Delivery of Care

A conversation with Dr. Nicole Alexander Scott

How the director of the R.I. Department of Health assesses the future challenges of health for Rhode Islanders

Photo courtesy of the R.I. Department of Health

With Dr. Nicole Alexander-Scott delivering a flu shot, Steve Klamkin of WPRO pulls off the extremely rare vaccination selfie, as part of the the R.I. Department of Helath’s annual flu vaccine kickoff on Sept. 25.

By Richard Asinof
Posted 10/9/17
As the health care ecosystem continues to evolve in Rhode Island, a conversation with Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health, offered some insights into future roadmap to be followed.
How will the Congressional machinations around the future of health care change the flow of federal money into Rhode Island? Will the Trump administration attempt to dismantle the Center for Medicare and Medicaid Innovation, and with it, funding for the Accountable Health Communities model, a five-year pilot program that was awarded to Integra at Care New England? How will the 10 health equity zones measure and benchmark the outcomes of the work in their communities? Will the R.I. Office of the Health Insurance Commissioner consider developing a new affordability standard for pharmaceuticals?
As part of the 2014 statewide health IT survey, a number of narrative questions were included, asking providers to describe their interactions with electronic health records. A qualitative analysis of the responses conducted by Healthcentric Advisors revealed a growing frustration with the burdens of documentation and the way that technology was changing the nature of the relationship between patient and provider.
As the Department of Health moves ahead with its surveys for the upcoming statewide inventory of health resources, with answers from community residents to be included, perhaps there could be a qualitative analysis undertaken of narrative responses by community members about how they feel about the health care delivery system.

PROVIDENCE – Dr. Nicole Alexander Scott, the director of the R.I. Department of Health, has often found herself on the front lines of the evolving conversation around health equity and health care delivery in Rhode Island.

Alexander-Scott serves as co-chair of the Governor’s Task Force on Overdose Prevention and Intervention, helping to develop a coordinated, evidence-based response to the epidemic of drug overdose deaths, which claimed the lives of 336 Rhode Islanders in 2016.

She also has helped to lead the charge to establish health equity zones in Rhode Island in 10 communities, making sure that the initiative is fully integrated within the State Innovation Model approach on the transformation of state health care delivery.

From suicide prevention to delivering flu shots to reporters, from promoting access to healthy food to childhood health advocacy, Alexander-Scott has been a forceful presence, despite her low-key demeanor and calm tone of voice.

When ConvergenceRI first interviewed Alexander-Scott in June of 2015, soon after her appointment as director by Gov. Gina Raimondo, Alexander-Scott spoke about her desire, if she could, to change the name of the agency to reflect an emphasis on healthy communities.

“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.”

That same passion to promote health equity as a fundamental precept of health planning – and health care delivery planning – still resonates strongly for Alexander-Scott.

“We want to include all of the elements of the community, the social, economic and environmental determinants of health within health care planning, and within health planning,” she told ConvergenceRI in a recent phone interview.

Here is the ConvergenceRI interview with Dr. Nicole Alexander-Scott, some two and half years into her role as director of the R.I. Department of Health.

ConvergenceRI: At a recent budget hearing, there was testimony that the R.I. Department of Health has lost something like 23 percent of its total state funding in the last few years. How has that impacted the ability of the agency to carry out public health initiatives? How dependent is the agency on federal funds for its work? Is the R.I. General Assembly been made aware of the potential consequences? Will you ask for more money?
ALEXANDER-SCOTT:
Those are important questions. In terms of the impact on the agency to carry out public health initiatives, we’ve had funding cuts across the board – in our HIV/AIDS work, in tobacco prevention, in equity institutes.

In our public health functions, we have been impacted by cuts to licensing of facilities and inspections for food safety and protection.

In addition to cuts in each of these specific areas, the other challenge is that the department’s operational infrastructure has been affected, as with our laboratory.

The cuts have also impacted significant operational activity, including financial operations, our employee relations, legal services, and our IT functions, as well as workforce and career development, which is key to [retaining] a skilled, competent diverse workforce.

These “impacts” are not always visible to the public; despite the challenges, we are focused on keeping the department moving and thriving and focused on our mission.

There have also been the impacts of cuts in the federal budget; federal funding represents 62 percent of our department’s budget.

For sure, every time I get the opportunity to engage with my colleagues in the R.I. General Assembly, I talk with them candidly about our progress and all that we do in spite of our hurdles and funding challenges.

When we testified [recently] before the Senate Finance Committee, the members wanted to make sure we had the opportunity [to talk about the budget]. The members of the General Assembly care deeply about the health and wellness of Rhode Islanders.

