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How Academic Health Systems Can Achieve Population Health in Vulnerable Populations Through Value-Based Care: The Critical Importance of Establishing Trusted Agency

Wesson, Donald E. MD, MBA; Kitzman, Heather E. PhD

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doi: 10.1097/ACM.0000000000002140
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Abstract

America’s current health care model focuses on restoring the health of individuals after it has been lost. This reactive model not only has failed to improve the health of the population but also does not incentivize healthy outcomes and is extremely costly.1 Improving population health may require health systems to proactively engage patient populations as partners in the implementation of healthy behaviors as a shared value using strategies that incentivize healthy outcomes for the population as a whole. This proactive model of so-called value-based care has the added benefit of lowering health care costs through the reduced need for consumption of expensive health care resources like emergency departments and inpatient hospital care.2,3 This is particularly relevant for vulnerable populations, such as low-income, uninsured, or underinsured individuals, who have limited access to primary care and a greater reliance on expensive health care services such as those mentioned above.4

Vulnerable populations are also more likely to experience unfavorable disparities in chronic disease prevalence and mortality.5–7 In a large multicohort study, lower as compared with higher socioeconomic status was an independent predictor of mortality after controlling for traditional risk factors.5 Accordingly, there is a growing recognition that social and environmental variables, or social determinants of health (SDOH),8 significantly contribute to health disparities and population health.9 SDOH are typically not addressed in the traditional health care model and thus not routinely considered in clinical care.6 To impact SDOH and improve health, health care systems must reach beyond the traditional boundaries of clinical care and into the communities they serve for value-based care to be effective.10

To ensure that value-based care leads to consistently better health outcomes, health systems must continually evaluate the clinical and preventive care they provide by conducting research within the populations they are serving and in the environments in which those populations live. This research is in addition to that traditionally done within the walls of the health system.11 Furthermore, health systems must educate their professionals as to how best to execute this value-based care. This need for new and proactive models of care, research, and education fits well with the traditional tripartite mission of academic health systems, but it will also require a new skill: establishing trusted agency with the community served via trusted agents.10

A trusted agent has the trust of the population being served (e.g., faith communities, schools, community-based organizations, local government and policy makers). We argue that identifying, engaging, and leveraging trusted agents is necessary for health systems to achieve population health. We believe this approach is particularly necessary for vulnerable populations, whose interactions with health care systems have historically not been routinely focused on maintaining health but instead have generally been episodic interactions occurring at times of crisis when health has been lost.

The Current State

The current reactive model employed by health systems, which focuses on restoring the health of members of the population after it has been lost, does not fit well with the shared value of a healthy population. In this model, health system engagement requires that population members overcome the inertia of routine and disengage from their daily lives to instead engage with health systems and hopefully have their health restored. Further complicating this model is that the health care system is difficult to navigate and population members might not trust that the entity will act in their best interest. This latter challenge is particularly difficult for individuals from vulnerable populations.4,9 Consequently, many population members may wait until their health concerns are disruptive to their normal routines (e.g., when they are unable to work). This reactive model does not enhance overall population health but instead leads to population members presenting with advanced stages of illnesses, including chronic illnesses, which consume a disproportionate share of health care resources.12

Because health systems are not proactively engaged in the daily lives of population members, participation in clinical and community-engaged research is often seen as foreign and disruptive,13 and vulnerable populations are particularly wary of research or partnering with health systems.14 To improve health outcomes through research that will determine what types of care add value, health care systems must be trusted. Because health systems have traditionally not been proactive in community outreach, however, they have historically not developed this trust and will need the help of third-party community entities and individuals to do this.

