Innovation Ecosystem

One on one with Dr. Nicole Alexander Scott

New director of the R.I. Department of Health talks about her vision, strategies for the agency moving forward

Photo by Richard Asinof

Dr. Nicole Alexander-Scott, the new director of the R.I. Department of Health, sat down with ConvergenceRI to talk about her strategic priorities for the agency and her focus on health equity.

By Richard Asinof
Posted 6/22/15
A sit-down, in person, one-on-one interview with Dr. Nicole Alexander-Scott, the new director of the R.I. Department of Health, reveals she is an administrator who took the job with clear strategic priorities to address the social and environmental determinants of health, to promote health equity and eliminate disparities, and to ensure access to quality services.
How will the crosscutting strategy of the creation of the R.I. Department of Health Academic Center, strengthening the agencies research capabilities, be implemented? How can a mapping process of health innovation be seen as a way to distinguish Rhode Island’s leadership, as a tool of strategic economic development? In a nation and in a state becoming more polarized and divided by economic and racial disparities in health care, how does that conversation around race, ethnicity and equity change and converge? What can the state of Rhode Island do to encourage the creation of clinical medical practices that address pain without the prescription of opioids?
When ConvergenceRI first interviewed Alexander-Scott’s predecessor, Dr. Michael Fine, and asked him about the changing landscape in the state’s health care delivery system, Fine responded with a blunt, candid answer: there was no statewide health care system, it was a health care market, and there was a wealth extraction system.
While Alexander-Scott has carefully aligned her agency’s work with Gov. Raimondo’s vision and with Secretary Elizabeth Roberts’ objectives, her renewed focus on health equity will, at some point, collide with the economic realities of health care.
The current filter by which health care is delivered is through a cost equation. Changing the focus to health equity and addressing the social and environmental determinants of health requires a different kind of budget calculation – investing upfront monies with the goal of producing, in the long-term, a better return-on-investment in health, wellness and prevention. That requires a sea change in strategic economic thinking, where “real jobs” are created by “real health” investments.

PROVIDENCE – In public health, there is almost always an unexpected, emergency crisis, where the array of forces at the command at the R.I. Department of Health must respond immediately to protect the public.

On Wednesday, June 17, it was the sudden death of a 13-month-old child who had been attending a daycare center in Warren, with symptoms that resembled a possible meningococcal infection. It turned out the infection was an aggressive strep infection, but the agency still had to jump into action, tracing the epidemiological steps back to anyone who might have come into contact with the child and administering prophylactic doses of antibiotics – while at the same time managing the public’s fears and the news media’s demands for more information.

There are also long-term, simmering, urgent public health crises, such as the epidemic of accidental drug overdoses, which has afflicted Rhode Island for the past four years, with hundreds of Rhode Islanders dying.

On that very same day, June 17, the Trust for America’s Health released a report that a report that showed Rhode Island had the seventh-highest rate of drug overdose deaths in the nation from the three-year period of 2011-2013.

That bad news prompted the Raimondo administration to convene an ad hoc news conference and roundtable on Monday morning, June 22, to discuss “the growing epidemic of drug overdose deaths in Rhode Island” [not exactly breaking news], and talk about what can be done about it. Gov. Gina Raimondo, Sen. Jack Reed, State Police Colonel Steven G. O’Donnell, along with Dr. Nicole Alexander-Scott, director of the R.I. Department of Health, will be participating.

[For the record, ConvergenceRI has been reporting on the plague of drug overdose deaths since July of 2011, responsible for bringing the issue to the attention of Dr. Michael Fine, the former director of the R.I. Department of Health. But that’s a story for another day.]

The context is that in the midst of all that was happening, ConvergenceRI sat down to talk one-on-one with Alexander-Scott on June 17, at her office. The interview, which had taken more than a month to schedule after the initial request, delved into long-term plans that Alexander-Scott has for the agency, her vision and future strategies.

The director shared her strategic priorities in a document she said she had distributed during her first week on the job to agency staff, to create a framework under which to align their work. Her priorities include: addressing the social and environmental determinants of health, eliminating disparities and promoting health equity, and ensuring access to quality health services for all Rhode Islanders.

“We want to make sure that all Rhode Islanders have the opportunity to live in the healthiest communities and have the healthiest lives that they can,” she said. “I like to say, if I could change the department name, it would be to the Department of Health and Health Equity.”

Here is the interview by ConvergenceRI with Alexander-Scott:

ConvergenceRI: Do you think we need a mapping process in Rhode Island to chart the different initiatives underway that are part of health innovation, as a way of breaking down the silos?
Absolutely. Health innovation is such a crucial element [in our work].

What I appreciate most about taking this position on, some of which you heard yesterday [at the symposium on “Race, Ethnicity and PCMH: Ensuring Everyone Has a Voice”], with Secretary [Elizabeth] Roberts, is that I look at her as being a corner point of health innovation. With all the work that’s going on with the State Innovation Model plan, with reinventing Medicaid, within many of the health and human service agencies.

