Bridging the Gap Between Clinical Care and Community Population Health

00;00;01;02 - 00;00;29;26
Tom Haederle
Clinical care and community population health are two sides of a coin. One approach treats patients with procedures, medicines, Visits to the emergency room or as an inpatient. The other approaches broader in scope addressing behaviors, environmental conditions and social determinants of health that affect entire communities. As we continue the shift to value based care and see an increased emphasis on health equity, can the gulf between these two approaches be bridged in a way that benefits everyone?

00;00;29;29 - 00;00;57;28
Tom Haederle
Let's find out. Welcome to Community Cornerstones, Conversations with Rural Hospitals in America, a new podcast series from the American Hospital Association. I'm Tom Haederle with AHA Communications. Kevin Barnett is a senior investigator with the Public Health Institute and a board member for Trinity Health. In this podcast, he talks with The AHA’s Julia Resnick about what it will take for rural providers in particular to bridge the gap between clinical care and community population health

00;00;58;00 - 00;01;15;14
Tom Haederle
as providers cope with finite resources while addressing what it will take to improve health equity in their communities. Barnett says it starts with rural care providers having a deeper understanding of the full spectrum of services and supports that are needed in the community. With that, let's join Kevin and Julia.

00;01;15;16 - 00;01;41;17
Julia Resnick
Hi. This is Julia Resnick, director of Strategic Initiatives at the American Hospital Association, coming to you from the age Rural Health Care Leadership Conference in San Antonio, Texas. I am here today with Dr. Kevin Barnett, who is a senior investigator at the Public Health Institute as well as a board member at Trinity Health. So Kevin comes to this work with a public health lens and a health care lens, which I think makes you the perfect person to have this type of conversation with.

00;01;41;18 - 00;01;42;13
Julia Resnick
So welcome, Kevin.

00;01;42;18 - 00;01;44;01
Kevin Barnett
Delighted to be with you.

00;01;44;03 - 00;02;07;06
Julia Resnick
So what we really want to talk about today was how to resolve that tension between clinical and community as we're thinking about value based care and what it's going to take to improve health equity in our communities and really move into the future of health care. So before we dive too much into that, can you talk a little bit about your role at Trinity Health and what Trinity Health is doing in the value and equity space?

00;02;07;08 - 00;02;40;12
Kevin Barnett
Sure. Well, as you noted, I'm a member of the board for Trinity Health and and I was recruited for the board specifically because of the work that I have done for the last now 30 years in the community health arena. And my focus in this work has specifically been initially as it relates to hospitals, is to help these institutions be more strategic and thoughtful about how they allocate these resources with an eye towards producing measurable improvements of health in their communities.

00;02;40;15 - 00;03;06;12
Kevin Barnett
Now, in the early days of community benefit, it was often described as hospitals engaged in random acts of kindness, And those acts of kindness were nice to talk about, nice to report. But we did not often find a way to document them beyond the fact that we helped Mrs. Rodriguez and she's really happy as a result of this program.

00;03;06;14 - 00;03;57;18
Kevin Barnett
So moving from random acts of kindness to measurable improvements required folks to be much more thoughtful about the populations they're serving. Doing some front end analysis of where problems are concentrated in a way that we could effectively document more than impact upon very small cohorts. In that process and along the way, it began to emerge that much of what was going on was being done in a way that might be viewed as marketing, might be viewed as benefiting not just those who need it most, but signaling to commercially insured patients that we want to come to our hospital, that we're doing good things for them as well.

00;03;57;20 - 00;04;26;08
Kevin Barnett
And so there was a a backing away from that orientation. Let's disconnect what we're doing in our community from our marketing department and focus more on how we actually improve health status. So all of this is happening in a fee for service environment. And so the the only real argument for doing this work well was to say, let's be good stewards of these charitable resources.

00;04;26;08 - 00;05;04;22
Kevin Barnett
Let's make sure that every dollar that we spend in meeting our charitable obligations yields the maximum impact. And that begins to move the thinking towards how do we reduce the number of people coming into our emergency room for preventable conditions. And the more people that we can impact by taking more proactive, more strategic steps and the more we can leverage and build capacity in our communities of other organizations that we partner with to do this, then we are clearly making optimal use of our charitable resources.

00;05;04;24 - 00;05;47;10
Kevin Barnett
Now, we are still very much on that path. When you look at the community benefit expenditures of many hospitals across the country, there is still a preponderance of what they report as community benefit in the form of treatment of preventable conditions in emergency room and inpatient settings. However, it provides a perfect target in the context of moving to risk based payment, value based payment, whatever we call it, moving gradually towards establishing a budget for treating and caring for people and paying incentives.

