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August 6, 2015

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The National Quality Strategy: Best Practices to Improve Community Health. August 6, 2015 [Slide 1]

Operator: Ladies and gentlemen, thank you for standing by. Welcome to the National Quality Strategy Best Practices to Improve Community Health Webinar.

I would now like to turn the conference over to Heather Plochman. Please go ahead.

Housekeeping [Slide 2]

Heather Plochman: Thank you for joining this National Quality Strategy Webinar. Before we get started, we have a few housekeeping notes, which you can see on the slide shown.

If you have any Webinar-related technical questions, please submit them via the chat box. If you lose your Internet connection, please reconnect using the link emailed to you. And if you lose your phone connection, please redial the phone number listed to rejoin. ReadyTalk support can be reached at the number on your screen. And the closed captioning link is also up on the slide there as well as in the chat box.

Agenda [Slide 3]

Heather Plochman: Here is today's agenda. First, Dr. Nancy Wilson will touch on the importance of the National Quality Strategy and how it relates to community health. Then Dr. Nazleen Bharmal, Director of Science and Policy from the Office of the Surgeon General of the United States, will share some of the Office of the Surgeon General's priorities related to community health.

Finally, Ayesha Cammaerts, Manager of Programs and Population Health in the Office of Community Health at Boston Children's Hospital, will discuss how her organization is working outside of traditional health care to improve health care quality for children with asthma in their community. We will then open the line for questions and answers.

If you'd like to join the conversation on Twitter, please use the #qualitystrategy. You will also have time for questions after the presentation portion. Feel free to enter any questions to our presenters directly into the chat box. We will try to answer them at the end of the Webinar.

Importance of the National Quality Strategy, Nancy Wilson, B.S.N., M.D., M.P.H. [Slide 4]

Heather Plochman: Now we will hear from Dr. Nancy Wilson, who serves as the executive lead for the National Quality Strategy on behalf of the ������Ƶ.

Background on the National Quality Strategy [Slide 5]

Nancy Wilson: Thanks, Heather. I'm excited to have this call and to have those of you that have signed up to be on this call. I think that it's sometimes forgotten that what we're talking about with the National Quality Strategy is health as well as health care for all Americans. So I'm delighted that today we're going to focus a little bit more on health in addition to health care.

The National Quality Strategy was established by the Affordable Care Act back in 2010 to improve the delivery of health care services, patient health outcomes, and population health. And again, that's the key to today's talk and why we're featuring it as part of the National Quality Strategy Webinar series.

This is a strategy that is nationwide. It was iteratively developed by the private and the public sector. We really want it to be owned by everyone, not something that's owned by HHS, or even the Federal Government at large. It's really a gift to the country and hopefully will help people organize their activities to drive health improvement.

The strategy is to concurrently pursue three aims: [Slide 6]

Nancy Wilson: So again, the strategy is better health, better care, at lower cost. The goal is healthy people and healthy communities. I really like that focus on communities as well as individuals.

The Relationship Between the Institute for Healthcare Improvement's Triple Aim and NQS Three Aims [Slide 7]

Nancy Wilson: We worked very consciously on basing the National Quality Strategy on and using the foundational work of the Institute for Healthcare Improvement's Triple Aim. If your organization has embraced the Triple Aim, fine—this Strategy is aligned with that aim and they work together.

We elaborate a little bit more on affordability, greater than just lower cost. And we elaborate a little bit more on patient experience from the better care perspective and on the improving the health of populations with healthy communities. But these are consistent, and so either one can be a guiding star for your organization.

The National Quality Strategy: How It Works Graphic [Slide 8]

Nancy Wilson: This is our How It Works graphic. At the very center, it's showing you better care, affordable care, healthy people. We then show the six priorities of the National Quality Strategy, which are patient safety, person- and family-centered care, care coordination, health and well-being, affordability, and reduction of the leading causes of morbidity and mortality that affect most Americans.

Once you get beyond that, we start to talk about how organizations can change to align to the Strategy. We have fixed priorities. So what do you do? The levers represent your core business functions. And that could be measurement, workforce development, payment incentives. There's a variety of approaches that you can use to drive improvement for those priorities.

I think the Centers for Medicare & Medicaid Services gets a lot of talk right now because so much is being driven by value-based purchasing. But there are lots of different levers that can help you think about how to make improvement on those

The very outer most circle is who else involved. And it's all of us. It's employers, it's payers, it's individuals, it's providers, it's communities. It's all of us. As we align our activities, we can drive improvement towards those three aims of better care, healthy people, healthy communities, and affordable care.

The National Quality Strategies Priorities [Slide 9]

Nancy Wilson: Today, we're going to talk about health and well-being, and I'm so excited about this.