Although education is a vital part of the mission of health systems, this enterprise has traditionally focused on the education of health care providers and less so on the education of the population. As health systems aim to improve population health through the delivery of value-based care, effective mechanisms are needed to understand the needs of communities and population members so that health needs can be successfully addressed.10 This is particularly true given the increasing recognition of the impact of SDOH on individual health.8,9 There is a growing focus by national organizations and the scientific literature on the value of community and patient engagement approaches to better understand and address health needs.15–17 Using these approaches, the education enterprise becomes a mutual or co-learning endeavor, in which health professions trainees learn not only the practice of their respective disciplines but also how to engage the population being served. Involving patients and community members in this endeavor of mutual learning may also lead to greater involvement from the population in health improvement programs. However, as mentioned above with research, getting patients and community members involved will require community entities and individuals who have the trust of the population being served and are willing to act on behalf of the health system.18

The Evolving State

One of the most studied forms of community engagement research is community-based participatory research (CBPR), an approach to develop equitable partnerships between community members, patients, researchers, and health systems.19 These equitable partnerships involve co-learning, sharing of resources, asking the population being served how health system resources can be deployed to serve their health needs, community involvement in all aspects of research or health care services design and implementation, and sharing results and dissemination efforts with the community. These partnerships also involve the development of long-term trust with community entities and individual leaders that can serve as trusted agents,18 which, on the basis of our own experiences, is something we have found to be important to the successful implementation of population health approaches.20–22 Which entities and individuals can best serve as trusted agents will likely vary according to the particular setting but often include faith communities, schools, community-based organizations, and local government and policy makers.

These CBPR approaches which include community and patient engagement are considered essential to improving the health of communities, particularly to closing the gap in health disparities caused (in whole or in part) by SDOH.23 Nevertheless, implementing these CBPR approaches in clinical settings is not easily accomplished and requires organizational support.16 For example, establishing ongoing community advisory boards that include community stakeholders and patient advocates who can routinely provide input on population health approaches has been associated with positive health outcomes.24 The employment of community health workers is another strategy for including the voice of community members in the day-to-day operations of the health system that has been shown to improve health outcomes in vulnerable communities.25,26

Patient-centered approaches embody principles similar to CBPR and have become increasingly popular in health systems and with funding agencies such as the Patient Centered Outcomes Research Institute. Such approaches include communication and partnership between patients and providers to better understand patient needs and develop more relevant and effective treatments.27 In addition, patients who are more engaged with the health care system have better health outcomes and reduced health care costs.17 Achieving this type of engagement requires health systems to identify, engage, and leverage trusted agents within the population being served.

Identifying community entities and individuals who could be trusted agents requires input from individual community members, which can be gleaned though surveys, colleagues, task forces, and other working groups. Health systems might begin this search by getting input from their employees who reside in service areas. These employees, particularly those with high administrative positions or positions associated with trust (e.g., chaplains), can be valuable resources for identifying and engaging candidate trusted agents. Then, to leverage a trusted agent, health systems will need to integrate practices, such as establishing ongoing community advisory boards and the employment of community health workers, into their routine operations.

The community-level health interventions employed by the Baylor Scott & White Health and Wellness Center (BSW HWC), which have led to broader health system benefits, are examples of the trusted agency approach. The BSW HWC is a collaboration between Baylor Scott & White Health (BSWH) and Dallas Park & Recreation that has leveraged the trusted agency of many community entities, most notably the faith community, since 2010 to improve the health of the low-socioeconomic-status community it serves. The trusted agency–directed health interventions that have resulted from this collaboration have led to a significant reduction in the utilization of the emergency department and inpatient resources at BSWH and thus in health care costs.2

An example of the trusted agency approach as applied to research within this collaboration is a BSW HWC study funded by the National Institutes of Health22 to improve weight and diabetes risk in African American women through an enhancement of the Diabetes Prevention Program delivered in faith-based organizations. This study integrated community pastors and their spouses into a community advisory board that provided input on all aspects of the study design and implementation. With the valued input of the advisory board, the study met all recruitment and retention goals and demonstrated significant reductions in weight using CBPR approaches. Another research example from the collaboration whose success depended on trusted agency is a translational study showing that the addition of fruits and vegetables to the diets of individuals with chronic kidney disease was kidney protective and reduced their blood pressure and body weight.20,28,29 An important component of this study was partnerships with local churches whose food banks provided the fruits and vegetables and instructed study participants on their preparation. These partnerships were also critical to both the recruitment and retention of participants, who were predominantly African American.

