Taking Collaborations to Scale to Improve Population Health

1. Taking Collaborations to Scale to
Improve Population Health
Ahmed Calvo, MD, MPH | Marianne McPherson, PhD, MSPH | Laura Seeff, MD
#PPBMeeting

2. Learning Objectives
At the end of this workshop, you will be able to:
 Discuss technical methodologies and adaptive, relationships-based
approaches to achieving spread and/or scale
 Apply principles of taking collaborations to scale to your local context

3. Workshop Agenda
 Framing: Doug Englebart’s Networked Improvement Communities
 Overview of CDC’s 6 |18 Initiative and 100 Million Healthier Lives
 Key elements of spread and scale up, with examples from the field
 Workshopping your spread & scale-up insights: Innovation disco -
breakout groups – and sharing out to a conversation-of-the-whole

4. Questions-to-run-on
How we would like you to listen and engage:
• What is the one most interesting idea that
popped into your brain as you heard the
presentations as applicable to your work?
• How do you activate a “whole-of-nation” effort
with action at the local community?

5. 5 Ahmed Calvo
Taking Collaborations to Scale to Improve Population Health
Framed Using Doug Engelbart’s Concept of
Networked Improvement Communities (NICs)
A Network-Centric Approach leverages
the People-Centered Internet (PCI) and
Information-Communication-Technology (ICT)
Ahmed Calvo,MD,MPH
Director,National Health Leadership and Public Service Fellowship
Haas Center for Public Service,Stanford University
Senior Fellow,Thought Leadership and Innovation Foundation
Senior Medical Officer,Health Resources and Services Administration
U.S.Department of Health and Human Services

6. Taking Collaboration to Scale
After framing for this interactive session, we will focus on two key efforts:
•CDC’s 6/18 Campaign
•100 Million Healthier Lives Movement, convened by IHI
– Laura Seef, MD
– Director, Office of Systems Collaboration
– Centers for Disease Control & Prevention (CDC)
– Marianne McPherson, PhD, MSPH
– Senior Director of Implementation, 100 MLives
– Institute for Healthcare Improvement (IHI)

7. Key Principles For Success
• Spread and scale-up happen at the speed of trust
– And takes place via a network process (AKA net-centric method).
• Technical and strategic components are important
– particularly for cross-sector collaboration
• But solid trust relationships are the true secret ingredient
• We will frame these principles for spread and scale-up
– using a variety of networked insights

8. Key Definitions
• Doug Engelbart – concept of “networked improvement communities” –
two co-evolving improvements of both IT systems and human systems –
“Augmented Intelligence” (AI) concept in Augmentation Research Center
laboratory at SRI International (Stanford Research Institute) – and of
“bootstrapping” as start-up method for a network or center.
• FQHCs (Federally Qualified Health Centers) – sites of Community Health
Centers (CHCs); over 9,000 FQHCs with active patient volume of ~ 23
million patients and over 90 Million patient-visits/yr – 170,331 staffers
(2014 UDS numbers). Funded by HRSA (Health Resources and Services
Administration) – an agency in the US Department of Health and Human
Services (HHS).

9. Breakthrough Series (BTS) Collaborative Model
Drawing on a napkin by Paul Batalden over 20 years ago –
from Don Berwick, Institute for Healthcare Improvement (IHI)

10. HRSA Health Disparities Collaboratives added ICT support to
learning process – as key needed infrastructure (1998)
Select Topic
Planning
Group
Identify Change
Concepts
Participants
Pre-work
LS 1
P
S
A D
P
S
A D
LS 3LS 2
Rudimentary ICT Supports
E-mail Visits
Phone Assessments Senior Leader Reports
Time for setting aims, allocating resources, preparing
baseline data leading to the first 2 day meeting.
Action period 1: Adapt
and test the ideas for
improved system of care
Action period 2: further develop the
system of care at the pilot site and
spread the system to other sites

11. Evolved Perspective of the HRSA Health Disparities Collaboratives
as a National Framework for Change (1998-2008)
Establish
National
Agenda
National
FACULTY
Identify
Measures,
Priorities
Evidence-Base
Developed by Partners
Pilots
Evolved ICT Infrastructure
www.healthdisparities.net ° Regional Infrastructure ° www.hdnr.org ° Phone TA ° Monthly
Measures and Senior Leader Reports ° National Faculty Consultants ° Topical Conference
Calls/Webinars
Small scale pilots for the purpose of developing the
change package to facilitate rapid deployment of a
new evidence-base
Adapting
Evidence Base
-- Chronic Care
Model, Model for
Improvement
Supporting
National
Learning
Community
For Best
Practices
Population
Health
Mgt.
•Registry
•Reporting
Executing
National
Health
Policy
•Partnerships
National
Vision For
Healthcare
Transformation