Priority 5: Working with communities to promote wide use of best practices to enable healthy living [Slide 10]

Nancy Wilson: One of our priorities is working with communities towards the three long-term NQS goals here. And as you can see, the priorities are focused on improving socioeconomic environmental factors promoting the adoption of the most important healthy lifestyle behaviors and having effective clinical preventive services. These are goals that were created by a public-private partnership called the National Priorities Partnership of the National Quality Forum, who believed that these were the things that were the issues most critical for us on this particular priority.

Surgeon General's Priorities. Nazleen Bharmal, Directory of Science and Policy [Slide 11]

Nancy Wilson: And now I'm going to turn it over to the expert in this area, Dr. Nazleen Bharmal. I'm so delighted to have her here as part of our Webinar series.

Nazleen Bharmal: Thank you, Nancy. I'm the Director of Science and Policy at the Office of the Surgeon General of the United States. Thanks for inviting me to the Webinar, and Dr. Murthy also sends his regards.

My professional identity prior to joining the Surgeon General's Office is that of a health services researcher and a practicing clinician in primary care, first at UCLA and then at RAND Corporation, with a focus on health disparities, chronic disease prevention, primary care innovation, and working directly with communities on interventions. I joined the office in March to help Dr. Murthy implement his vision for the Nation's health during his 4-year term as surgeon general.

I still practice in a Federally Qualified Health Center, but what's so great is that the National Quality Strategy is an example of the Federal Government supporting this intersection between health care and community health, which was my previous life.

Culture of Prevention [Slide 12]

Nazleen Bharmal: You know, it's an exciting time to be in health care right now with millions of Americans having been covered through the Affordable Care Act. But it sounds like, seeing a lot of the folks that might be on this call, there's still just a lot more for us to do.

We know that health is not the absence of disease. And in that same light, coverage is not the only step towards better health in the Nation. In fact, it's essential but insufficient. We continue to have high rates of obesity. Half of adults have a chronic disease. We lose nearly half a million lives to tobacco-related diseases, and 2 million people still struggle with mental illness.

We do a wonderful job investing a great deal in treatment. Those investments have led to extraordinary advances in treatment, and have helped so many people who suffer from illness that need those advances. As a physician myself, I've been part of delivering so much of the benefit that's been accrued through years of research to patients at their bedside and I'm very, very grateful for that privilege. But we don't really invest nearly as much in prevention and ensuring that we're as good at preventing illness as we are as treating it.

And I suspect this group knows better than anyone that the most expensive health care system is not necessarily translating into better health for our patients or the nation. We continue to rank low—or least low when compared to other developed countries—in infant mortality; preventable death; quality of life; and providing safe, efficient, and equitable care. And while these trends are concerning, here at the Office of the Surgeon General we feel we can overcome this trajectory in partnership with a number of different sectors to build this culture of prevention.

The foundation for the culture of prevention is built, not only in prevention at the community level, but also in health equity; the idea that all the patients that we see should not see variable care based on demographics.

For folks on the phone who are not familiar with the Office, the Office of Surgeon General doesn't make laws; we are not a regulatory enforcement office. We actually have two main roles. The first is to communicate information to improve people's health. And the second is to command the 6,700 U.S. Public Health Service Commissioned Corps uniformed officers who are here to protect, promote, and advance the health and safety of the Nation, which is why the surgeon general wears a uniform. We're part of the uniformed services.

When we talk about building this culture of prevention, it's not about just the programs and policies, which are important but they're often insufficient. We actually want to take that next step in this office, in this new tenure, to work with communities to change many norms, beliefs, and attitudes. That means not only thinking of making the healthy choice the easy choice, but messaging where we make the healthy choice into the desirable choice.

It also means modernizing how we communicate health information. As part of our role here, we are realizing that people don't receive information through reading a newspaper or watching CNN— which, I have to be honest with you, is actually new information to me. Most people don't necessarily receive information through these wonderful comprehensive Surgeon General reports or through listening to speakers at venues. It's really our job to understand new forms of how to communicate health information, especially in this digital age. We've already seen that if you want to do have a message sink in, the person has to be exposed to that message at least 14 times, and that's double the amount that it was just a few years ago because we've been inundated with messages. Part of that is not just the technologies of how we communicate information, but also who we partner with, who are our messengers and our influencers, and I'll give you a concrete example.

