Delivery of care

Taking care of an entire city, redefining population health

Ground was broken on the new Neighborhood Health Station facility being built in Central Falls, and it promises to change the health care delivery system in Rhode Island in profound ways

Photo by Richard Asinof

Viola Davis, sixth from left, joins in ceremonial groundbreaking for the new Neighborhood Health Station being built in Central Falls by Blackstone Valley Community Health Care. From left: Melanie Slivka, Jane Hayward, Peter Marino, Rep. David Cicilline, Central Falls Mayor James Diossa, Davis, Ray Laovie, Dr. Pablo Rodriguez and Neil Steinberg.

Photo by Richard Asinof

Dr. Michael Fine address gathering at groundbreaking ceremony for the new Neighborhood Health Station being built by Blackstone Valley Community Health Care. Behind Fine, from left: Rep. David Cicilline, Ray Lavoie, executive director of Blackstone Valley, Central Falls Mayor James Diossa, Dr. Pablo Rodriguez, and Neil Steinberg, president and CEO of the Rhode Island Foundation.

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By Richard Asinof
Posted 10/10/16
The participation of Viola Davis brought star power to the groundbreaking of the new Neighborhood Health Station in Central Falls. But the real story was about how the new facility will provide 90 percent of the health care services for 90 percent of the population in one location, redefining population health. For the first time in Rhode Island and in the U.S., a community health center will be responsible for providing most of the clinical and preventive health services for a entire city.
After Central Falls and after Scituate, representing both urban and rural versions of a Neighborhood Health Center, what will be the next community to launch a similar facility? How will the work of Blackstone Valley Community Health Care and its new capability to manage the health care of an entire city change the way that accountable care is defined? Is there a way for the nursing program at Rhode Island College or at the Rhode Island Nurses Institute Middle College to collaborate with Central Falls to develop a certified nursing assistant program for residents? Will the potential success of the Neighborhood Health Station model change the State Innovation Model plan?
The kinds of collaboration and sharing of information across hospital systems and competing agencies and insurance companies who are participating in the weekly multidisciplinary team meeting in Central Falls point to a new way to think about health care: not as competitors trying to capture the largest market share, but as collaborators attempting to improve health care outcomes for patients whose needs often cross the artificial boundaries. The interoperability extends not just to health IT systems and EHRs but to finding solutions to health care problems.

CENTRAL FALLS – Welcome home, Viola Davis, proclaimed the banner unfurled across Broad Street on Oct. 8, a special greeting for a favorite daughter who grew up in the square mile city. Davis had come back to the Comeback City to help break ground on a new Neighborhood Health Station facility being built by Blackstone Valley Community Health Care.

The ability of Davis to overcome adversity growing up in Central Falls and become a successful actor has, in many ways, mirrored and personified the grit, resilience and determination of the poorest city in Rhode Island to forge a new beginning after a descent into bankruptcy.

Davis was in town in part to lend a hand in the groundbreaking for the new Neighborhood Health Station building at 1000 Broad St., arriving just in time to help shovel dirt in the ceremonial groundbreaking that featured a host of dignitaries.

The new facility, being built on the location of the Notre Dame Urgent Care Center, formerly owned by Memorial Hospital, seeks to usher in a new model for the delivery of health care services in Rhode Island, focused on providing 90 percent of the health services needed for 90 percent of the community in one location, in a coordinated, collaborative fashion. [A second Neighborhood Health Station is now under construction in Scituate.]

The money shot with Davis and dignitaries digging with shovels included: Central Falls Mayor James Diossa; Congressman David Cicilline; Rhode Island Foundation President and CEO Neil Steinberg; Dr. Pablo Rodriguez, president and CEO of Women’s Care; Peter Marino, president and CEO of Neighborhood Health Care of Rhode Island; Jane Hayward, president and CEO of the Rhode Island Health Center Association; Ray Lavoie, executive director of the Blackstone Valley Community Health Care center; Dr. Michael Fine, the Senior Clinical and Population Health Officer at Blackstone Valley; and long-time Blackstone Valley patient Melanie Slivka.

Among the notables in the audience were Dr. Nicole Alexander-Scott, director of the R.I. Department of Health, and Sen. Joshua Miller.