Trusted agency can also enhance medical education. The Texas A&M College of Medicine’s education program is aligned with BSWH as its main clinical partner and is integrated with BSWH’s CBPR enterprise. This integration provides trainees with innovative research and educational experiences that have led to multiple student-coauthored publications.30,31

The Future State

The goal of improving population health through community and patient engagement approaches, whereby community entities and individuals are included in research and health care service innovations from the beginning and their input is gathered throughout the process to effectively address issues affecting health (including SDOH), can improve health outcomes, identify high-value programs, and reduce health care costs.17,18,24,25 For these approaches to become routine, health systems may need a workforce that is trained to implement them. Relatedly, one strategy to close the gap in health disparities recommended by the Commission on Social Determinants of Health is to develop a workforce trained in SDOH.32 This strategy can be implemented in medical education programs with several potential benefits, including having medical students recognize the need to engage with communities to learn their specific health needs and strategies for this type of engagement. Clinicians, however, might need to recognize the importance of SDOH to better understand health disparities and work with individuals from diverse backgrounds. Further, to implement population health approaches that address SDOH, it is necessary to engage effectively with patients and community stakeholders. Providing education on community and patient engagement approaches in medical training could greatly improve the likelihood that these approaches are routinely used in health systems.

As mentioned above, as health systems aim to improve health through population health approaches, effective mechanisms are needed to understand the needs of communities and patients to successfully address SDOH. In turn, the population being served must better understand how health system resources can be used to address their health needs. This co-learning requires equitable partnerships through which the health system and the population they serve work together to improve population health and provide value-based care. Such a well-functioning relationship can only be established and maintained in the long term through trusted agency.18

Concluding Remarks

For health systems to improve the health of the population they serve, they must transition from their current reactive model of health care to a proactive one that involves establishing and maintaining long-term, trusting, and equitable partnerships with the population. Doing this will require health systems to identify, engage, and leverage trusted agents within these populations. Because improving the health of the population will involve the tripartite missions of care, research, and education, we think that the trusted agency approach would be an ideal one for academic health systems to implement.

