A New Way of Thinking About Health: Changing How We Change

Bruce Behringer, MPHJune 1, 2017

Deputy Commissioner for Continuous Improvement and Training

Tennessee Department of Health (Retired)

Initial comments

• Your regional challenge• Your selected priorities• The wording you choose

• Advantages and disadvantages of being Tri-State • Strength of sense of regional

community • Different policies, people, priorities and

portions• Ability to feed ideas across lines

Your regional challenge

Your selected priorities are troubling issues that require:

• Continuing and continuous care • Coordination of effort between patients

and providers and among providers • Focus on risk reduction• Really hard behavior change• Broader more comprehensive public

interventions

Clarify your language: Differentiate between health problems and

solution• Regional health

issues– Behavioral and

substance abuse– Chronic Disease

• Strategies address issues – Access to care – Data and technology

• Learn from lack of clarity in nation health care reform debate Health, health care, or health insurance? Which essential benefits?

• Access to what? Treatment, coordinated care, preventive services, knowledge and skills to adopt healthy behaviors

Five ideas for your consideration• Units of practice to expand who could be

involved with regional population health improvement

• Working together strategies to reconsider steps in process toward change and success

• Give-Get Grid to identify and value contributions and benefits of the many

• Aspects of community health to record, track and evaluate regional population health issues

• Strategic maps to display visible outcomes of effort

Units of practice, Units of solution • Helps to consider “who

else” contributes to health?

• What is your organization’s traditional unit of practice?

• How could effectiveness be improved with broader units of solution?

• Engages and involves more in the solution

From:  Stewart G. (1993). Social and Behavioral Change Theory. Health Education Quarterly. Supplement 1: S113‐S135.

TOOL 1

Working Together Strategies• Networking: Exchanging information for mutual

benefit• Coordinating: Exchanging information for mutual

benefit and altering activities for a common purpose

• Cooperating: Exchanging information for mutual benefit, and altering activities, and sharing resources for a common purpose

• Collaborating: Exchanging information for mutual benefit, and altering activities, sharing resources, and enhancing each other’s capacity for a common purpose

Arthur Turovh Himmelman. 2007 CDC Cancer conference.

TOOL 2

Working Together Strategies• Provides framework for planning

• Classify each opportunity for working together

• Consider requirements to move to next step

• Cooperating becomes a regional goal for change

• Incidents of collaborating should be identified, documented, evaluated, and awarded

• Important to recognize common purpose and how organizations increase each other’s capacity

Behringer, 1992 (multiple references)

TOOL 3

Explanation of cells in model• Each partner to defines own “Give” and

“Get” cells • Cell contents

– Gives – promised contributions– Gets – expected benefits

• Negotiate relationship together to …– Learn each other’s missions, values and

resources (and limitations)– Discover value of own resources (not

necessarily money) as contributions – State expected benefits to hold partners

publicly accountable to process and shared outcomes

What the Give‐Get Grid is not

• “Giver and receiver” relationship between those of greater and lesser power and resources

• Set of short‐term promises just to get a grant or express support for a program

• Traditional “win‐lose” approach or even “win‐win” thinking 

What the Give-Get Grid is• Focuses on development of long term,

continuing relationship • Provides framework for dual and shared

and benefits • Promotes a sense of accountability among

partners• Framework to share new external sources

support that address community-identified issues and open doors to community

• Used for formative evaluation of a planned collaborative program

Background beliefs • Partnerships defined as redistributed

power brought about through negotiations (Arnstein)

• Equality of partners achieved through recognizing assets, not just needs (Kretzman and McNight)

• Value participation and development of relationships based upon contributions seen as meaningful, challenging (Depree)

• Define own and others’ interests leading to stating expectations of benefits (Fisher and Ury)

Give‐Get Grid Example 1992:Community Partnerships for Health Professions Education 

University gave:-New curriculum-Student time in community-Faculty expertise-New health service site

University got:- Rural training location- Expanded service area- National rural reputation- Recruit new faculty/students

Community got:- More doctors and nurses- New preventive services- Strengthen health system- Their children in college

Community gave: - Permission, time and energy- Use of practice and services- Space, homes- Teaching “Small Town 101”

Example 2007: Appalachian Communities and Comprehensive Cancer Control Coalitions

Communities gave:- Volunteer community time- Local knowledge of cancer - Ally for advocacy- Local credibility and leaders

Communities got:- State recognition of local needs and accomplishments- Connection for cancer information and resources - More programs and services- Address cancer problems

CCCs got:- Help to complete and implement state plan- New partners and members- Local evidences of success- Reduce state burden of cancer - Statewide interconnectedness

CCCs gave:- Appreciation and recognition- Materials, services, paid field staff to support local efforts- State cancer plans, data and coalition infrastructure- Support health policy change

U Pittsburgh-Oakland

Get

Give

Center for Rural Health as a regional collaborative

group project

Get Give Give Get

U Pittsburgh-Bradford Bradford community organizations

Example 2009: Bradford (PA) Center for Rural Health with multiple partners   

Value of the Give-Get Grid• For planning across multiple parties

– Level of participation – Time commitment – Expertise

• For evaluation of cooperative efforts – Repeat use of grid every year and compare

promises with reality– Count number of contributions and benefits

cumulatively over time

How to address typical frustrating dilemma

Patients and community 

Health care providers and systems 

These common attitudes just do not serve a region well

or promote cooperation to improve region’s health.