During the measles outbreak, the Surgeon General partnered with Sesame Street and Elmo to talk about vaccinations and he did a video. That video went viral—it was funny, but it was informative. If you haven't seen it, it's on YouTube or in Daily Dot and you can check it out. What was important about that partnership was the impact that we saw that it had on both children and parents alike. We've received feedback that seeing America's doctor partnering with Elmo helped children connect not only with physicians but understand the role of vaccinations or injections themselves. But what was even more interesting was that parents came to us when they saw the video. They saw it had comprehensive information about vaccinations. I'm a parent myself. And even for me, as a health care provider, I'm often struck by how many vaccinations my child has to get during her year—you know up to year one, year two—it's daunting. You don't want to see your child in pain.

Parents saw the video and they shared it with their children, and they felt a lot less stressed about going to the doctor and having their children get vaccinations. So it's understanding that we need to work with those types of influencers, not just on “Sesame Street” or celebrities on TV, but also at the local level, schools and teachers, faith leaders, civic leaders, employers, and more times than not, even the doctor.

We talk about wanting to achieve this idea of structural and cultural change, or at least starting that conversation. And we plan to do that through five priority areas that we are calling campaigns.

Campaigns [Slide 13]

Nazleen Bharmal: So the first one is the Active Living campaign. That's a campaign where we are going to be focused on physical activity, where we plan to release a call to action called the Surgeon General's Call to Action on Walking in Walkable Communities.

The title is actually sums it up. It's not just about the message of integrating walking into your everyday life or that it's a great way to be active. You socially connect to friends and family and have improvement of well-being. It's also recognizing that role of the built environment, that everyone should have access to walkable spaces. And quite frankly, not everybody does. We need to fix that, whether that be the threat of getting shot or mugged in your neighborhood, or not even having a sidewalk to walk, or if you're in a wheelchair, to roll on.

There's this wonderful example. When the Surgeon General first took office, he actually went and did a listening tour for the first 3 months and went around the country with the goal of finding out what some of the problems facing different communities were when it came to health issues. What he said is that while the intention was to find out about problems, what he found was a solution.

One of the examples is actually in Indian River County in Florida, a county where 50 percent of the residents live in poverty. There's a lot. There's no sidewalks, streetlights. or safe public parks. The health department, over the course of 2 years, decided to have a goal to create safe public places for walking, exercise, and play. They went ahead and they did that. They surveyed the residents a year after they had implemented this, and they found that 95 percent of residents said they spent more time exercising outside than they had 2 years earlier. And they attributed those changes directly to streetlights and the creation of safe places to exercise and walk outside. They felt like it made a huge difference in their quality of life. These kind of examples are happening all over the country. We see our job, at least one of our jobs, is highlighting that and bringing that to scale. That's the Active Living campaign.

The second area is Tobacco- and Drug-Free Living. We know that prescription drug opioid use has skyrocketed in the last 20 years, and unintentional overdoses have tripled in that same period. We see our role here as specifically a call to our profession as providers, clinicians, dentists, pharmacists, health care executives, that in our good intention to treat pain, we're actually contributing to the prescription drug abuse epidemic that can often lead to even worse outcomes such as overdose or injection of illegal substances like heroin. In a similar way, for those of you who may remember, Dr. Koop—a very iconic surgeon general—wrote a letter to all physicians in America at the height of the HIV/AIDS crisis calling upon them to take it upon themselves as a profession to do something to stop the crisis around HIV and AIDS. Our office would like to do something similar to engage physicians; not just to give them a guideline, but to actually own this issue and be part of ending the prescription drug abuse epidemic.

With tobacco, the Surgeon General's Office has always played a role in a tobacco-free America. Last year, we released the 50th anniversary of the first Surgeon General's report, a very seminal report on tobacco and health. And we'll continue to do so, especially educating the public about the harms and/or benefits of these new devices that deliver nicotine such as e-cigarettes, and exposure to use around regular cigarettes or these newer devices.

For Emotional and Mental Well-Being, we know that 50 percent of those that are going to be diagnosed with a mental illness will show signs by age 14. I have to say, when I first joined this office, to me it feels like it's the chronic disease of the young. Here, we specifically would like to work with the faith community to start some tough conversations and address the unacceptable discrimination or stigma that's often associated with mental illness. We see this very much as a clinical-community collaboration, where the conversation starts in the faith realm. But then it's passed on and leveraged to behavioral health specialists, to clinicians, to primary care. So that's where we see that sort of campaign going.

The last two I'll just briefly mention. We have our Healthy Eating campaign, with a focus on added sugar or hidden sugar; and then the Ending Violence campaign, specifically violence against women but just violence in general and how that's an important public health issue that both goes within the health care sector and in community health.