References

1. Dieleman JM, Squires E, Bui AL, et al. Factors associated with increases in US health care spending, 1996–2013. JAMA. 2017;318:16681678.
2. Wesson DE, Kitzman HE, Halloran K, Tecson K. A population health model reduces emergency department utilization through improved access to non-emergent healthcare and addressing social determinants of health. Health Aff (Millwood). In press.
3. Burwell SM. Setting value-based payment goals—HHS efforts to improve U.S. health care. N Engl J Med. 2015;372:897899.
4. Moy E, Chang E, Barrett M. Potentially preventable hospitalizations—United States, 2001–2009. MMWR Suppl. 2013;62:139143.
5. Stringhini S, Carmeli C, Jokela M, et al.; LIFEPATH Consortium. Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: A multicohort study and meta-analysis of 1.7 million men and women. Lancet. 2017;389:12291237.
6. Nicholas SB, Kalantar-Zadeh K, Norris KC. Socioeconomic disparities in chronic kidney disease. Adv Chronic Kidney Dis. 2015;22:615.
7. Odutayo A, Gill P, Shepherd S, et al. Income disparities in absolute cardiovascular risk and cardiovascular risk factors in the United States, 1999–2014. JAMA Cardiol. 2017;2:782790.
8. World Health Organization. Social determinants of health: Key concepts. http://www.who.int/social_determinants/thecommission/finalreport/key_concepts/en/. Accessed December 27, 2017.
9. Agency for Healthcare Research and Quality. 2016 National Healthcare Quality and Disparities Report; AHRQ Pub. No. 17-0001.2017.Rockville, MD: Agency for Healthcare Research and Quality.
10. American Hospital Association Committee on Research. Next Generation on Community Health. 2016.Washington, DC: American Hospital Association.
11. McGlynn EA, McClellan M. Strategies for assessing delivery system innovations. Health Aff (Millwood). 2017;36:408416.
12. Cheung PT, Wiler JL, Lowe RA, Ginde AA. National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries. Ann Emerg Med. 2012;60:410.e12.
13. Simonds VW, Garroutte EM, Buchwald D. Health literacy and informed consent materials: Designed for documentation, not comprehension of health research. J Health Commun. 2017;22:682691.
14. Chen MS Jr, Lara PN, Dang JH, Paterniti DA, Kelly K. Twenty years post-NIH Revitalization Act: Enhancing minority participation in clinical trials (EMPaCT): Laying the groundwork for improving minority clinical trial accrual: Renewing the case for enhancing minority participation in cancer clinical trials. Cancer. 2014;120(suppl 7):10911096.
15. Constand MK, MacDermid JC, Dal Bello-Haas V, Law M. Scoping review of patient-centered care approaches in healthcare. BMC Health Serv Res. 2014;14:271.
16. Salimi Y, Shahandeh K, Malekafzali H, et al. Is community-based participatory research (CBPR) useful? A systematic review on papers in a decade. Int J Prev Med. 2012;3:386393.
17. Hibbard JH, Greene J. What the evidence shows about patient activation: Better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013;32:207214.
18. Jagosh J, Bush PL, Salsberg J, et al. A realist evaluation of community-based participatory research: Partnership synergy, trust building and related ripple effects. BMC Public Health. 2015;15:725.
19. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: Assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173202.
20. Goraya N, Simoni J, Jo C, Wesson DE. Dietary acid reduction with fruits and vegetables or bicarbonate attenuates kidney injury in patients with a moderately reduced glomerular filtration rate due to hypertensive nephropathy. Kidney Int. 2012;81:8693.
21. DeHaven MJ, Ramos-Roman MA, Gimpel N, et al. The GoodNEWS (Genes, Nutrition, Exercise, Wellness, and Spiritual Growth) trial: A community-based participatory research (CBPR) trial with African-American church congregations for reducing cardiovascular disease risk factors—Recruitment, measurement, and randomization. Contemp Clin Trials. 2011;32:630640.
22. Kitzman H, Dodgen L, Mamun A, et al. Community-based participatory research to design a faith-enhanced diabetes prevention program: The Better Me Within randomized trial. Contemp Clin Trials. 2017;62:7790.
23. Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J. Achieving Health Equity: A Guide for Health Care Organizations. 2016.2016 ed. Cambridge, MA: Institute for Healthcare Improvement.
24. Anderson LM, Adeney KL, Shinn C, Safranek S, Buckner-Brown J, Krause LK. Community coalition-driven interventions to reduce health disparities among racial and ethnic minority populations. Cochrane Database Syst Rev. 2015;(6):CD009905.
25. The Community Guide. Diabetes prevention: Interventions engaging community health workers improve risk factors and health outcomes. https://www.thecommunityguide.org/content/community-health-worker-interventions-help-prevent-diabetes. Accessed December 27, 2017.
26. Kane EP, Collinsworth AW, Schmidt KL, et al. Improving diabetes care and outcomes with community health workers. Fam Pract. 2016;33:523528.
27. Fleming C; Health policy brief: Patient engagement. Health Affairs Blog. http://www.healthaffairs.org/do/10.1377/hblog20130215.028299/full. Published February 15, 2013. Accessed December 27, 2017.
28. Goraya N, Simoni J, Jo CH, Wesson DE. A comparison of treating metabolic acidosis in CKD stage 4 hypertensive kidney disease with fruits and vegetables or sodium bicarbonate. Clin J Am Soc Nephrol. 2013;8:371381.
29. Goraya N, Simoni J, Jo CH, Wesson DE. Treatment of metabolic acidosis in patients with stage 3 chronic kidney disease with fruits and vegetables or oral bicarbonate reduces urine angiotensinogen and preserves glomerular filtration rate. Kidney Int. 2014;86:10311038.
30. Roehm B, Simoni J, Prusynski J, Wesson D. Cigarette smoking partially negates kidney protection by angiotensin converting enzyme inhibition in non-diabetic CKD. Am J Nephrol. 2017;46:260267.
31. Tan M, Mamun A, Kitzman H, Mandapati SR, Dodgen L. Neighborhood disadvantage and allostatic load in African American women at risk for obesity-related diseases. Prev Chronic Dis. 2017;14:170143.
32. Marmot M, Friel S, Bell R, Houweling TA, Taylor S; Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health. Lancet. 2008;372:16611669.
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