12. ICT and Policy Change Infrastructure at HHS for ACA Implementation
– a National Collaborative Framework (2009-2016)
ACA Passed
(Affordable
Care Act)
Networked
National
FACULTY
Identify
Measures,
Priorities (NQF
Contract)
Evidence-Base Developed
by Partners (e.g. PCORI)
CMS Pilots
Further Adapted ICT Infrastructure
° National Leadership Network shifted to CMS ° State Infrastructure °
www.heathycommunities.org ° Link with QIOs ° National Measures Massive use of Webinars –
and maybe shifting to MOOCs
Small scale pilots and demonstrations for the purpose of
developing the change package to facilitate rapid
deployment of a new evidence-base and massive scale-up
via CMMI at CMS
Community
Adapting
Evidence
Base-- via
foundations
(private $$)
Supporting
National
Learning
Communities
(Partnership
for Patients)
EHRs-HIEs
Pop Health
Mgt.
•Registries
•Reporting
•Analytics
Nation’s
NQS &
NPS –
With ONC
Standards
Incentives
Going from
Healthcare
To Health
- as a Vision

13. Envisioning Collaboration via the PCI -- A Collaborative NIC Framework (2017)
Topic: Health –
in a digital age
Planning
Group: US
Citizenship
Change
Concepts:
Community
Action
Evidence-Base Developed by
Digitally Native Citizen-Partners
(using: PCI, smart phones, apps)
Pilots
Further Evolved (Decentralized) ICT Infrastructure
° Evolved Leadership Network ° Evolved Infrastructure °
° New Metrics ° Massive use of Webinars – and MOOCs °
Small scale pilots and demonstrations for the purpose of
developing detailed change package to facilitate rapid
deployment of a new evidence-base for massive scale-up
Community
Adapting
Evidence
Base-- via
foundations
(private $$)
Supporting
Learning
Communities
-- as “going
concerns”
-- already
in action
Better ICT: - PCI
- Collaborate.org
- EHRs
•Registries
•Reporting
•Analytics
US
Culture
Of Health
Going from
Healthcare
To Health
- in context of
new realities

14. Culture of Health
Entities exist already working in the private sector:
•100 Million Healthier Lives Movement
•Communities Joined in Action (CJA)
•New Breakthrough Collaboratives (Foundations)
•Healthy Communities Collaborative for America, the AIMM
Collaborative, and PCI
•Wellbeing in the Nation (WIN) Initiative
•Creating Wellbeing Leadership Group
•Collaborate.org

15. Centers for Disease Control and Prevention
2nd Annual Practical Playbook Meeting -
Improving Population Health: Collaborative
Strategies That Work
Scaling Collaboration For Greater Impact - CDC’s 6|18
Initiative: Accelerating Evidence into
Action, June 1, 2017
Laura C. Seeff MD
Director, Office of Health Systems Collaboration
CDC Office of the Director

16. Opportunity Knocks: The Transforming Health System
 Increased health care coverage
 Payment reform: volume  value
 Clinical care models more patient-
centered/comprehensive
 More opportunities to deliver
prevention 46%
19%
13%
8%
10%
Employer
Medicaid
Medicare
Other
Uninsured
“Other” Insurance
Coverage:
• Other Private – 6%
• Other Public – 2%
About 90% of All Americans are Insured
as of 2014
"Health Insurance Coverage of the Total Population." State Health Facts.
The Kaiser Family Foundation,
Juliette Cubansk; Barbara Lyons; Tricia Neuman; Laura Snyder; Anne Jankiewicz; David Rousseau. (2015). Medicaid and Medicare at 50. The Journal of the American
Medical Association, 314(4), 328. doi:10.1001/jama.2015.8129

17. Another Major Trend: Public Health Evolution
 Recession cuts unrestored – 52K
fewer jobs
 48% locals reduced public health
services in 2012
 29 states decreased public health
budgets in 2012