I'll close with the one thread that runs through all of these campaigns, besides their impact on the chronic disease rate, which is the idea of emotional well-being. Research shows us that 10 percent of our sense of meaning, purpose, happiness, and self-determination is due to the external world; 90 percent of it is internal. Many practices, such as social connections, practicing gratitude, mindfulness for meditation, are things that can help us really understand how to make the healthy choice not only the easy choice, but the desirable choice. That's an area we will also start to have a conversation with the public around; what it means to have emotional well-being. Many of these practices actually don't cost as much money as many of our treatments, and really have a role to play in well-being and resilience.

And finally, I just want to say that, you know, we are really looking forward to working with the folks at the National Quality Strategy, and also at the community level, about how to execute and operationalize many of our evidence-based campaigns: whether it be in executing them, or measuring their success, or thinking about the goals. We look forward to working closely with you. Thank you.

Boston Children's Hospital Community Asthma Initiative [Slide 14]

Nancy Wilson: Thanks so much, Nazleen. This is great. I hope, towards the end of our call when we have time for questions, we can talk a little bit more about the link between violence and mental health and sort of where the Surgeon General's Office comes in on that area. I forgot to say, I was a psych nurse before I became a general intern, so I kind of go back and forth between those worlds of behavioral health and general medicine.

But first, we really want to hear from Ayesha Cammaerts about the Boston Children's Hospital Community Asthma Initiative, because this is an area where they actually have working at the grassroots level to make improvements, and I think they've done a fantastic job. Ayesha received her M.B.A. from Brandeis, with a concentration in health policy and management. And she's been working on community health initiatives throughout Massachusetts ever since. I'm so impressed by the work that you're doing, and we want to hear about it now.

Ayesha Cammaerts: Thank you, Nancy, for that generous introduction. I have been here in Massachusetts, doing work in the public health and policy space, for just about 10 years now. I was a community health worker before I got into policy and public health program development, and so it's really a pleasure to join this group and to be speaking in the company of the National Quality Strategy. And, Dr. Bharmal from the Surgeon General's Office, I so appreciated the points that you made. Really, thinking about how our initiative has addressed that 90 percent of people's internal experience and needs is something that I think is really valuable.

We in the Office of Community Health are really the birthplace of the Community Asthma Initiative, which I'm going to be referring to as CAI, and we continue to support that program's growth and evolution. Our mission is to bring together the hospital and community resources to address health disparities, improve health outcomes, and enhance the quality of life for children and families in Boston, and this really aligns phenomenally well with the National Quality Strategy's priorities. I'm looking forward to sharing with you how it demonstrates the power of community-based work to support effective care coordination and family-centered care partnerships. Today, I'm going to review the model, the services, evaluation, and results and some potential health financing of such models.

Community Asthma Initiative (CAI): Impacts Multiple Levels of the Socio-Ecological Model [Slide 15]

Ayesha Cammaerts: We approached health from the socioecological model, and you're probably all pretty familiar with this model. CAI impacts all domains. First, at the individual and the interpersonal levels, CAI nurses and community health workers provide culturally competent and individualized case management and home visits, meeting patients and families where they are to help them look and learn about how to manage their asthma.

At the institution and community level, we provide asthma education workshops, participate in social marketing campaigns, and organize community asthma events and programming in school partners with our community health centers. And these are all grassroots methods for reaching out to the community to address wide community health needs, including asthma. And finally, at the systemic level, we work with coalitions to support payments for asthma programs to advocate for policy changes to address social determinants of health. So we're going to focus on the case management home-visiting portion of the program.

Patient Population [Slide 16]

Ayesha Cammaerts: Our patient population is the highest-risk asthma patients here in Boston. We were created to respond to the needs of the surrounding Boston communities. The pilot initially targeted the Roxbury and Jamaica Plains neighborhoods, and then used demographically similar communities of north and south in Dorchester as a comparison population.

You can see on the slide that the yellow and black stripes are the original intervention communities, and the orange are the comparison population. That little red dot is one of our premier health centers, which we own, called the Martha Eliot Health Center. The hospital is the blue star just on the border between Fenway and that yellow and black area, just to give you a little context of what the map is looking at.

In 2003 and 2005, during that time period, which were the 2 years when we were planning this program, asthma was the leading cause of hospital admissions at Boston Children's Hospital. The hospitalization rates for African American and Latino children in 2003 were four to five times the rate of White children. Seventy percent of children hospitalized for asthma came from five low-income, predominantly African American and Latino neighborhoods, so the statistics demonstrated major health disparities. And unfortunately, the trends in the asthma population do continue. However, CAI is really making great strides to address these issues family by family and community by community. And we now make services available across the Boston area and its surrounding communities.

