What does it mean to improve the health of the population? That's the question MaineHealth's trustees asked of senior staff in charge of community health improvement in 2009. They wanted to know if the Portland-area system's significant investments, which had leveraged millions of additional dollars from other private as well as public sources, were making measurable improvements in the health status of communities in the health system's service area.
The board's challenge was a reasonable request given the system's vision of making its communities "the healthiest in America." And the board believed that quality in general, and community health in particular, should receive more of its attention. But focusing on community health is not easy, and it raised three difficult questions:
- One health care system seldom serves all the members of a community. While MaineHealth is the state's largest system and its eight hospitals and numerous other facilities and services are spread over 11 of the state's 16 counties, there are several other providers within its service area. Would it be fair to hold MaineHealth accountable for community health if some of it was beyond the system's reach?
- There are no commonly accepted standards of community health that could be measured and tracked. How would the board measure progress?
- Focusing on community health represents a major cultural shift. Most health care providers have necessarily been in the "fix-it" mode rather than the "prevent-it" mode, and have not been rewarded for efforts to prevent hospital or office visits. And, frankly, most boards find it easier to talk about financial matters than the softer subjects of quality and community health. How could we change the culture at all levels?
Fortunately, the staff, led by President Bill Caron, were aware of these issues and began the process of shifting attention to improving community health.
'It's the Right Thing to Do'
Better alignment of medical care and public health care systems is essential to achieving significant improvements in population health. But what does this mean in practice? What is the role of a health care system, beyond achieving excellent outcomes among individual patients, in improving the overall health of the population? Isn't this the job of state and local health departments or community groups?
The board's response to this question was unequivocal. As the state's largest provider of health care, MaineHealth had an obligation to be actively engaged in population health improvement for three reasons. First, prevention not only saves lives, it saves money. Making sure that patients get recommended screenings for cancer, helping patients to quit smoking, and delivering appropriate well-child care are examples of services the health system must provide to reduce the downstream costs of care. Second, improving population health is central to providing the highest-quality care. The ultimate reason to improve clinical systems and processes of care is to achieve better overall patient outcomes like quality of life. Finally, as one board member said, "It's the right thing to do. We need to be part of the solution, not just fixers of the problems."
Over the past decade, MaineHealth's investments in clinical quality improvement and community health initiatives have totaled more than $40 million. In 2008, board and senior management increasingly were seeking ways to assess the value and impact of these investments. They proposed that any system developed by MaineHealth to measure population health improvement should meet four core criteria:
- Be consistent with the board-established vision and direction;
- Have the potential to influence health outcomes;
- Provide an explicit framework for securing and allocating resources;
- Provide better accountability for health system actions.
The first step was to look at other health systems, foundations, payers and government agencies that had attempted to answer these tough questions, and assess the results they had achieved. After considerable investigation, the approach that best met MaineHealth's established criteria emerged: America's Health Rankings, an assessment that annually measures the overall health status of every state published by United Health Foundation, American Public Health Association and Partnership for Prevention.
While Maine consistently has ranked in the top 25 percent of states since 1990, our position on several indicators has changed dramatically, including a marked decline in childhood immunization rates. The 2011 AHR report ranked Maine eighth in the United States. Endorsement of AHR's conceptual framework, which recognizes such external contributors as health behaviors, policies and environment to both individual and community health, was a key milestone. Explicit recognition that multiple sectors have a role to play in addressing the state's biggest health issues was a critical step in reassuring the board that MaineHealth would not — and could not — "own" potential solutions. Rather, the role would be to partner effectively with others and, together, achieve shared improvement in health status.
Public-Private Work Group
Under the leadership of the system's vice president for community health, a Health Index advisory work group was formed, with representation from each of the system's member and affiliate hospitals, local and state public health officials, health data experts, clinicians and researchers. Active involvement by the chair of MaineHealth's board led to frequent, well-informed communication about progress to the full board.
Using a formal selection process, the group identified 14 of the 22 measures used by AHR that were thought to be most appropriate for MaineHealth and its partners. This list was shortened further through consideration of four criteria: potential for improving health status; likelihood of success; alignment with partners; and consistency with MaineHealth's mission and interests. The result was six high-priority measures that form the core of MaineHealth's Health Index:
- immunization coverage (percentage of children aged 19-35 months)
- prevalence of smoking (percentage of total population)
- prevalence of obesity (percentage of total population)
- cardiovascular deaths (per 100,000 population)
- cancer deaths (per 100,000 population)
- preventable hospitalizations (per 1,000 Medicare enrollees)
Next, a systematic inventory was completed of all related strategic and tactical activities currently under way across the system and region to assess their effectiveness and impact. Relevant data were collected and analyzed to determine gaps in focus and activity and develop a multiyear plan for aligning priorities and resource allocation. The final and most important step was to advocate for significant new resources to fund the resulting priorities, which included both new and expanded initiatives. Since 2010, nearly $10 million has been dedicated to these efforts.
The most visible product of the Health Index initiative is an annual report published each December to coincide with the release of AHR. Maps are used to compare key indicators among counties and regions. The report provides highlights of the progress toward reaching each of the six priorities, including graphs and charts that illustrate clinical, community and policy strategies. Thousands of copies of the report are distributed each year to MaineHealth system leaders and local stakeholders. Highlights are presented to hospital boards, legislators, community stakeholders, business leaders and others to mobilize the community and accelerate the allocation of human and financial resources toward measurable, sustainable improvements in population health.
Operational Implications
Three years later, the Index clearly is having an impact on MaineHealth's strategy, operations and resource allocation. Each year, the system's management team and board set a series of focused goals that engage CEOs, clinicians and member organizations in meeting high-impact, cross-system performance outcomes. For the first time in 2012, one of the goals challenged all eight member hospitals to set and achieve health status improvement goals within their service area, and all are on track to meet or exceed their targets by year-end. This would not have been possible without the framework and contributions of the Health Index. As a result, system boards now regularly grapple with issues like childhood obesity and tobacco use and the roles that community hospitals can play as leaders, supporters, conveners or simply participants in improving the health of the population.
"MaineHealth's Health Index takes United Health Foundation's America's Health Rankings to an exciting new level by turning data into action at the regional level and integrating community health and clinical medicine," says Reed Tuckson, M.D., executive vice president and chief of medical affairs, UnitedHealth Group. "Both of [these] present extraordinary opportunities for transformative health improvement and the potential for enhancing population health."
Peter Haynes (plhaynes@aol.com) is a trustee of the MaineHealth board and served as its chair from 2005 to 2009. Deborah Deatrick (deatrd@mainehealth.org) is senior vice president of community health improvement, MaineHealth, Portland.
