Delivery of Care

In search of a common language about disruptive health innovation in RI

Health equity zones, neighborhood health stations, accountable care, and housing prescriptions, oh my

Image courtesy of R.I. Department of Health from presentation by Dr. Nicole-Alexander Scott at the MLPB breakfast.

A detailed chart of the priorities, strategies and population health goals by the R.I. Department of Health showcases the complexities of sharing the messaging around health equity zones and community health workers.

Photo by Richard Asinof

Sen. Jack Reed, left, at "Our Voices, Our Homes" celebration recognizing his leadership in the creation of the National Housing Trust Fund.

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By Richard Asinof
Posted 5/7/18
The efforts to create a new, innovative, disruptive change in the way that health and disease are addressed in Rhode Island is moving forward, despite difficulties in finding a common language to talk about the convergence.
When will the Greater Providence Chamber of Commerce talk about health equity zones and neighborhood health stations as part of their discussion of economic development in Rhode Island? What are the best ways to publicize the way that the legal community and the medical community are collaborating in finding solutions to social disparities in health care? Will the R.I. General Assembly commit more funding to support the development of affordable housing in Rhode Island to address the current crisis?
It is hard to compete with the daily barrage of news that is car crashes, house fires, airplane crashes, murder trials, outstanding warrants for political candidates and drug busts, but there is a distinct difference between urgent and important. If we are always distracted by urgent concerns, it is easy to forget to focus on more important items. When it comes to health care delivery, the red engine light warning is no longer blinking, it is on all the time on our dashboard. The tendency is to ignore it – until it becomes a personal story, often a tragedy.
It is worth repeating: recent polling by the Kaiser Family Foundation has identified that health care costs are the top issue voters want candidates to talk about in the 2018 campaigns. But, here in Rhode Island, no one has conducted any polling on health care to date, so it has not yet emerged as a topic of conversation for reporters to ask the candidates about. Why is that?
Even simple questions for those running for statewide elected office in 2018, such as “How much do you pay for your health insurance a month, what is your co-pay, and what are you out-of-pocket expenses?” remain unasked and unanswered.

PART TWO

PROVIDENCE – Welcome to Side Five. Today, we will learn three new words in Turkish. Bath, towel, border. Border. May I see you passport, please.

That was how the comedic team of Firesign Theater began a routine on its first album, “Waiting for the Electrician or Someone Like Him,” released in 1968, which satirized the way Americans might learn to talk in a new language about health and disease, including a memorable sketch of a TV reality show, “Beat The Reaper,” where contestants had 10 seconds to identify the “really big disease” they had been injected with. The penultimate disease that stumped the contestant [and killed him] was the plague. As an unintended consequence, the plague then swept through the city.

Five decades later, the U.S. health care delivery system [some have called it a market of wealth extraction, not a system] is at an inflection point: medical costs keep increasing, health outcomes keep falling, and patient distrust and dissatisfaction keep growing.

Here in Rhode Island, in response to the health market being in disarray, there are a number of new, disruptive health initiatives being launched, in part because Rhode Island’s population size of 1 million makes it a good proving ground before scaling up.

As a result, residents, reporters and politicians are being asked to learn how to speak in a new vernacular embracing a number of innovative, disruptive concepts around health and disease: health equity zones, neighborhood health stations, accountable entities, and housing as a prescription.

Each of these initiatives seeks to realign the way that health care is conceived and delivered:

A neighborhood health station in Central Falls, being built by Blackstone Valley Community Health Care, with its new $15 million, 47,000-square-foot facility opening in September, integrates primary and urgent care around community needs, in coordination with EMS services. “A neighborhood health station is pretty much a one-stop shop, where 90 percent of the folks in Central Falls can get 90 percent of their health needs met,” explained Ray Lavoie, executive director of Blackstone Valley, keeping the money spent on health care in Central Falls, the smallest, poorest city in Rhode Island. A similar but different approach to neighborhood health stations has also been launched in rural Scituate, focusing on providing access to primary care and screening to all residents.

There are nine health equity zones now operating in Rhode Island, creating community-based action plans and solutions to address the health, social and economic disparities in each community, braiding resources together at a neighborhood level. Most recently, in Bristol, a new recovery center was opened on May 2, offering peer-to-peer support services, health and wellness activities, employment assistance programs, and community outreach, in partnership with the Bristol HEZ. On April 26, a “walking school bus” program was launched in Pawtucket, identified as a community priority by the Pawtucket and Central Falls HEZ.

“Unless you work in the community, addressing the conditions that are creating that burden of disease, you are always going to be rescuing people,” said Ana Novais, executive director of Health at the R.I. Department of Health. “And, there is no money, not enough money, to rescue people indefinitely. If you start to diminish the conditions that led to the poor outcomes, then you are going to be more successful.”

Accountable entities seek to realign the way that Medicaid dollars are spent by managed care organizations, moving away from fee-for-service toward value-based care, through government re-engineering known as the reinvention of Medicaid, supporting by the State Innovation Model initiative. But some have questioned the implementation process, particularly as it relates to shared savings.