Service Model [Slide 17]

Ayesha Cammaerts: So the service model, in some ways, is elegant in its simplicity. Highly skilled nurses and community health workers assess the asthma patients that are identified through hospital logs and emergency department (ED) visits and inpatient admissions. We look at hospitalization and ED visit logs on a daily and weekly basis, and we also review a small portion of referrals from primary care clinics and community health centers.

But the automated system of identifying and targeting patients at their teachable moment when they're interfacing with the hospital is what's unique about our model. And following the intake that we do, we then respond to the patients' and family needs through home-based assessment and followup care. And for the past 3 years, we provided at least three home visits to each family over the course of 12 months.

While this may sound simple, it's the family-centered, culturally competent care really meeting the complex needs of patients and families which allows them to manage their asthma effectively. We review environmental and socioeconomic factors that impact asthma, services often provided in the same language of the family, and we assist in planning asthma management in a family-centered way that has proven highly successful.

Service Model Continued [Slide 18]

Ayesha Cammaerts: So, these are our major service details. We work to identify and address the barriers to get asthma controlled, looking at patient- centered education, medication monitoring and adherence, school and environmental triggers. And we also really want to make sure that people have access to their care by helping them with their insurance and coverage benefits and understanding copays for their medications, especially their medications that help to maintain their control.

We provide materials such as integrated pest management, HEPA vacuums, and bed encasings. We also do work directly in partnership with our city inspectional services that can help bring cost control to certain housing developments that might need it. We do this in a way that is really looking at where the family is, and making sure that we're meeting them where they are so that their housing is not put at risk if we bring inspection services in.

Evaluation Framework [Slide 19]

Ayesha Cammaerts: You can see our services are really robust, and very much family-centered, so we evaluate wanting to take into account all the different things that impact the outcomes of this intervention. This framework is showing that we have measures of health outcomes, quality of life, and the cost analysis and the data that informs those measures.

Return on Investment (ROI) Results: [Slide 20]

Ayesha Cammaerts: Our return on investment and our social return on investment formula are structured this way. We have cost savings from the reduced emergency department visits on hospitalizations, divided by program costs for the return on investment. And our social return on investment includes quality-of-life benefits, which focuses on workdays missed and schooldays missed.

Health Outcomes Results: Decrease in % patients with any ED Visits or Admissions due to asthma N=1470 (through March 2015) [Slide 21]

Ayesha Cammaerts: Here are our exciting health outcome results. We collect the data at the baseline, 6 months, and 12 months after enrollment. And this statistic means significant improvements in health outcomes. There was a 56 percent decrease in the percent of patients with any emergency department visits, and an 80 percent decrease in the percent of patients with any hospital admissions due to asthma at 12 months And while the major drop happens after the first 6 months, we really emphasize the drop and change in 12 months because of the similar season of the baseline and the 12-month points.

ROI and SROI: Total Cost Per Patient ED Visits + Admissions (N=102) [Slide 22]

Ayesha Cammaerts: Our return on investment and social return on investment results are pretty phenomenal, and we're very excited about them. The CAI costs in blue initially at the baseline are higher than the green comparison population at baseline, and that's due to the higher complexity of our population. What's especially noticeable is that the costs dropped to a similar level as the comparison population after 1 year, and that's actually a greater change. Then the CAI patients continue to drop in costs in the second year, even after the intervention's already been complete, whereas the comparison population does not.

So this results in a calculated return on investment of $1.46 saved for every dollar spent and a social return on investment, which, as I said, looks at the estimated cost of missed school based on the cost to school for attendance and missed workdays based on household income data, and we calculate that when we incorporate those into our ROI, we actually see savings of $1.73 for every dollar spent.

Driving Financing Strategies [Slide 23]

Ayesha Cammaerts: So, we really see the opportunity of these outcome successes and cost analysis successes to help drive change in our current system, and we know that the change is already happening. But in our world, what we're really looking at is how we can make sure that the not-traditionally covered services today are covered and that we can move away from some of the standard fee-for-service coverage. We're working with our Office of Community Health to leverage the partnerships that we have, the philanthropic funds that we receive and our hospital community benefits to support the comprehensive programs like CAI and prove the value of potential savings and providing care with these models. And in this way, CAI and community health programs are the gears that move coverage in alternative payment models.

Children's High-Risk Asthma Bundled Payment (Medicaid Pilot) [Slide 24]

Ayesha Cammaerts: One example of that is the Children's High-Risk Asthma Bundled Payment pilot program. It's currently being planned by myself and in its real final stages of going into implementation, but it has not yet been implemented. However, we see the planning progress still as significant. We worked at Children's towards advocating to have this become a part of the State budget. In fiscal year 2011, there was a budget amendment made to fund this pilot. And while it was a lengthy process to get the Federal Medicaid waiver complete to allow for the funding, the RFP for the contracting of these services was released in 2013 and the potential service providers are currently in the contract process. But as I said, we have not yet implemented and it's not quite yet there but we're very hopeful that it's about to start.