18. 6 18High-burden
health
conditions | Evidence-based
interventions that
can improve health
and save money
 Establish sustainable cross-sector partnerships between public health and
health care purchasers, health plans, and providers to address shared health
priorities
www.cdc.gov/sixeighteen; Hester, J. A., J. Auerbach, L. Seeff, J. Wheaton, K. Brusuelas, and C. Singleton 2015. CDC’s 6|18 Initiative:
Accelerating evidence into action. National Academy of Medicine, Washington, DC. http://nam.edu/wp-content/uploads/2016/02/CDCs-618-
Initiative-Accelerating-Evidence-into-Action.pd
Collaboration between public health, health care purchasers, payers, and
providers to promote adoption of evidence-based interventions
 Improve health and control costs using specific evidence-based
interventions

19. 6 18High-burden
health
conditions | Evidence-based
interventions that
can improve health
and save money
www.cdc.gov/sixeighteen; Hester, J. A., J. Auerbach, L. Seeff, J. Wheaton, K. Brusuelas, and C. Singleton 2015. CDC’s 6|18 Initiative:
Accelerating evidence into action. National Academy of Medicine, Washington, DC. http://nam.edu/wp-content/uploads/2016/02/CDCs-618-
Initiative-Accelerating-Evidence-into-Action.pd
Collaboration between public health, health care purchasers, payers, and
providers to promote adoption of evidence-based interventions
Example

20. High- burden
Preventable
Scalable
Purchasers &
payers
Costly

21. Eighteen Evidence-Based Interventions

22. State Medicaid – Public Health Department Implementation
Launched February 2016:
 Early Progress
– Baseline data being collected
– State Plan Amendments
– Managed Care Organization
contractual negotiations
– New scope of practice legislative
authority
– Member and provider education tools
and training
 Upcoming
– Staged expansion
– Shared learning platform
CO
SC
MI
LA
MA
RI
MN
GA
NY
GA
3
Focus Areas: Tobacco,
Asthma, & Unintended
Pregnancy Prevention
Action Plans
State Medicaid Agency & Public
Health Programs Teams9

23. Evaluation and Theory of Change
State
readiness to
change
payment
Payment
change for
18 services
Increased
provider delivery
and patient
utilization of
services
Improved
health
outcomes
Decreased
costs

24. – Payer-specific/multi-payer initiatives
– Initial focus: DPP, HTN & asthma control
– Shared learning platform
– Added issues: behavioral economics, provider
engagement, targeted member engagement
Expanding 6/18 to commercial payers

25. Public Health and Health System Complementary
Roles
PUBLIC HEALTH
 Contributed condition-
specific subject expertise
 Translated epidemiologic evidence into
benefits for coverage
 Developed awareness campaigns
targeting providers and patients
 Promoted linkages with community
services
MEDICAID AGENCY
 Developed a business case for chosen
interventions
 Utilized available policy levers to
improve coverage and promote
increased uptake of services
 Engaged with Medicaid managed care
plans to enhance benefits
 Engaged providers and members

26. Engagement Preparation
Identify Evidence-Based Intervention
 Significant disease burden
 Strong health & cost evidence associated with intervention
 Fills current gap
Identify key purchaser-payers
 Assess likely receptivity
 Align with purchaser-payer priorities
 Match burden of condition and insured population
 Prepare customized case
Consider
 Provider engagement & provider supply
 Level of support from key decision makers
 Measurability
Likelihood of success
 Readiness for rapid change
 Resources required for success

27. CO
SC
MI
LA
MA
RI
MN
GA
NY
GA
NC
AK
TX
NV
UT
MD
District of Columbia
Los Angeles County
Health Department
Expansion (spread and scale) to New Localities

28. Visitthe6|18Website
CDC.gov/SixEighteen
Evidence Summaries
Detailed summaries of
the 6|18 interventions,
based on scientific
studies and expert
consultations
FAQs
Answers to common
questions about the
6|18 Initiative including
goals,strategy, and the
intervention selection
process
Coming soon!
Additional Tools:
Readiness checklist
How to be a 6|18 Partner

29. Taking Collaborations to Scale to Improve Population Health
2017 Practical Playbook National Meeting ~ June 1, 2017
Spread and Scale Up:
Lessons from 100 Million
Healthier Lives
Marianne McPherson, PhD, MS
Senior Director, 100 Million Healthier Lives
Institute for Healthcare Improvement, Cambridge, MA
mmcpherson@ihi.org @MariannePhD

