Changing What “Counts” as Healthcare October 18, 2016 Texas Association of Community Health Centers Annual Conference ©2016 Health Leads Inc.

Mismatch Between Drivers of Health and Spending Patients’ lives outside the clinic drive vast majority of health outcomes Source: Healthy People/Healthy Economy: An Initiative to Make Massachusetts the National Leader in Health and Wellness. 2015. Data from NEHI 2013. http://www.tbf.org/tbf/56/hphe/Health-Crisis. ©2016 Health Leads Inc.

Resource Connections at Work ©2016 Health Leads Inc.

Paradigm Shift ©2016 Health Leads Inc.

Change the Definitions Sick? …or Hungry? ©2016 Health Leads Inc.

Unmet Resource Needs  Poor Health, Inefficient Utilization Patients with comorbidity X (%) Patients without comorbidity X (%) Source: Berkowitz, S.A. et al. 30 November 2015 British Medical Journal Quality and Safety: “Addressing Basic Resource Needs to Improve Primary Care Quality: A Community Collaboration Programme.” ©2016 Health Leads Inc.

“What is the role and responsibility of the healthcare system with respect to patients’ social needs?” This central question – what “counts” as healthcare? Recently, Ray Baxter, an SVP at Kaiser Permanente, one of HL’s partner integrated delivery systems, framed this dilemma: “There’s a spectrum from, at one extreme, simply pretending these issues don’t exist in our patients’ lives, and, at the other, just going ahead and building affordable housing. We know neither of these is the right answer, but what is the role and responsibility of the healthcare system with respect to patients’ social needs?” Simple but powerful – not on either end of the extremes Ray Baxter Former Senior VP, Community Benefit, Research and Health Policy Kaiser Permanente ©2016 Health Leads Inc.

Social Needs Intake ©2016 Health Leads Inc.

The Challenge of Execution “In healthcare we have an inexplicably high tolerance for poor execution.” Jim Yong Kim, President, The World Bank Group Journal of Delivery Science and Innovation, 2013, vol. 1(1-2), pp. 1-3 ©2016 Health Leads Inc.

Core Elements: Driver Diagram Primary Drivers Secondary Drivers Systematic Screening Protocol Screening tool Clinical integration Resource Referral and/or Navigation Services Scope of service Community resource database Case management protocol & tool Quality patient interaction Dedicated Workforce Roles & Capacity Training Management Data Systems & Performance Improvement Technology platform Database infrastructure Reporting capability Leadership & Stakeholder Engagement Clinic & Administrative Champions Physician, clinic staff engagement Strategic & Financial Commitment Community engagement Patient engagement ©2016 Health Leads Inc.

Social Needs Dashboard ©2016 Health Leads Inc.

Rapid-Cycle Learning: Workforce and Resource Connections ©2016 Health Leads Inc.

Data Systems: Resource Landscape Health Leads’ Community Resource Usage, FY15 ©2016 Health Leads Inc.

“Historic” CMS Pilots: Powerful Market Signal Accountable Health Communities (AHC): Comprehensive Primary Care+ (CPC+): Targeted implementation: $157 million/5 years; up to 44 awardees Fees for screening & navigation to social resources Scaled implementation: Up to 2,500 primary care practices Alternative payment model incl. social needs screening & resource directory 3M+ patients screened annually 12M+ patients screened annually ©2016 Health Leads Inc.

“All you have to do is be the kind of physician your patient is hoping you will be.” This central question – what “counts” as healthcare? Recently, Ray Baxter, an SVP at Kaiser Permanente, one of HL’s partner integrated delivery systems, framed this dilemma: “There’s a spectrum from, at one extreme, simply pretending these issues don’t exist in our patients’ lives, and, at the other, just going ahead and building affordable housing. We know neither of these is the right answer, but what is the role and responsibility of the healthcare system with respect to patients’ social needs?” Simple but powerful – not on either end of the extremes Tom Lee, MD Physician, Brigham and Women’s Hospital Chief Medical Officer, Press Ganey ©2016 Health Leads Inc.

Shifting the Paradigm: Leadership ©2016 Health Leads Inc.

Shifting the Paradigm: Leadership ©2016 Health Leads Inc.

A New Paradigm ©2016 Health Leads Inc.

©2016 Health Leads Inc.