I love that we are actually talking about being able to coordinate out plans. To me that seems like an improvement from [the past], and the fact that silos existed. We are moving toward at least starting to coordinate services. We are constantly engaging in those conversations, and that really allows for a better utilization of services, and to [provide] opportunities to really interject the innovation component – and to make a difference.

ConvergenceRI: In those discussions, how do we wrap our arms around the different, competing models, say, for patient-centered medical homes, to determine what model is best, and not just from a cost-cutting perspective, but for patients and communities?
What I appreciate about [the question] is the fact there is significant room for improvement; that we have a ways to go in terms of coordination.

I am also encouraged by the fact that we have the benefit of the [work on health innovation] being in Rhode Island.

I’m a believer in taking it a step at a time, to really get us to where we need to go, while maintaining that health equity and community-based lens as well as a focus on quality and value. And, to allow each of those elements to grow and develop [at the appropriate speed.]

With the State Innovation Model, there’s work that needs to be built into that.

With the ACO, there’s work that needs to be built into that.

Those are the first steps that need to happen. But then, the beauty is, with this being Rhode Island, we have more of an opportunity for us to converge as we figure out…

ConvergenceRI: [interrupting] I love that word.
: [laughing] It fits perfectly. … As we figure out what works best, and best impacts our communities that we’re trying to serve.

So, as an example, the new ACO with Care New England, [CEO and President] Dennis Keefe is part of it; he’s also the [co-chair] of the Reinventing Medicaid task force. And, that’s also connected through Secretary [Roberts] with what’s going on with the SIM project.

Even though the conversations are different, it’s many of the same people involved in the conversations.

We have to keep this push [toward health innovation], as you were saying, to bring it together at the forefront, to keep quality and health equity [as part of the conversation], and to make sure that the community is served as an anchor for it, so that our work can converge.

ConvergenceRI: How does the pilot initiative at the R.I. Department of Health on toxic stress fit into the equation? Is there a need to convene a broader conversation, because the concept is not well understood? Could that serve as a point of convergence?
I really appreciate the connection with that concept of addressing toxic stress. For me, it’s analogous for when we are talking about addressing the social and environmental determinants of health.

They are really on the same spectrum; it’s the way of saying the same thing.

If we don’t properly address those social and environmental determinants of health, you have toxic stress – that can have a negative impact on pregnant women, on the subsequent newborn infant, on childhood development, on school-age development, and the rest of life.

[All of which] directly impacts the economy that, as a society, we are going to have to deal with.

If we can address toxic stress early on, from preconception, then during pregnancy, and then early childhood, it can make a difference, so that children do not experience the challenges that so many children are experiencing [today].

It will create a generational return on investment that can positively impact our society, from a social and environmental standpoint but also from an economic standpoint.

ConvergenceRI: From the vantage point of convening a broader conversation, would you welcome bringing in someone like Dr. Jim Padbury, to talk about the research he’s conducting as part of the Perinatal Biology COBRE center?
Yes, he’s one of my heroes, without a doubt.

ConvergenceRI: And, someone such as Peter Simon, who has emphasized the need to look at lead as a key factor in the environmental determinants of health?
He’s served as a coach for me as well.

ConvergenceRI: And, the R.I. Alliance for Green and Healthy Homes? How do you think we can bring everyone into the conversation?
[sharing six-page document, entitled “Strategic Priorities”] That is a perfect segue into how we are prioritizing our work as a department, and how we are bringing these conversations together. This is an outline of our strategic priorities [at the agency].

I shared [this document] with the department on Day Two of taking over and having this opportunity as a director. It was really to serve as a framework for what already is going on, but to set the course for how we can stay connected.

Certainly, the overarching goal is to really highlight the purpose and importance of public health [for Rhode Islanders].

But the key element is the strategic priorities, and making sure that they are at the forefront of what we’re doing: the social and environmental determinants of health; eliminating health disparities in Rhode Island, and ensuring access to quality services.

What I appreciate is that through each one of the strategic priorities, we can highlight within the department [the ongoing work], because so many components of what we are doing in our programs [fall] within that framework. We can bring it to forefront, with drinking water quality and food protection and healthy homes and communities, with state health laboratories.

We can’t achieve this without continuing our partnership with the Executive Office of Health and Human Services, with R.I. Housing, with the Department of Children, Youth and Families, with Elderly Affairs, and certainly with Behavioral Healthcare, Development Disabilities and Hospitals.

I am putting a lot of energy into developing partnerships and strengthening relationships with directors at each of those agencies because of how crucial it is for us to embrace these [strategic priorities] and really push it into the forefront. It is truly the only way we are going to achieve that health equity model, of making sure that everyone had equal access to health services, to living a quality life with a good school and all the access that’s necessary.

ConvergenceRI: In the future, what role will the R.I. Department of Health play in determining who owns the data and who analyzes the data around population health management? How will the metrics and benchmarks be established? And what will be the relationship to health equity?
It’s perfect that you asked those questions. Have we thought about it? Absolutely. Let me direct you back to our strategic priorities framework: we are planning to create a Department of Health Academic Center.