Really, what this bundle does is looks at continuing to pay providers for their fee-for-service asthma clinic visits and then doing monthly monitoring of the patients that they see that are high risk and adding an additional wraparound per-member per-month rate to cover services not typically covered for those patients. That means doing more home visits and doing more intensive provisions to manage the high risk asthma patients and ultimately control the cost of that population and improve the quality of care.

Future Efforts [Slide 25]

Ayesha Cammaerts: So for our future efforts, we're really excited that we have a replication model available. You can go to the link that's on this slide to get that replication model, and we have already used it in Alabama and also here at the University of Massachusetts Memorial Medical Center.

We partner dynamically with our city and statewide partners in asthma care and delivery to make sure that we're all sharing our best practices. Currently, we're working to look at how some of our work can be fit within the population management of asthma populations in our community health centers. And we have a robust network of 23 Federally Qualified Health Centers just in the Boston area and up close to 50 across the State, so looking at how these tools can be used there.

We also are collaborating with insurers like our State Medicaid program and our private insurers to make sure that there are bundled payments available to include these services. And so in this way, we see that CAI is an example of how we can achieve the Triple Aim: investing in community-based, culturally competent care models, completing and disseminating progress evaluations, and implementing these models with financing strategies that expand the impact across the health system.

Contact Information [Slide 26]

Ayesha Cammaerts: Thank you for your interest and attention. We really look forward to responding to any questions and comments. This is the contact information for the leaders of our asthma team, and you have my contact information there as well.

References [Slide 27]

Ayesha Cammaerts: The final slide is a list of our references, and we are expecting soon for a report to be released that shows the most up-to-date data. We're very excited about the publications that we've had to date and our successful outcomes and analyses. Thank you.

Discussion/Question and Answer [Slide 28]

Nancy Wilson: Thank you so much, this is great.

Questions and Answers [Slide 29]

Nancy Wilson: So while people may be gathering their thoughts and figuring out some of their questions, I have one for Ayesha. How did you get your data from the hospital emergency department and primary care team? Do you get the data in real time?

Ayesha Cammaerts: I think that one of the things that is important to note as a sort of natural benefit that we have is that we are based in a hospital. We're a community health program that's not a satellite, not separate. We sit in our adolescent medicine clinic across the street from our emergency department. We have very close partnerships with the asthma care team in our hospital-based primary care outpatient clinic. We work with the different specialists who deal with the high-risk asthma patients across our hospital, and we're able to get into our system and see the admissions that are happening sort of on a daily basis. We can look at admissions logs and see the high-risk asthma patients. Having the systemized access, I think, is key. That being said, I do think it is very possible for more satellite or remote community asthma programs to get linked and get embedded.

I don't think it's necessary that you have a daily feed. I think a weekly feed is sufficient because really what it is, is working with the providers who work with these patients and making sure that we know the patients that need that care and that we're targeting them and that we get notified when they are interfacing with our system. The closer that you can get to the moment that those patients are actually in the care system that you're working in, the better.

Nancy Wilson: Yes. That makes sense.

Ayesha Cammaerts: We eventually had to really emphasize that a lot. Many of the folks that we've talked to about replication have wanted to try to replicate the model without having access to that kind of rapid data and that type of collaboration with the other providers. And unfortunately, it does mean that you have to do a lot of chasing down and really doing an intensive outreach to get people to re-engage. If you miss that teachable moment, it can be really quite challenging.

But we're doing a couple of different things to address that aside from the data. We're also suggesting that by doing more upstream work, and helping people learn about asthma in their primary care early on, that we're able to reduce the number of people who get to the point where they are high-risk patients. That's definitely a very important approach we're taking.

Nancy Wilson: So it sounds like building ongoing patient-provider relationships is part of what you need to have when somebody comes in, they're thinking about connecting with you as well. They're not waiting, you're not chasing. They think about calling you.

Ayesha Cammaerts: Right. Systematized access to data is really helpful because providers have so many different things they have to think about. Even if you have a strong relationship, it can be difficult. We don't want to always rely on them picking up the phone.

Nancy Wilson: Yes, that's a very good point. Nazleen, one of the questions that come up for the Office of the Surgeon General has been whether that you've seen some examples of innovations, when you've been out on the road or the Surgeon General's been out on the road. What are some of the examples of solutions that you've seen? You mentioned that that was something that came up.