Redefining population health, driven by community needs
Blackstone Valley currently provides health care at three different sites for about 40 percent of Central Falls’ population, which in 2015 was 19,406, according to the U.S. Census Bureau. With the new Neighborhood Health Station, Blackstone Valley’s goal is to provide care to some 10,000 new patients and raise enrollment to 90 percent of the Central Falls population.

In doing so, Blackstone Valley, is redefining the concept of population health and how to achieve public health outcomes, according to Fine and Lavoie.

“I don’t think there is any other community health center [in the nation] that has taken on, as its moral, ethical and clinical responsibility, the health care of everyone in a city,” Fine told ConvergenceRI, in an interview two days before the official groundbreaking ceremony.

That’s what is different about the Neighborhood Health Station in Central Falls, Fine explained. “Everyone else depends on people walking through the doors.”

While Blackstone Valley has proven to be dynamic in its integrated approach to health care, the funding sources have not always been that nimble, according to Fine.

Fine praised the leadership of Lavoie, citing Dr. Bernard Lown, who won the Nobel Peace Prize in 1985 for his work in creating International Physicians for the Prevention of Nuclear War, and who also served as a mentor for Fine.

“Lown said: ‘If you can see the invisible, you can do the impossible.’ What’s been invisible in the U.S. is that we don’t have a health care system,” Fine explained.

As a result, it has often been hard for funders, Fine continued, to grasp and understand what the heck we’re talking about, “because they’ve never seen it before.”

The Neighborhood Health Station in Central Falls is so important, Fine said, because it is the first one.

A health care melodrama
The story of the Neighborhood Health Station in Central Falls – and the numerous subplots leading up to the groundbreaking – is a complicated tale to tell, reminiscent perhaps of a Hollywood melodrama, filled with lots of Rhode Island noir, with plenty of twists and turns.

When Dr. Michael Fine resigned his position as director of the R.I. Department of Health in March of 2015, after Gov. Gina Raimondo refused to let him give a state of the state’s health report to the R.I. General Assembly, his efforts to push for the development of Neighborhood Health Stations as part of a comprehensive strategy to redefine the system of health care delivery in Rhode Island appeared to have come to an abrupt halt.

Since his appointment by then-Gov. Lincoln Chafee in 2011, Fine had used the bully pulpit of his position to advocate for a different kind of health care delivery system, with varying degrees of success.

In a memorable interview with ConvergenceRI in March of 2011, soon after becoming director, Fine had made his disruptive views transparent. When asked about his views on the health care delivery system landscape, Fine corrected the reporter: it was not a system, Fine said, it was a market. There was not a system of health care delivery, Fine continued, but rather, there was a “system of wealth extraction.”

In his advocacy for the Neighborhood Health Station model, Fine had often encountered resistance: the planning document for the State Innovation Model for transforming the health care delivery system in Rhode Island had excluded, for whatever reason, the Neighborhood Health Station from its defining vision.

Still, Fine persisted, working to create a school-based health clinic at Central Falls High School as well as engaging in numerous conversations and discussions with community leaders. [See link to ConvergenceRI stories below.]

Affordable, accessible care
Meanwhile, in Pawtucket and Central Falls, Ray Lavoie, the executive director of the Blackstone Valley Community Health Care center, was busy responding to the growing demand under the expansion of Medicaid to serve the populations of Pawtucket and Central Falls, overseeing the construction of a new building at 39 East St. in Pawtucket, and the rehab of another building on 1145 Main St. near the border with Providence.

“Lots of folks now have health insurance cards as a result of the Affordable Care Act,” Lavoie said, in an interview about the expansion of the 1145 Main St. facility in January of 2015. “But that’s half the solution. The other half of the solution is having a place to get care and use that insurance card.”

In addition, Lavoie had also been busy building out health IT infrastructure and the health center’s own health information exchange to support the kind of population health management analytics needed to support integrated, coordinated care in an accountable care world.

In addition to being a leader in health outcomes in the delivery of patient-center care, the community health center had consistently been able to bend the medical cost curve by millions of dollars each year for its Medicaid managed population.

In early 2016, the R.I. Executive Office of Health and Human Services and the R.I. Medicaid Office declared that Blackstone Valley was an accountable entity as part of the new Reinventing Medicaid law.