Model of Health Care Access, Anderson and Aday (1981)

Measured by consumer satisfaction

Population Needs

Measured by Utilization of services

Health PolicyFinancing and Organization 

Structural Availability of care

Aspects of Community Health Model

Characteristics of population

and community

Characteristics of health

services and systems

Behringer Adapted from: Model of Health Care Access, Aday and Anderson (1981)

Population Health

Outcomes

TOOL 4

Aspects of Community Health Model

Characteristics of population and community 

Characteristics of health 

services and systems

Providers  Patients

InteractionsSystem  Community 

Population Health 

Outcomes 

One successful use 2014: TDH Focused Community Assessment

Model Variables Health Status and 

Outcomes • Risk• Morbidity• Mortality

Characteristics of the Population and Community

• Demographics• Cultural

• Environmental Interaction• Satisfaction

• Evaluation findings

Characteristics of Health Services and 

System• Use of services• Cost• Workforce

Assessment process identified eleven variables  

Part of Community Health Assessment and Improvement Plan 

process

Aspects of Community Health Model Data Collection Tool

Health issue problem statements 

Health services and system factors

Population and community factors 

Interaction factors 

Use of Aspects model - HOW• Use sheets to collect data and ideas for

topic problem statements, population and systems factors.

• Create central visible repository to accept and integrate input

• Key questions– Who will collect data?– How will it be shared in a timely manner?– What participatory processes can interpret it?– Who will be responsible for acting on

findings?

Use of Aspects model - WHY• “No numbers without stories, nor stories

without numbers”• Root solution in community’s lived experience

and collective impact • Data is valuable regional asset IF collected,

shared and interpreted together• Repository as regional asset to:

– Explain reasons why the problem exists and factors that contribute to problem change theory

– Guide development of interventions from assessment to concepts to strategies to evaluation

Taken together, a framework of regional leadership without

authority• Most regions have no continuing public forum for communication, debate and accountability

• Engage without finger pointing • Partnering, not ownership, as the key

principle • Focus cooperative energy on agreed upon

changeable issues • Build in accountability with understandable

outcome measures• Collaboration = combined investments with

shared benefits • Give it time to work

The Strategic Map• One-page “map” that documents actions and

efforts– “The relationship between the drivers and the desired outcomes constitute the hypotheses that define the strategy“ – Kaplan and Norton 

– CDC adaptation is an excellent tool for public consumption – “We are doing something!”

• Promotes inclusive thinking– Focus on regional cooperative actions– Include adoption of individual organization’s best

practices

TOOL 5

Public Health Approach to the Opioid Abuse Epidemic Tennessee Department of Health Strategic Map, 2016

Expand efforts to reduce NAS

Actively support community coalitions

Expand use of optimalprescribing guidelines

Provide prescriber/dispenser education on

regulation & enforcement

Improve collaborationwith law enforcement

Expedite investigationssupporting Board oversight

of prescribers

Adopted1/11/16

Expand treatmentalternatives toincarceration

Partner with Mental Healthto expand treatment

options for opioid misuse

Optimize use ofthe CSMD

Improve the high riskpatient model

Link other data sourcesto the CSMD

Destigmatize & approach addiction as a

treatable chronic illness

Eliminate “Pill Mills”Develop a high riskprescriber model for

individuals and practices

Improve legislation toallow proactive regulation

Reduce Opioid Misuse, Abuse & Overdose

Improve PrimaryPrevention

ImproveRegulation andEnforcement

Increase Utilizationof Treatment

(2º Prevention)

ImproveMonitoring and

Surveillance

A B DC

Secure/Realign Resources and Infrastructure to Implement Comprehensive Approaches

Facilitate communityinterventions, includingsafe disposal of drugs

Expand appropriateuse of MAT

Expand SBIRT training and use

Advocate for Prescriptionfor Success includingtreatment and care

Expand and Strengthen Key Partnerships and Collaborative Infrastructure

Use Data, Evaluation and Research to Inform Interventions and Continuous Improvement

Improve education for consumers,

families & HCWs

Develop a high risk dispenser model

Reduce harm from needle use

1

2

3

4

5

6Improve proactive use of clinical monitoring tools

Work with academicpartners to improve

training of prescribers

Describe how patientcare is impacted by

sudden clinic closure

Require pain managementclinic physicians to have

specialty certification

Increase Access toAppropriate Pain

Management

E

Increase access foruninsured

Develop a model fordesirable integrated

pain practices

Expand the availabilityand use of Naloxone

Some generic strategies to consider• Customer Services• Operational and process improvement• Legislation/regulation/enforcement• Advocacy• Surveillance, research and response• Initiative development, including strong evaluation • Individual, group and community education, including involvement of public media   

• Staff development/training (professional and public)• Working together projects: network, cooperate, coordinate

• Shared financing with public: collaboration

Do the ideas fit?• Units of practice and solution: who else to

invite to the regional table?• Working together strategies: adopt as way

to challenge regional efforts to move to next step!

• Give-Get Grid: tool for getting started after identifying focused proprieties and issues

• Aspects of community health: consider a regional repository of diverse inputs on regional population health issues

• Strategic maps: consider the good that is being done now

Final comments, 1• Can’t do everything

– Focus– Do it well– Document it and celebrate success

• Find what is going right and learn from it• Promote creativity and inclusivity in

cooperative ventures• Form follows function

Final comments, 2• Pay attention to process of cooperation as well as outcomes

• Reinforce positive employee behaviors of working together– Coordinate among health organizations – Cooperate with community groups and agencies

• Make participation in regional effort seen as Meaningful Work – Personal satisfaction of acknowledgement for effort and effectiveness

– Ability to document and see of discretionary results – Perseverance in meeting community expectations for regional health improvement