Nazleen Bharmal: Yes. I think there are a lot of things are happening at the local level. Some of these things even I have seen. I've lived on the West Coast and the East Coast, and then the Midwest and I've seen different examples of all of these throughout so I think it's more just highlighting them, but I'll give you some examples.

In New York City, there is this myth that poor people don't want to eat fruits and vegetables in general. That's why many bodegas or convenience stores don't stock them up because they feel that they don't sell. What happened in New York City was that a foundation developed a green card program where street vendors would actually have fruits and vegetables instead of street vendors giving out hotdogs or pizza. They actually had fresh fruits and vegetables. With that, they had bilingual street vendors that had recipe cards. They went to certain communities around New York City, low- income communities, often your bodegas.

What they found is people were not only taking those fruits and vegetables—interacting with the street vendors and using the recipes—but they looked at the success of that. They measured that. As an unintentional result, the surrounding bodegas saw that there was a demand for fresh fruits and vegetables, and started stocking up on fresh fruits and vegetables themselves because they saw there was an increased demand and saw this as profitable.

Another area is something that we've seen in schools, so especially in San Francisco. There's a number of programs that instituted a very low-cost intervention of 30 minutes of quiet time in schools that had high suspension rates, chronic absenteeism, and poor graduation rates. What they found is that just 30 minutes of quiet time with these students every day resulted in increased enrollment—significant increases in enrollment—98 percent decreased stress, a total decrease in expulsion rates, and better outcomes for teachers. And that's such a very low-cost, small intervention that probably had other compounding variables with it, but just having quiet time or time to think.

We also saw something in Detroit, Michigan, called Access, which is a wonderful example of where community and clinic come together. This is an example in Dearborn, Michigan; it has a large Muslim population. The Muslim community center decided to have a comprehensive service with both a behavioral health specialist and traditional practitioners working together to provide health care needs for both physical and mental health. But they also did that next step, which is providing things like housing or job training and placement or helping people get on food stamps.

There's a program here on the east coast, Health Leads. So these are the types of programs that we see that have been successful that are embraced by the community and are comprehensive. This is just a number of them. So there's a lot of innovation helping and happening on the ground. I do think in our current health care environment, where we're thinking about new delivery and reimbursement payment models, that people are more and more interested in combining these clinical and community collaborations to provide better health.

Nancy Wilson: Do you think that the payment models—such as accountable care organizations (ACOs), etc.—the new payment models have made a change in what you're seeing for community health improvement? Or is the payment model kind of separate from the collaboration that you're seeing in communities where there's innovation?

Nazleen Bharmal: Yes. And I think I can't give a comprehensive answer. But I'll just give one. And I think it's – it's more of the latter, which is that these innovations are happening because there's needs in the community.

Nancy Wilson: Yes.

Nazleen Bharmal: It's not necessarily driven by ACOs or different delivery model systems or potential payment models. For example, in Los Angeles, many Federally Qualified Health Centers have community health workers because they realize that results in more efficient and coordinated care for their patients. But often those are grant supported. And they've predated any of the payment model reform. I think they would love if that was in a reimbursable service. But as of right now, that's not unless you are, you know, a nurse practitioner, are licensed—unless you're a licensed professional. And I think you're right. It's driven by the needs and the desires of the community. It was happening on the ground.

Nancy Wilson: Yes.

Ayesha Cammaerts: Can I chime in on that?

Nancy Wilson: Please do.

Ayesha Cammaerts: I definitely agree with that point. I think that we'd seen huge networks of community health workers develop across the country and some really amazing things happen at the State level to look at how you regulate their certification and trying to put into regulations, how to fund them. And actually, there have been reimbursements put in place because the value of community health workers has been proven for decades now, far before the new payment models.

But I do think that the new payment model conversation, because it's an opportunity for some of these community-based organizations to find something extreme that they haven't previously had, is helping foster new coordination and collaboration, and so that people are thinking a little more systemically, instead of my health center has these many community health workers and this is how we're going to grant-fund them this year, and let's figure out how we can grant-fund them next year. It's a little bit more like, okay, how can me and my six other neighbor community health centers work together to create a system-wide approach. I'm not saying that those system-wide approaches haven't been considered already. But I think that it is happening a little bit more, and certainly that's something we're seeing here.

Nazleen Bharmal: Great. I definitely have to agree with that. I do think it's allowing this conversation to start, and some people to think more broadly.

Nancy Wilson: Well, I think that that's a positive—that's positive. That's great to think that it is—so many times—you know having been in the Federal Government long enough, so many times, I think that we sometimes do think them. And we have to be very careful about our untoward consequences. It would be that are negative.