In the late fall of 2015, Fine began work at Blackstone Valley in collaboration with Lavoie. The two pushed ahead with the concept of the Neighborhood Health Station in Central Falls, with Fine working with community leaders on the ground, building collaborative relationships, and Lavoie securing the grants and additional support needed to turn the concept into a reality.

The teamwork and shared responsibilities paid off, leading to a happy ending – and the groundbreaking for the new 47,000 square foot facility.

“You can’t do everything yourself, so it’s been great having Michael on board,” Lavoie told ConvergenceRI. “People in the community just can’t say no to him. He’s a very good salesman for selling his idea about Neighborhood Health Stations.”

With people much more aware of the costs of health care, Lavoie continued, “Everybody wants to do something about it. With Michael, I was able to stay focused on the business of running the community health center.”

Here is the interview with Ray Lavoie, executive director of Blackstone Valley Community Health Care, and Dr. Michael Fine, the Senior Clinical and Population Health Officer at Blackstone Valley, as they describe their collaboration in bringing about the creation of the first Neighborhood Health Station in Rhode Island, focused on managing the population health of an entire city, the first of its kind in the nation.

ConvergenceRI: The groundbreaking is a very exciting event. How long has this process been underway?
LAVOIE:
For three years.

ConvergenceRI: Sometimes, it’s hard for people to understand how long it takes to bring something like this to fruition. Can you talk about the process to get here? And why it was important to have everyone on the same page?
FINE:
It has been amazing thing for me, to watch it happen, and the extent to which people have volunteered, and the extent to which so many people have stepped up to the plate.

I never in my wildest dreams thought that people would be so good about [collaborating].

Blackstone Valley stepped up. The Brown Department of Family Medicine [lent its support].

Then, Blackstone Valley sat down with Memorial Hospital and worked something out around this building and the urgent care center, because the whole idea was to have the urgent care center become part of [the Neighborhood Health Station].

That they would work together was amazing; I thought [initially] that they would be dyed-in-the-wool competitors.

I never thought that we would get [agreement] from the Y about participating, and then creating this program where they bus people to Pawtucket and Lincoln for exercise and swimming, which addressed a need that people [in Central Falls] really wanted.

I never thought that we would get Gateway and the Providence Center in the same room once a week [for a multi-disciplinary team meeting] thinking about patient care.

I never thought that we would get Anchor [Recovery Community Center] to jump in with two feet, to help with substance abuse care.

When I started talking about the city housing authority [participating], some said I was a little crazy, yet somehow we worked out this collaboration, where they are part of the multi-disciplinary team, and they now have a bus that takes people three or four times a week from the two housing authority buildings in Central Falls to our facilities here and in Pawtucket.

LAVOIE: You can’t do everything [yourself], so it’s been great having Michael on board. People in the community just can’t say no to him. He’s a very good salesman, selling his ideas about Neighborhood Health Stations.

ConvergenceRI: How important is the health IT infrastructure to achieving success with the Neighborhood Health Station?
LAVOIE:
As Michael has pointed out, this is the first time that we will have an entire city population and their electronic medical records in one system. It will provide infinite avenues to study and to improve population health.

FINE: This week, we launched a program called Fresh Start, in collaboration with Pro-Change Behavior Systems [in South Kingstown, a firm that uses evidence-based behavior change solutions that optimize population health and well-being].

Once upon a time, when I was at the R.I. Department of Health, and we wanted people to stop smoking, we could certain things: we could put up billboards, and we could work with cities and towns and sometimes the state to change regulations, so that we were able to get smoking off state beaches and parks. And, towns passed ordinances to make smoking illegal in housing authorities.

And that was good, but it only took it so far.

With its health IT system, Blackstone Valley knows whether every patient is a smoker or not. With Fresh Start, it allows us to identify every single patient who is a smoker and reach out to them, asking them if they want to enroll in the program electronically, and if they do, whether or not they are ready to quit smoking.

Then we will work with Pro-Change, to ask them if they are ready to quit. If they are, we help walk them through the process of change. If they’re not ready, we text them again with a different message in a couple of weeks.

We don’t know how well this is going to work for this population.

The texts are in English or Spanish, depending on the person’s expressed language preference.

We have two community health workers, supported by two VISTA workers, who are going to be signing people up, helping walk them through the process.