30. Mission
Improve health and
health care worldwide
Vision
Everyone has the best
care and health possible
Strategic Approach
IHI applies practical improvement
science and methods to improve
and sustain performance in health
and health systems across the
world. We generate optimism,
spark and harvest fresh ideas, and
strengthen local capabilities.
How We Work
• Convene
• Innovate
• Partner for Results
Health Equity
What We Do
Joy in Work
Safe &
High Quality
Care
Health of
Populations
Value
Improvement
Science
Institute for Healthcare
Improvement (IHI)

31. How We Work
31
Convene
Bring people
together to build
skills, learn
from one
another, and
bring energy to
accelerate
change
Foster creative
solutions to
complex
problems
Drive system
level
results for the
individuals,
populations, and
communities
we serve
Partner for ResultsInnovate
www.ihi.org

32. IHI’s Triple Aim
System designs that
simultaneously improve three
dimensions:
– Improving the health of the
populations;
– Improving the patient experience
of care (including quality and
satisfaction); and
– Reducing the per capita cost of
health care.
Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, And Cost. Health Aff. 2008;27(3):759-769.
doi:10.1377/hlthaff.27.3.759.
Whittington JW, Nolan K, Lewis N, Torres T. Pursuing the Triple Aim: The First 7 Years: Pursuing the Triple Aim: The First 7 Years.
Milbank Quarterly. 2015;93(2):263-300. doi:10.1111/1468-0009.12122.
32

33. The 5000:1 reality of chronic disease management
In the U.S., at least 1/2 all
adults—117 million people—
had at least 1 chronic health
condition.
Leading causes of death in
the US; projected 57% global
disease burden by 2020
Among the most common,
costly, and preventable of all
health problems.
5000-to-1: person’s hours of
self-management to health
care contact
• Asch DA, Muller RW, Volpp KG. Automated Hovering in Health Care — Watching Over the 5000 Hours. New England Journal of Medicine. 2012;367(1):1-3.
doi:10.1056/NEJMp1203869.
• Ward BW, Schiller JS, Goodman RA. Multiple Chronic Conditions Among US Adults: A 2012 Update. Preventing Chronic Disease. 2014;11. doi:10.5888/pcd11.130389.
• World Health Organization: The Global Burden of Chronic Disease: http://www.who.int/nutrition/topics/2_background/en/.
33

34. Health care determines only 10-20% of overall
health
Social
circumstances
15%
Environmental
exposure
5%
Behavioral
patterns
40%
Health care
10%
Genetic
predisposition
30%
Proportional Contribution to
Premature Death
"Health Policy Brief: The Relative Contribution of Multiple Determinants to Health Outcomes," Health Affairs, August 21, 2014.
http://www.healthaffairs.org/healthpolicybriefs/
Graphic adapted from McGinnis JM, Williams-Russo P, Knickman JR. The Case For More Active Policy Attention To Health Promotion. Health Aff. 2002;21(2):78-93.
doi:10.1377/hlthaff.21.2.78.
Interaction
Intervention
possibility
slim

35. Identity: An unprecedented collaboration of change agents
pursuing an unprecedented result:
100 million people living healthier lives by 2020
Vision: to fundamentally transform the way we think and act to
improve health, wellbeing, and equity.
Equity is the “price of admission.”
Convened by the Institute for Healthcare Improvement as a partnership
100 Million Healthier Lives
www.100mlives.org

36. Our theory of change
Unprecedented
collaboration
Innovative
improvement
System
transformation
100 Million
People Living
Healthier Lives
by 2020

37. 1. Develop healthy, equitable communities
2. Create bridges between health care, community public health
and social sector
3. Create a health care system that is good at health and good at
care
4. Scale up peer to peer supports
5. Develop new culture and mindsets
6. Create enabling conditions
100 Million Healthier Lives: 6 Core Strategies 37

38. A growing movement:
>1100 members in 27+ countries worldwide
www.100mlives.org/map
Interactive Map:
www.100mlives.org/map

39. 1. Join us by
signing up
2. Create an
action plan
3. Start
measuring
4. Learn more &
stay
connected
Join us!
www.100mlives.org

40. Spread & Scale-up
Key Concepts and Elements
40

41. Spread and Scale-Up
Different yet complementary concepts
Spread
Scale-
Up
41

42. Applying the Science of Improvement to
Spread and Scale Up
Barker PM, Reid A, Schall MW. A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implementation
Science. 2016;11(1):12. doi:10.1186/s13012-016-0374-x.
Langley GJ, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd
ed. Jossey-Bass; 2009.
Image Credit:
IHI,“Getting
Results at
Scale”Seminar,
4/7/2016.