00;05;47;12 - 00;06;04;13
Kevin Barnett
If people actually improve health and reduce treatment and prevention of preventable conditions in clinical settings. So that's the path that we're on. We have a ways still to go in that regard for a number of reasons, but I'll stop there.

00;06;04;14 - 00;06;23;01
Julia Resnick
Yeah, it's always struck me that there's really like this chasm between the world of community health and community benefit and what we're seeing in population health, where in population health is really focused on clinical care management and trying to address those community health needs clinically versus investing in communities, looking upstream, you know, getting outside of hospital walls.

00;06;23;04 - 00;06;29;07
Julia Resnick
And there have been efforts to bridge those. But how do we build that bridge? What does that look like?

00;06;29;09 - 00;07;16;06
Kevin Barnett
Well, we have to build that bridge first by ensuring that the people that we engage in this work are not only competent, but that we have alignment of incentives up the line to the senior leadership level of the organization, that these are the kinds of things that we do. As it stands now, to the degree that one can make the case as a director of community health or a VP for community health, the degree to which you can make the case that the intervention or interventions that you've designed will actually reduce preventable eating and patient utilization in many cases across the country, you're taking money out of the pocket of the hospital and your chief

00;07;16;06 - 00;07;47;04
Kevin Barnett
medical officer is going to say, what are you thinking? And so how do we how do we dig our way out of that? Well, we do that in part by beginning on this path of understanding where we're going and be in a position with payers and with others to negotiate for risk based payments that actually reward you for keeping people healthy and out of your emergency rooms in inpatient settings.

00;07;47;06 - 00;08;10;00
Kevin Barnett
So I'm not saying all of this happens in a very orderly way. Hospitals, I mean, there are many brave hospitals in health systems that are on this path, knowing that at least in the near term, it's not likely to yield significant returns on that investment in financial terms. But they recognize nevertheless that this is a critically important work that we're doing.

00;08;10;07 - 00;08;32;27
Julia Resnick
Yeah, And I think implementing those care models, whether or not you have the payment behind it to really truly incentivize it will be important down the line as those financial incentives align more. And I've always one of the things that's always fascinated me is like we talk about this move to value, but at what point in the fee for service versus value ratio does care actually change?

00;08;33;01 - 00;08;33;25
Julia Resnick
Does it like...

00;08;33;25 - 00;09;00;28
Kevin Barnett
Do I have a ratio in mind? I know folks talk about tipping points. Yeah. It's getting to 40, 50, 60% as being a point where where really changes behavior. But in those cases where we have moved more quickly, it it clearly changes behavior, whether you're talking about physicians or anyone in the care and in the care delivery process.

00;09;00;28 - 00;09;11;08
Kevin Barnett
Again, it requires courage on behalf of those in the senior leadership, and it requires board members that are asking the right kinds of questions. Mm hmm.

00;09;11;10 - 00;09;18;15
Julia Resnick
So I feel like as a board member, you can be an instigator of this. What kind of questions would you advise asking leaders?

00;09;18;18 - 00;10;04;07
Kevin Barnett
Well, for example, there is a lot of talk these days about ways in which we engage community health workers, promoters, whatever you would call them, as a way of extending our reach from the clinical setting and to understand what's going on in communities, what's going on in the home. And these are people with lived experience, people that understand their culture and are and know, for example, to ask the questions that in most primary care physicians might not know to ask of people. They might not be aware that Mr. Rodriguez is afraid to raise issues with the doc because she may be judged or I don't want to bother the doctor with these kinds of things.

00;10;04;09 - 00;10;35;13
Kevin Barnett
So community health workers represent a powerful extension of what we do in the clinical setting into understanding what's going on in the community setting. In most cases of community health worker engagement across the country, we're still sort of taking little steps and let's deploy two or three here and two or three there. And often without a linear line of sight to where are we going to go with this?

00;10;35;13 - 00;11;26;14
Kevin Barnett
If this works, then what? And how does this represent a definitive movement of the kinds of things that a community health worker could do that you would report as a community benefit, because it's clearly addressing real drivers of poor health in local communities. And at the same time, it it not only improves health status, not only reduces preventable ED and inpatient utilization, but it it ultimately yields more returns for the institution. Where this is being discussed, particularly the one of the more interesting developments in this regard in an important area of focus in my work is is how we can get hospitals and health systems who are otherwise competing in urban areas

00;11;26;16 - 00;12;21;19
Kevin Barnett
where they have overlapping service areas. And some of them, by dint of their location, are more proximal to low income communities, have more people on Medicaid coming into their emergency rooms than others. But they lack the financial wherewithal because of the fact that they are safety net institutions to invest substantially beyond what they already are. So to the degree that we can get other hospitals with whom they are competing, at least for the commercially insured population, not competing that well, mind you, but the recognition that they can come together and yield far more impact and far more scale, far more dose than they could then they can on their own.