We aim to get the bulk of our 2,800 patients who are smokers enrolled. We’re touching every single person who is a smoker.

In other environments, this has helped to reduce smoking by 25-35 percent.

We have to prove that it will work in the same way with a community health center.

And, imagine in four years, when we have 90 percent of the population of Central Falls enrolled, we will be touching almost every smoker who lives in Central Falls.

We will have feet on the ground; we will have a way to help every smoker who wants to quit. The public health implication of that is amazing, how we are putting public health prevention into practice in Central Falls.

ConvergenceRI: How does the new building integrate that kind of innovative thinking in its design?
LAVOIE:
One of the primary [drivers] that brought us [to the decision] to create a new building was that you had the downsizing of Memorial Hospital, coupled with fact that Blackstone Valley was made an accountable entity by the state.

Accountable entities, in order to grow and prosper, need to have a large population [base] to serve. The building was designed to accommodate an additional 10,000 new patients, to accommodate our current Central Falls facility and the urgent care facility, for 16.000 patients a year, with 50,000 to 60,000 patient visits a year.

ConvergenceRI: There is no other place like this in Rhode Island? Is that correct? Is there any other place like this in the U.S.?
FINE:
There are a couple of other community health centers around the country that are similar, where they bring together many different kinds of services.

But I don’t think there is any other health center that has taken on, as its moral, ethical and clinical responsibility, the care of everyone in a city. That’s what is different. Everyone else depends on people walking through their doors.

ConvergenceRI: Will there be a pharmacy nearby?
LAVOIE:
There will be a pharmacy inside [the building].

ConvergenceRI: Is there an opportunity to add onto the building or expand as new needs are identified?
LAVOIE:
We are pretty much at capacity because of the lot, because of the building size and the number of parking spaces needed.

FINE: If you gave us all the money in the world as a way to fund it, I would say, let’s buy a lot next door, and build a gym and a pool, and connect to it. Because when you provide [those services], you really have the ability to enroll people in ways that don’t push.

As our community health workers knock on the doors of businesses in Central Falls and explain what we’re doing, [we are discovering that] the two major draws are not primary care – the two major draws are dental care and urgent care. Those are the services that people really want that they don’t have access to.

What I’ve learned to accept is that traditional primary care only works for maybe 50-55 percent of the population. That not everyone wants to access care in the same way.

Our job, from a public health perspective, is to keep all of the doors open.

So that if we touch people because they walked into an urgent care facility, we know how to reach them and can bring prevention services to them.

If we touch people because they come to use a gym or a pool, or if we touch people because they called 911 and used emergency medical services, we ought to be able to bring prevention [services] to them, even if they don’t do the traditional, yearly physical exam.

I think we’ve all gotten stuck in the description of a family doctor [in primary care]. I am a family doctor. But it turns out that primary care doesn’t reach the lives or needs of the entire population.

If you are going to improve the health of the whole population, you have to be where everyone is, as they are, and meet them where they are.

ConvergenceRI: How important is it for the local dollars spent on health care to stay here in Central Falls?
FINE:
Hugely important. It’s huge.

ConvergenceRI: You sound a bit like Donald Trump.
FINE:
[laughter] It’s huuuuge.

In some rural areas, 25 percent of all local economic activity comes from health care.

And, if you want to look at Central Falls and follow the money, you can begin to how health care contributed to the [economic downturn] of the city, because for many years, people had to go out of the city for most of their care, and when they did that, they took their dollars with them.

If you keep that money in one location, and spent it at one location, it has a multiplier effect, and you can create a vibrant economic engine.

If we can bring 75 or more new jobs here in the short run, and probably more than that, it will help Central Falls to kickstart things.

I also serve as the health policy advisor to the city of Central Falls, and one of the things we learned recently at a meeting with the multi-disciplinary team is that nobody can find CNAs [certified nursing assistants], particularly Spanish-speaking CNAs. There’s a huge shortage of Spanish-speaking CNAs, mostly because we don’t pay them a decent wage.

Upon learning of that, I had a conversation with the mayor, and we are starting to think about what it would be like to train people from Central Falls, who are starting out, to become CNAs.

Some of those jobs would be located here. And then they could begin to climb up the economic ladder. That is understanding how health care can function as an economic driver in addition to functioning as a protector of the population’s health.

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