Integrated Health for Integrated Health for Socially Complex People in Socially Complex People in

Socially Complex Socially Complex NeighborhoodsNeighborhoods

Chairs:Chairs:Kirsten PeacheyKirsten Peachey

John BartlettJohn BartlettSteve TierneySteve Tierney

Michelle TierneyMichelle Tierney

CEO interviews—point of stress for leaders is the movement CEO interviews—point of stress for leaders is the movement from the current health environment (World 1) to the new from the current health environment (World 1) to the new health care environment (World 2)health care environment (World 2)

World 1 to World 2World 1 to World 2

World 1

World 2

Area of focus for this work group—1st steps in moving into “World 2”

3 areas where we need to 3 areas where we need to focus further work of the focus further work of the

TeamTeam““Make the Case”Make the Case”Don’t Wait to InnovateDon’t Wait to InnovateDescribe “The WayDescribe “The Way””

Make the case for treating Make the case for treating the SDOH/Whole Personthe SDOH/Whole Person

What is the true nature of the problem and What is the true nature of the problem and the solutions? Grown-up eyes and thinkingthe solutions? Grown-up eyes and thinking

Treat the whole person (including their Treat the whole person (including their context) and how that translates financiallycontext) and how that translates financially

In “World 2”, it makes sense to use Social In “World 2”, it makes sense to use Social Determinants of Health (SDOH) language Determinants of Health (SDOH) language and thinkingand thinking

Practically—Data platforms, governance Practically—Data platforms, governance shifts, metricsshifts, metrics

Don’t Wait to InnovateDon’t Wait to Innovate

Don’t be slaves to Don’t be slaves to processes/evidence baseprocesses/evidence base

Start with outcomes versus Start with outcomes versus processesprocesses

Recognize and address Recognize and address anxietiesanxieties Specific models and examplesSpecific models and examples

Describe “The Way”Describe “The Way”

What are practices that we know What are practices that we know work/ that are “good” practices? E.g. work/ that are “good” practices? E.g. Policy/AdvocacyPolicy/Advocacy Mutual engagement with communityMutual engagement with community Relationship buildingRelationship building CBPR (Community Based Participatory CBPR (Community Based Participatory

Research)Research)

Partnership Team collaborationPartnership Team collaboration

Areas for our InfluenceAreas for our Influence

We also identified 3 areas We also identified 3 areas where we feel the larger HSLG where we feel the larger HSLG may use its influence to create may use its influence to create a more ready environment for a more ready environment for this work. This is longer term this work. This is longer term work—probably beyond the work—probably beyond the spring meeting with CEOs.spring meeting with CEOs.

Areas for Our InfluenceAreas for Our Influence

1.1. Influence federal partnersInfluence federal partners• How can CMS reinforce this How can CMS reinforce this

approach with concrete rewards approach with concrete rewards for health systems that practice for health systems that practice in this way?in this way?

• We need to be proactive voices to We need to be proactive voices to drive the ACO conversationdrive the ACO conversation

Areas for our InfluenceAreas for our Influence

2.2. Data InfrastructureData Infrastructure• Nimble data platforms and Nimble data platforms and

systems with accessible systems with accessible and timely feedback for and timely feedback for course correctioncourse correction

Areas for our InfluenceAreas for our Influence

3.3. Engagement with Denominational/ Engagement with Denominational/ Religious Sponsors/PartnersReligious Sponsors/Partners

Partners in influencing governmental Partners in influencing governmental partners to reward community-based partners to reward community-based practice?practice?

Access theologies/values/principles Access theologies/values/principles that can guide and support role of that can guide and support role of health care systems as stewards of the health care systems as stewards of the community’s health.community’s health.