Aim High

Bellin Health’s goal is to maintain and improve the health of an entire population…one person at a time

The Bellin Health team has a simple but sweeping vision: The people in its region will be the healthiest in the nation. With a goal like that, is it surprising that one of those charged with helping the Green Bay, Wisc.-based IDN get there has the title “chief learning and innovation officer?”

“We realize, as an organization, that coming up with new ways of thinking about health and healthcare delivery is going to be critical as we look into the future,” says Peter Knox, executive vice president and chief learning and innovation officer. “Our emerging need is, ‘How do we harness innovation, and how do we build a structure and framework around broad-based learning and innovation?’”

Not a simple task. But it’s one that everyone at Bellin Health – clinicians, administrators and others – has undertaken enthusiastically, says Knox, who is responsible for population health strategies, accountable care strategies, employer strategies and physician networks. And he believes that the population around Green Bay will embrace the task as well.

Bellin Health comprises an acute-care hospital, psychiatric center, critical-access hospital, 26 primary care clinics and several retail clinics known as Bellin Health FastCare. The IDN operates Bellin Health Partners, a physician-hospital organization with more than 200 specialty physician members.

Several years ago, Bellin Health joined forces with ThedaCare, a community health system based in Appleton, Wisc., to coordinate care to the population in 12 counties in northeast Wisconsin. In November 2011, Bellin Health-ThedaCare Healthcare Partners was selected as one of 32 organizations nationwide to be part of the Pioneer Accountable Care Organization program of the Centers for Medicare & Medicaid Services. The ACO comprises about 700 physicians, 57 primary care locations, three tertiary hospitals and four critical-access hospitals.

Population management
It’s tough to pinpoint when Bellin Health’s vision of the healthiest region in the country – or what might be called population management – first emerged. “It was an evolution,” says Knox, who has been with the IDN for more than 30 years. Roughly four or five years ago, the emphasis was on the lifelong health of those people who engaged with the IDN, either as inpatients or outpatients. “But as we’ve been on our journey, we started to think about the impact we wanted to have on the entire region,” he says. “It’s good to be focused on people who engage with us, but that’s somewhat limiting in terms of impact and numbers.” So about two years ago, the IDN expanded its vision to include everyone in its service area, not just those who visit Bellin.

The vision dovetails with the Institute for Healthcare Improvement’s Triple Aim, something with which Knox – a Senior Fellow at the Institute and author of two books – The Business of Healthcare and Destination Results – is very familiar. IHI believes that new designs in healthcare delivery must and can be developed to simultaneously accomplish three objectives: improve the health of the population, enhance the patient experience of care (including quality, access and reliability), and reduce – or at least control – the per capita cost of care.

“We’ve created a population strategy that is very broad in its reach and scope,” says Knox. “The question we have to ask ourselves is, ‘How does our vision change the way we think about our role, the relationships we have in the broader community, and the way we extend our influence even [to those with whom] we don’t have that direct touch?’”

Executing the strategy is no small feat. For one, many things – not just the actions of the healthcare delivery system – affect people’s health. In fact, it’s estimated that between 20 percent and 40 percent of the determinants of health lie outside healthcare providers’ traditional boundaries, says Knox. Second, as they try to implement a “population management” approach, healthcare providers still have to deal with dated methods of reimbursement.

Bellin Health’s path, like that of most providers, can be described as a corridor, says Knox. It begins at a point of low risk/low coordination, and ends at a point of high risk/high coordination.

In today’s fee-for-service environment, providers bear relatively little risk, he explains. You provide care, you get reimbursed. There’s not much coordination of care required. But as one moves toward population management, that is, ensuring the health of a large group of people, the emphasis is on coordinating care, and reducing variation and utilization of services.

“As an organization moves along the corridor, falling off either way can hurt the organization,” he says. “Unfortunately, in a fee-for-service world, if you’re effective at reducing utilization, you can hurt yourself. On the other hand, if you assume risk but you’re unable to coordinate care, financially, you can find yourself in a very difficult position.”

Navigating this corridor can be confusing to providers and administrators, he says. “You have a foot in both worlds. In one world, the more you do, the more you get paid. In the other, the more you reduce variation and manage care, the more effective you are in managing the entire continuum, and the better you will do.”

