.
Creating a network of volunteer community health workers. "We already have something like 50 churches that have been engaged with identifying individuals to be trained as health coaches," says Foster. Those individuals might meet with chronically ill patients in their homes to help educate them about their disease, coach them on how to properly take medications, and ensure they are making and keeping medical appointments.
Meanwhile, Long hopes that churches may start screening and monitoring blood pressure levels of church members. Other ideas that have surfaced: Churches or community groups might develop transportation pools for people who need rides to physician appointments, and community gardens might be developed to increase access to fresh vegetables.
"Identifying the right interventions first required an understanding of why people aren't able to get the care that they need, and then empowering the residents to create the solutions amongst themselves-neighbor to neighbor-that address their needs," says Long.
Changing the payment model. Meanwhile, payers and providers will support the community initiative by changing the way they interact. Primary care providers plan to adopt the patient-center medical home model, and the Blues has agreed to pay physicians more when they can demonstrate that they have improved the management of patients with chronic diseases. The insurer will also pay providers for new kinds of care-including pharmacist visits, home visits, e-visits, and care management services-that are not typically reimbursed in the traditional payment system.
One likely outcome of the South Carolina Organizing for Health initiative: Hospital leaders will advance their thinking about ROI. "The traditional ROI model probably won't work well here," says Foster. "You have to look at it with, 'What's the ROI of making your community healthier?'"
For example, rather than spending money to increase ED capacity, providers will need to increase patients' access to primary care and work to reduce ED and inpatient admissions-and make it work financially.
Payers also have to change their approaches. "We must pay for quality outcomes, and we must align incentives, and we must find a way to engage people in their own health," says Long. "The only way of removing the waste and the duplication in our system is to work together to remove the barriers to care, poor continuity of care, and poor communication-and organize the revamped system around the patients."
"What we're trying to do hasn't been invented yet," says Zara. "We're trying to develop an approach that deals with key economic and community realities, and we're seeing if we can create different partnerships and different levels of accountability-and, ultimately, develop a more cost-efficient way to deliver care."
Lola Butcher is a freelance writer and editor based in Missouri.
Interviewed for this article:
Rick Foster, MD, is senior vice president of quality and patient safety, South Carolina Hospital Association, Columbia, S.C. (firstname.lastname@example.org).
Laura Long, MD, MPH, is vice president for clinical quality and health management, BlueCross BlueShield of South Carolina, Columbia (email@example.com).
George A. Zara is president and CEO, Providence Hospitals, Columbia, S.C. (firstname.lastname@example.org).
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