I think that it's great if something that the federal government is doing is actually supporting and encouraging and nourishing what communities want to be able to do anyway, and just personal opinion, it doesn't always work that way. Are there other questions that have come up?

Nancy Wilson: I'm going to ask one more controversial question to Nazleen. Is the Surgeon General's Office going to talk about mental illness and guns at some point?

Nazleen Bharmal: Sure. I think that Dr. Murthy has been very public about what he has initially said on this topic. For those of you don't know, he had a challenging confirmation process. And he has said that guns are a public health issue. He's always stood behind that. I think one of the difficult parts of this conversation is that we don't want to say that people with a mental illness are prone to violence. And I think that sometimes that happens when conversations happen about gun and gun violence. And at the same time, we don't want to say that the only reason that people use guns or prone to violence is because they have a mental illness. So you know there are other root causes for violence including racism, sexism, whatever. Our office is open to having that conversation about violence in general. And Dr. Murthy's always stood behind what he's always said on this topic.

Nancy Wilson: Well, I would agree with you. I mean I know most people with mental illness are not violent. I would never want to suggest that the converse is true. But I think that it would be really interesting to have someone championing the issue of the availability of guns in our country.

Ayesha Cammaerts: It seems like people want to know a little bit more about our criteria for high risk and how some community-based organizations can do better at identifying these types of patients. The first point I can share is a little bit about how high risk is defined. And generally, it has to do with the number of emergency department visits or admissions the patients have had already within the past year. So that's something where we're looking at data over time.

When we ask for referrals from our partners, we ask for them to look at in the last 12 months if there has been one emergency room visit for asthma exacerbation, a prescription for oral steroids, or a hospital admission for asthma exacerbation. So those are all sort of clinical definitions and criteria for out-of-control asthma. We also look at overuse of what we would refer to as rescue medications or your daily management medications for asthma, if there have been frequent urgent care visits, and then we look a little more broadly. We ask the providers to think about what some of the environmental factors might be or some of the social factors might be—so if the parent or guardian smokes, if there are a lot of animals, then there are mice, chemicals, insects in the housing space. To the extent that providers are able to learn about these things from their patients, those are all factors we try to use for identification criteria.

But ultimately, we are getting those lists from our hospital and with our community health centers that we're working with to help manage this a little bit more upstream. Many of them do have electronic medical records that do capture medication use, but do not capture whether or not patients have been to hospitals or emergency rooms or if they've come in to the clinic for urgent care visits. They also send them to look at just peak flow readings and how they've been managing their asthma over time from a sort of anecdotal assessment perspective. If the patient's not looking like their asthma's in control, and they come in for their well visit, the clinician might dive in and ask some more and do a deeper level assessment to make sure that that patient is an appropriate fit for our program or for a more intensive intervention that they might have based at their own community health center.

So I do think it is possible to use the data systems that are based in community-based organizations and community health centers especially to identify these patients, to create patient registry lists for asthma patients, to track the patients over time so that we can work with them a little bit more upstream to help prevent the occurrences of them actually getting into the hospital. And that's something that's also really important to us and that we see as an important part of our intervention.

Nancy Wilson: How do you use smartphones or other telemedicine?

Ayesha Cammaerts: We think it's great to look at how to use different technologies for our interventions. And we do sort of occasionally use cell phone communication for some of our patient outreach. But generally, there are still some big strides that need to be made as around HIPAA compliance because there are great concerns that, for example, if we had an automated text message going out to our families about their asthma, that someone could see that, and then they would know the diagnosis. They would know the person's going to Boston Children's Hospital. They might know that a person takes medications. And those are all private health information data points that we don't want to be encouraging to be just easily accessed by someone's phone. So there is that balance of how much you can use the technology for outreach with how can you also make sure that patients are really fully protected and that their confidentiality is conserved.

But there have been some really interesting platforms, and there are great mobile software applications available on the provider side to actually track the community health worker's experience and work on a home visit. I'm familiar with a company called Dimagi that does great work here locally, and they actually create community health worker platforms. They have something called CommCare, which is their platform for community health workers to take down data into a mobile phone or a tablet device. And they're doing some other work domestically and globally.

What's Next for the National Quality Strategy [Slide 30]

Heather Plochman: Thanks so much, Ayesha. I think we've reached the end of our time here. On your screen, you'll see some of our next National Quality Strategy initiatives and some links for you to follow. Thank you very much for joining. If your questions did not get asked, we will follow up with you via email to answer your question. You should expect the transcript and slides to be sent to you in the next couple of weeks. So thanks, everyone, for participating.

Thanks for attending today's event [Slide 31]

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