This comes out of my own personal experience during the last several years of my career, when I was an academic clinician in adult and pediatric infectious diseases. I worked at the hospitals affiliated with Brown’s [medical school], allowing me to care for adults and children with infectious diseases, to engage in research and the latest clinical advances in education affiliated with that.

At the same time, I had the opportunity to consult as a medical director here at the Department of Health within the infectious diseases and epidemiology program for the office of HIV and AIDS.

What I saw with that was the tremendous opportunity for synergy, with how people in the academic clinical research world could truly benefit from the data resources that were available from the department of health.

The [development of a Department of Health Academic Center] can bring Rhode Island to the next level. I know that the Governor has said that one of the next things is for Rhode Island to be acknowledged and put on the map. The way to do that is to really combine the strengths that we have here.

One of the goals here at the Department of Health with our Academic Center is to allow for career development within the department, and to build up the subject matter expertise. But, also, to allow for better partnerships with our university and academic institutions, as new advances in research and clinical opportunities emerge.

Instead of what used to be, from my perspective, saying here’s the data, and that’s it, we’ll now have the opportunity to say: here’s the data that we’re sharing, here’s a well-thought-out, formalized plan for data requests and data sharing, so that we continue to protect the population with the information needed [to do that].

[Not just] let’s make it useful and share the data, but let’s also engage better in how we can partner. Not just have it be that you guys take the data but to understand what you’re working on, how it is impacting our community, and really have a partnership that makes a difference.

ConvergenceRI: That sounds very exciting. How does that get plugged into evidence-based research consortiums around what are the best interventions in early childhood around executive functions, nutrition, to know what works best and what doesn’t? Will the Department become a repository of research? How does it fit into the metrics of population health analytics, to make sure communities are not being shortchanged?
Exactly. That’s why this is crucial as a strategy for working together, to help us drive the push to making sure that we are addressing the social and environmental determinants of health, pushing policy that’s going to make a difference.

ConvergenceRI: There was some recent discussion in the news around whether or not the numbers for substance abuse deaths in Rhode Island were accurate. To be honest, I didn’t understand the problem. Could you please explain it?
: I’d be happy to explain that. It came out of the process of my starting as director and wanting to better understand how we were collecting and sharing the data, recognizing the significance of and the importance that the data is released frequently, but that it’s also as accurate and reliable as possible.

The communities that we are partnering with are depending on us to drive their interventions.

What we learned in the process [of looking at] all of what’s being collected, in reporting apparent deaths, we were taking additional time to develop a different database for in-house information. It was one step further to determine where we have confirmed deaths that were in a packaged database, and that was a little more efficient in the way we could share that regulatory data.

We took the step [to eliminate the use of the apparent deaths database] and said: that’s one less additional database that’s being kept separately and taking time away from our medical examiners being able to get the work done that they need to get done.

But we can still share reliable data frequently, and because of taking that step, we can now share [confirmed deaths] on weekly basis, which is what we have put up on our website this week. Every week we’re going to update the monthly numbers that we have of confirmed deaths, as a way to balance out that we’re moving from “apparent” to “confirmed.” We wanted to make it a little more streamlined for us to do, and to make sure that the numbers are coming out on a regular basis.

ConvergenceRI: I was asked about an apparent effort regarding a new system to certify peer recovery coaches, different from the one currently exists, that may be under development at BHDDH? Is that accurate and correct?
I’m still learning about this topic. Our goal, for sure, is to do what works most effectively in a collaborative format. We certainly want to make sure that the recovery coaches that are out there are available and can really make the difference that they can. We don’t want to do anything that would impede or slow down that process. But that’s something I’m still learning more about.

ConvergenceRI: Are there budget challenges that you face, with limited resources? Using the way the vaccine program is paid for, is there a way to create a similar program for Hep C drugs, and for new cancer drugs, so that the onus is not on the Department of Corrections or the Medicaid program to absorb such huge costs?
We always appreciate Peter Simon and his input on how we can be innovative. [See link below to story by Simon in ConvergenceRI discussing this idea.]

In partnering with Medicaid and the EOHHS system agencies, we are open to thinking through any and all possibilities. What certainly then becomes a challenge is when it comes to implementation.

We are open to conversations about what is possible, as long as we’re making sure that the people who need it are receiving quality services. Medicaid is certainly working hard that the people on Medicaid get the coverage they need, particularly for Hep C.

But the vaccine program has proven to be effective, with great credit to the health plans that contribute to help pay for them.

If you have any connections to help getting health plans to agree to a similar program…

ConvergenceRI: I don’t know. I may have used up my chits two weeks ago when I personally introduced a local entrepreneur to Peter Andruszkiewicz, the president and CEO of Blue Cross & Blue Shield of Rhode Island.

Are there any questions that I haven’t asked, that I should have asked? Or something you want to talk about? You have the last word.
You haven’t missed anything at all. Thank you for sharing with your readers and with Rhode Islanders the directions that we are looking to go toward as a state and at the department, given our priorities, to truly focus on health equity.

I like to say, if I could change the name of the department, it would be to the Department of Health and Health Equity, because we want to make sure that all Rhode Islanders have the opportunity to live in the healthiest communities and have the healthiest lives that they can.”


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