Housing as a prescription is a work in progress in Rhode Island, an attempt to secure Medicaid funds to be used for providing shelter, in particular for providing housing for the homeless population in the state. There are efforts underway in the R.I. General Assembly to secure the legal framework to treat chronic homelessness as a medical condition, using Medicaid waiver funds to create a pilot program supportive housing services, including case management, personal care, home and community based services, and housing support services.

“Getting people into housing takes away that giant roadblock, making it easier and more likely for them to stay connected with services, programs and employment, all of which improves their health in direct and indirect ways,” said Sen. Josh Miller, sponsor of the legislation. “There are strong indications that their health will cost less if they are not homeless. I’m confident a pilot will show improved health for the population, and I’m very interested in determining the cost benefits.”

Communicating what these initiatives seek to do, leaving the jargon behind, and making it bite-sized and understandable for the general public – and reporters – remains a big challenge. Today, we will learn three new words in health care…

Charting the upstream course
Two recent events captured efforts to change the conversation and the vernacular in disruptive health innovation efforts, neither of which made your local news coverage.

The first was the MLPB spring breakfast held on Wednesday, May 2, at the Warren Alpert Medical School [MLPB is the next generation evolution of the Medical Legal Partnership Boston, focused on upstream problem-solving strategies.]

The program, entitled “Charting the Upstream Course: Social Health Integration in an Accountable Care Environment,” featured Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health given the keynote address, focused on health equity zones and community health workers as two initiatives that are linked to changing the landscape in health policy and health disparities.

Following the keynote address, a panel discussion was held, entitled “Rethinking Risk and Reward: Person-centered Care for the 21st Century.”

The panel participants included: JoHanna Flacks, the legal director of MLPB; Arlenee Ash, professor and Division Chief, Biostatistics and Health Services Research at the UMass Medical School; Yvonne Heredia, manager of Care Management at Neighborhood Health Plan of Rhode Island; Elizabeth Torres, lead tech inspector and community health worker at St. Joseph Lead Center; and Dr. Pano Yeracaris, chief clinical strategist at the Care Transformation Collaborative.

The breakfast gathering was moderated by Samantha Morton, the CEO of MLPB.

A good portion of the panel discussion focused on a recent New York Times article entitled, “Why black mothers and babies are in a life-or-death crisis,” and the difference that a doula made in care, when the mother gave birth to a child after experiencing a stillbirth, as a way to identifying disparities in care for black women and their babies, supported by the statistical evidence.

One of the disparities, as Flacks pointed out to the audience, in asking them the question: “How much do you think that the doula was paid for her services?” It was miniscule amount, about $60 dollars, for attending the birth, according to Flacks.

Torres, in her comments, drew attention to the problems of enforcement related to lead inspection in housing and the larger overriding concern: “Housing in Rhode Island is not affordable for the lower classes,” she said.

The resulting interactive conversation created the kind of give-and-take often missing from siloed discussions around health care, working toward convergence, including pointed questions from a knowledgeable audience. What were the best ways to change structural problems looking at prevention and intervention related to the environment and social justice? What kinds of future funding would be required to sustain the health equity zone initiative in Rhode Island? How can Rhode Island overcome the lack of state health plan moving forward? When will pregnancy centered care be integrated into Medicaid innovation and cost containment?

“As Dr. Nicole Alexander-Scott said in her remarks, she was pleased that we weren’t just having a conversation about health disparities,” Morton told ConvergenceRI after the event. “We wanted to share with attendees a range of strategies that are under development, with a growing evidence bases, including public interest law resources.”

The housing party
The next day, on a summer-like Thursday afternoon, May 3, the housing community of Rhode Island, under the banner of “Our Homes, Our Voices,” as part of a national Housing Week of Action, celebrated the leadership of Sen. Jack Reed in the creation of the National Housing Trust Fund.

The event, held in the driveway at 267-269 Webster St. in Providence, the future site of renovated apartments to serve clients of Crossroads RI, was emceed by Brenda Clement, the director of HousingWorks RI, and hosted by Rhode Island Housing.

The occasion of the celebration was to mark the recent investments of some $3 million by the National Housing Trust Fund into creating affordable housing opportunities in Rhode Island. The National Housing Trust Fund, a Congressional initiative that Reed had labored for more than a decade to create, working in a bipartisan effort with Sen. Susan Collins from Maine.

Reed told the assembled guests of more than 45 from various housing groups not to wait, to go and spend the money right away, given it was unclear what next year would bring in terms of budget policy in Congress.

“Unless you have a safe, affordable, decent house, it’s hard to go to work, it’s hard to go to school, it’s hard to do anything,” Reed told ConvergenceRI. The effort to create more affordable housing, he continued, “is about how we can help our constituents to realize opportunity. What is happening is that people are realizing that it is no longer strictly an issue for low-income people.”

The connection between housing, health and economic development was made by every speaker.

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