00;12;21;22 - 00;13;13;07
Kevin Barnett
When we get to that point where we can demonstrate that, then not only will those systems be better positioned politically to push for other actions by whether it's a municipality or county and others to help really address those drivers of poor health. But we've also significantly improved the health status in our local communities. That's the we're sort of on the edge of considering what that looks like. I think this was encouraged by the pandemic and a recognition I, I have had multiple conversations with hospital leaders who said to me in the midst of the pandemic, I didn't realize just how difficult it is for the low income people in the community that I serve.

00;13;13;09 - 00;13;25;05
Kevin Barnett
So they're in the midst of a lot of other chaos and a national policy arena. I think there's a growing number of hospital leaders that really want to drop their bucket and do something solid in their own community.

00;13;25;07 - 00;13;45;26
Julia Resnick
I think they'll be really exciting thing to see both in the urban communities that you're talking about and the rural hospitals that are here. And I know that this work can can look different in a rural hospital because rural hospitals have different resources. The types of partners they have options to work with are different. How do you think rural hospitals can go about bridging that divide between community and clinical initiatives?

00;13;45;28 - 00;14;31;04
Kevin Barnett
Well, it is a shorter path in some ways for rural hospitals because they have such a smaller staff. They have such a small staff in many situations I where I've worked with rural hospitals, that the senior leadership is directly engaged, where in larger hospitals you're working with somebody well down the food chain from the senior leadership. And unfortunately, in this regard, not connected to strategic decision making and rural hospitals and more likely to have somebody who's a decision maker that you're engaging on these issues and as such, they're thinking about the survival of their organization.

00;14;31;04 - 00;15;07;07
Kevin Barnett
They're thinking about how this work that we're doing in the community directly relates to what we're doing in the clinical setting. So that's an advantage. Another advantage is, is because these are smaller communities, because there are less, for example, community based organizations competing for the same resources. You have more people that are used to wearing more hats and those people really have a deeper understanding and in many cases more sophisticated understanding of how we can come together and how we can leverage our limited resources.

00;15;07;09 - 00;15;24;24
Kevin Barnett
So those are all positive potentials. And mind you, it might sound like I'm trying to make light of of a of a very heavy lift for these these organizations. I don't mean to do that, but I it is important to reflect on the strengths that they do bring to the table.

00;15;25;00 - 00;15;31;08
Julia Resnick
Absolutely. And to empower them that they can do this work. And it is not out of reach even if they don't have the payment models in place.

00;15;31;09 - 00;15;32;06
Kevin Barnett
Absolutely.

00;15;32;08 - 00;15;42;06
Julia Resnick
So in terms of closing thoughts, like what is your vision for the future of rural America in terms of what its health care systems can do to improve health equity and community benefit?

00;15;42;11 - 00;16;28;20
Kevin Barnett
That's a great question. And in my most optimistic vision for that is a recognition that these institutions have a deeper understanding of the full spectrum of services and supports that are needed in a community. We're at a hospital association's conference, so we're talking about hospitals, but really the the vision for the future is for institutions that are capable of delivering the highest quality acute medical care services, but increasingly have the ability to deliver a broad spectrum and or collaborate with others to deliver a broad spectrum of services and supports that more proactively build health and well-being in our communities.

00;16;28;22 - 00;17;04;29
Kevin Barnett
That's the vision that I have for for the rural hospital of the future. That may mean that there will be additional acute care facilities in communities that close and or are converted to more multi-service centers. I think that's the more likely scenario. And I would just note there, as I have observed in and work in a couple communities just in this last year, that there was an opportunity missed to leverage what was a closed hospital.

00;17;05;01 - 00;17;25;13
Kevin Barnett
Because when you leave a building empty for any period of time, it will quickly become unusable, particularly facility like a hospital. So when we consider closing a hospital and we should consider what conversion of that facility might look like and not simply walk away.

00;17;25;15 - 00;17;36;05
Julia Resnick
So I think the path forward might be a little bit rocky, but there definitely is a path forward and we'll all keep leveraging our ingenuity and creativity for a bright future for rural health care.

00;17;36;07 - 00;17;40;00
Kevin Barnett
Well, it's rocky now, right? Hmm.

00;17;40;02 - 00;17;46;18
Julia Resnick
Mm hmm. Well, Kevin, thank you so much for joining this conversation. Really appreciate your all of your insights.

00;17;46;21 - 00;17;48;06
Kevin Barnett
Thank you. It's a pleasure to be with you.