The legislators wanted to hear [our testimony], and they have a frame of reference – the implications of cuts to programming and operations that are critical to their constituents and communities.

Of course, we would always appreciate more money, but we know it is important to be as innovative as we can, as thoughtful as we can, about what we can do differently and strategically as we [look] at the budget focus areas for the department, so that the money the General Assembly provides can be used for maximum benefit.

ConvergenceRI: Would you ever ask for more money?
ALEXANDER-SCOTT:
Our context is that we operate under the framework of the budget process that exists. I am honored to serve under the Governor. We cannot ask for money outside that of that process. Of course, we would welcome any additional resources.

ConvergenceRI: What is the current status of statewide health care planning efforts?
ALEXANDER-SCOTT:
First, let me differentiate statewide health care planning from statewide health planning.

It allows us to incorporate what we always talk about at the department: expanding the definition of health, and how health is created in a community and in the state. We’re hopeful that there can be some overlap.

We want to include all of the elements of the community, the social, economic and environmental determinants of health within health care planning, and within health planning.

Our State Innovation Model grant serves as a key resource.

We are also working on a statewide inventory of health care resources. The inventory was first published in 2015, and we are working on the second edition for 2017.

We are collecting data in a series of surveys, covering all the different health systems, facilities, primary care practices, long-term care facilities, acute care facilities, ambulatory facilities and urgent care centers.

This time, we are also including behavioral health and emergency and EMS services.

We are also including what community members have to say about their experiences.

This R.I. Department of Health inventory is one of many tools that are in place to build and to develop our health care planning.

ConvergenceRI: When will the inventory be released?
ALEXANDER-SCOTT:
It will be released either later in the year and early next year.

We intend to leverage our public health scholars and staff, working together, as we did with the 2015 statewide health inventory.

ConvergenceRI: The most recent data on the Health Department website shows that for the first six months of 2017, there were 157 confirmed deaths from overdoses. However, in recent days, sources have told me that that the total for the first six months was 172 deaths…
JOSEPH WENDELKEN:
That is a discussion that we should have after the interview.

ConvergenceRI: OK. How do harm reduction strategies fit into the work of the Task Force on Overdose Prevention and Intervention, specifically whether the state would consider setting up a safe injection site similar to Vancouver? Brown’s Brandon Marshall has recently analyzed the data from Vancouver, and Massachusetts lawmakers are considering opening up a safe injection site on the Cape.
ALEXANDER-SCOTT:
Harm reduction strategies are an important component to our action plan, incorporated in the Executive Order signed by the Governor in July. We are constantly in conversation about which type of strategy would be most effective.

We want to continue to look at harm reduction models, as we’re doing.

We can boil the conversation down to what’s the most effective way to prevent drug overdoses; harm reduction strategies are a key part of that.

But we want to keep our focus on the most effective way to treat opioid use disorders. We have made massive investments in [medication-assisted] treatment, using methadone, suboxone and vivitrol.

There has been a lot of hard work, along with these investments, particularly by our recovery community. So, we want to continue to explore all of the possibilities.

But our focus and approach is treatment [to promote] living a life of recovery.

ConvergenceRI: Will the integration of health equity zones in the conversation around health care delivery include the work being done on Neighborhood Health Stations in Central Falls and Scituate?
ALEXANDER-SCOTT:
Our focus with health equity zones is to empower and strengthen the local community, to build the local health infrastructure, because community is where health happens.

Health equity zones are a critical way to focus on systems-level changes, empowering economic development in each of the communities that we serve. There are a variety of ways to help achieve that, in addition to the Department of Health. Federally qualified community health centers are a huge partner as well.

The health equity zone model is so invaluable because it brings together all of those key partners. It is great to be able to include the Neighborhood Health Station that is being built by a federally qualified community health center, investing in the community of Central Falls, and in any other communities.

The goal is to support health where it happens, in the community.

ConvergenceRI: The initial grant to establish health equity zones in 10 Rhode Island communities will run for four years. The first two years have been completed. Are you looking for additional resources to support the program?
ALEXANDER-SCOTT:
Absolutely. What we have created is the infrastructure, which was our number-one focus. We made it clear, to ourselves and to the communities [involved], we wanted to create transformational community, systems-level change.

The grants were seed money to get that conversation going, to strengthen the assets and resources in the community, to let all of those brilliant minds [converge].

In our minds, it’s only the beginning. Our vision was to get the infrastructure built, but that the communities will need to continue this work for themselves, to secure additional funding for sustainability.

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