43. Spread
Scale-
Up

44. Elements of Spread
Spread
1. Shared
values &
identity
2. Creating trust
& relationships
as first principle
3. Setting
culture &
practice up
front of not
being terminally
unique
44

45. 1. Shared Values & Shared Identity
 Examples of tools for creating:
• Touchstones
• Ways of Being
• Core Principles
 How they’re used
• Shared, reflected up on at regular intervals (virtual & in-person)
• Co-created whenever possible
• May be revised as spread happens, shared identity evolves
45

46. Example questions for use at a meeting:
As you review the touchstones, reflect
upon:
1) What’s one touchstone that you feel
like you’ve “got” / is a strength for
you?
2) What touchstone is a growing edge
for you, either in general or for
today’s meeting?
46
Example: 100 Million Healthier Lives
Touchstones for Collaboration

47. Example: SCALE Initiative, Ways of Being 47

48. Example: 100 Million Healthier Lives Core Principles
http://www.100mlives.org/approach-priorities/

49. 2. Creating Trust & Relationships as First
Principle
 Culture of knowing one another as human beings
• Story of your name, story of your community
• “Speed dial” in the network
 Culture of failing forward, being vulnerable
 Creating regular times when people are interacting with one
another
• Large groups example: Leadership academies
• Smaller groups: Peer Community Teams, bright spot site visits
49

50. 3. Setting culture & practice up
front of not being terminally unique
 Calling out bright spots & useful tools for the field
 Tools and exercises where communities / network members get
used to solving one another’s problems
• Example: UFO exercise

51. 51
Spread
Scale-
Up

52. 1. Key Components of scale-up
2. The scalable unit
3. 5x scale-up thinking
Barker PM, Reid A, Schall MW. A framework for scaling up health
interventions: lessons from large-scale improvement initiatives in Africa.
Implementation Science. 2016;11(1):12.
52Scale Up: 3 Main Ideas

53. 1. Key Components
1. Use a clear sequence of
activities needed to take
interventions to scale,
2. Articulate the context and
environmental factors that
will foster scale-up of best
practices
3. Describe the infrastructure
that is required to support
scale-up
53
Barker PM, Reid A, Schall MW. A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implementation
Science. 2016;11(1):12. doi:10.1186/s13012-016-0374-x

54. 2. Scalable Unit
 It is the smallest representation of full scale that supports the
patient journey, and
 Includes components of a self-contained functional unit (i.e., the
people, processes and structures) that produces an output that is
representative of the whole.
 Questions to consider:
• Does it include all the elements that need scaling up?
• Is it representative enough of the whole system?
• Can it be scaled up?
Barker PM, Reid A, Schall MW. A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implementation Science.
2016;11(1):12. doi:10.1186/s13012-016-0374-x
54

55. 3. 5X Scale-Up Thinking
What are the systems
issues to address as
you move up by
multiples of 5?
Image credit: Pierre Barker, IHI
Barker PM, Reid A, Schall MW. A framework for scaling up health interventions: lessons from large-scale improvement initiatives in Africa. Implementation Science.
2016;11(1):12. doi:10.1186/s13012-016-0374-x
55

56. Workshopping Your
Spread & Scale Up Issues
& Challenges
Breakout Groups

57. Set-Up
 Take 2 minutes to write on an index card the most interesting
idea that popped into your head as you heard the presentations –
and that you want to share with group - ONE - or a
scenario/innovation you are working on – relative to
spread/scale-up.
 Please write legibly!

58. Time to disco
 For the next five minutes while the music plays, walk around the room,
switching cards with people as you go.
 When you get a new card, read the scenario on it and think about
whether you are:
• Not interested
• Somewhat interested
• VERY interested
in discussing the scenario on that card
 If you are VERY interested in discussing that scenario, draw a star on
the card.
 Repeat as many times as you can while the music plays!
58

59. Getting into breakout groups
 3 groups based on the 3 cards that received the most stars
• 1.
• 2.
• 3.
 Each facilitator will be at one breakout table
 Self-select based on what you’d like to discuss
 Jot down notes about what your “report-out tweet” will be (or
tweet in real time): #PPBMeeting
59

60. Real Time Twitter & In-Room Report Out
 Use #PPBMeeting to share your key takeaways from the small
group discussions.
Thank you for joining us today!
60