The vision
To execute on its strategy of population management, Bellin Health is engaging the residents of Green Bay and surrounding areas in new ways. “How do you create an experience that takes into account an individual’s health and life goals, and then design a connected experience across the continuum that can help people be successful in achieving those goals? How can we connect those islands? How can we build this infrastructure? Other industries are doing similar things. But you really have to rethink how we have designed our systems.”

At the core of Bellin Health’s strategy is the “activated individual.” It’s a concept developed by Judy Hibbard, Ph.D., professor of health policy at the University of Oregon and lead author of the Patient Activation Measure® survey.

Hibbard’s research has demonstrated that healthcare providers connect with people differently based on their activation level, that is, the degree to which individuals are motivated to maintain or improve their health. By increasing their knowledge, skill and resources, people can assume more accountability for their health. “We don’t feel people are victims,” says Knox. “But they don’t know where to go for support, resources and assistance. And we can help them.”

To do so, Bellin uses what it refers to as “rings of influence,” beginning with employers and others with whom Bellin Health has entered into long-term relationships based upon improving the health of the population. Other such rings of influence include primary care physicians, and acute-care and specialty-care providers. Outside the traditional boundaries of healthcare providers lie three more rings – groups of people who share some similarities, such as those in various high-risk categories, or children; community or grass-roots organizations; and lawmakers at the state or national level.

Turning the ship
Turning the ship from fee-for-service to population management is exciting – and tough. “It’s great to have this mission and vision and to really articulate something very different,” says Knox. “It’s a whole other thing to execute on that and implement it.”

Knox is a student of how organizations execute strategy. In fact, at press time, he was writing a book on the subject. “What you’ll find is that 70 percent of all strategies, regardless of business or country, fail to get executed or implemented successfully. We articulate really interesting missions and visions, but the deck is stacked against us in terms of being successful implementing them.”

To beat those odds, organizations have to “create clarity around the direction,” he says. “You have to [articulate] the compelling reason why it is exciting and important. And you need to develop a framework for aligning, deploying and executing on the strategy.” In other words, you must have a vision as well as a framework for execution.

Courageous and visionary leadership is a must. “Then you have to get the entire ship aligned around the strategies it will take to move in this direction.”

Knox has identified six components that are necessary for the successful implementation of mission/vision/strategy.

  • Strategic direction. “How do we create strategic clarity and align the organization, so we look internally at our competencies, and then take an important step that’s missed many times – identifying the aims for the various strategies on a longer-term horizon.” Some people believe that healthcare delivery is so dynamic, it defies long-term planning. Knox disagrees. “We need to take the longer-term view, then define measurable aims over the course of time.”
  • Translating strategic goals into what can be called the healthcare production system. Healthcare executives aren’t used to thinking about healthcare delivery in such terms, but they should, says Knox. Providers can use as their model industrial systems. The healthcare equivalent to industry’s “mass customization” would be a delivery system that is flexible and capable of delivering care that meets the unique needs of individuals. “These are all concepts that are possible. We’ve begun to implement them, and others have too.”
  • Measurement system. According to Knox, measurement must overlay the production system, so executives can gauge whether they are on track in meeting their specifications.
  • A performance improvement plan, with two components. The first is quality control, “where we lock down the systems and specifications that have been identified,” he says. The second, equally important, is the innovation track. “We are constantly managing a pool of innovations and trying to extend the boundaries of the system. We think you have to manage both simultaneously, and we do that through a disciplined cycle of improvement processes.”
  • Sales, marketing and/or communication. The organization has to connect with its various audiences to tell them how the organization has responded to their needs. What’s more, if a healthcare system has created, say, new access points for people to receive care to supplement the emergency department, it must inform them of that.
  • Cultural alignment. The challenge is aligning the culture, and engaging people within and outside the organization.

Seeing possibility
Physicians and payers are integral to the success of the mission, and the provider has to engage them in meaningful dialogue, or what Knox calls “the important discussion of what we want to create together.”

“We have constant conversations with our physicians, most of whom are not really happy with the care system as it is designed today,” he says. “They don’t feel they’re doing justice for their patients, and they’d like to see better coordination and a better experience. And we’ve been out talking to all the major insurance companies and employers. We’ve found very, very open-minded potential partners who really want to think differently and do things differently.

“If you can get a group of people together and agree on a common vision and aim, and engage in ongoing discussion about how we can get there, you can do extraordinary things. A lot of it is about possibility – creating possibility.” That’s what Knox’s and Bellin Health’s mission will be for the foreseeable future.

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