Across the nation different parts of the health care system are scrambling to figure out how they will respond and fit into a reformed approach to health care. Hospitals, professional practices, clinics, safety net institutions, health plans, schools and colleges see the parameters of the policy change, feel the movement of the market and are beginning to realize that they need to reposition their vision and strategic business objectives to align with these forces. While these institutional and organizational responses are to be expected and are needed to give shape and definition to the broad principles set out in the legislation, they generally fail to rise to another level of consideration for integration and improvement.
All professional practices, hospitals and clinics exist within a community or, as some would prefer, a health care market. For the first time in our history most of the individuals living in these communities will have insurance coverage and the institutions that provide services will increasingly be allowed to cooperate without fear of charges of collusion.
For the first time ever we have the challenge of considering all of the health care needs of all of the individuals in a community. We're beginning to see how they are interrelated and driven by a vast variety of factors, only some of which are the traditional health care inputs of an admission to the hospital, visit to a clinic or receiving a prescription. For the first time the value proposition for action is not limited by the boundaries of organizations and professions. The needs within a community, how they might be best met and how the vast array of resources both traditional and non-traditional, might be aligned in a manner to efficiently and effectively contribute to health has become a part of the action for improving the system of health in our nation.
To meet this challenge I think five things will be needed.
First, we need a picture of the whole: the whole problem, whole resource base, whole challenge. To approach this from a community perspective the first step is defining this work as a health challenge, not a health care issue. Once our focus is on health care then the debate will quickly turn to the negotiations between the silos. We have already been to this movie several times and we know how it will end. We need a new framework to see a bigger picture. This frame might be a single county or several counties in a region. In places with small populations with similar needs, it might be the entire state. This picture should be of the entire population and answer questions that are rarely gathered in one place. How many people are there with what characteristics? Where do they live? What do they need in terms of health and health care? How can they help others? What institutions are where and doing what? How do they connect to each other and to this bigger framework? We have lots of these inventories, but we have very few that bring in all of the relevant perspectives and knit together a picture of the whole. This first effort won’t be perfect, may not even be pretty, but it should be seen as the first step on a path that uses all of the rich information technology now available to create a living picture of the health landscape in every community in the nation.
There will be some that will see this as some grab of power by the government. They shouldn’t. The reality is that communities small and large, homogenous and diverse have always inventoried there assets and challenges and then organized to address the problems as they understood them. The tradition is as simple as a barn raising or co-op and as complex as local school boards leading education. But we have a local tradition or working together, we need to turn out attention to health and we will need to use the powerful new electronic communications and information tools to make this work.
Second, the inventory will begin the process of identifying the natural leadership networks both inside and out of institutions that will need to be connected in order to understand the whole and then take action to change things. Beyond identifying these individuals, they will need an introduction to each other and new places both physical and virtual to work together. The best way to do this will have them focus on specific problems and challenges and develop new leadership skills of how to work together. This might be organized as a leadership development program for emerging leaders, a collaborative on-going meeting of senior leaders, a mentoring program or any way that gets leaders or potential leaders that do not typically work with each other to come together around specific problems. To create a different type of health care reality we will need new leaders, with different expectations and a variety of skills.
I have alluded to how much of this work will depend on effectively using the backbone provided by the new information technology and systems. From social networking to shared electronic work spaces to new ways of engaging and involving every part of the public spectrum, leaders will find the tools to frame issues in new ways, involve consumers in exciting health related ventures and bring new providers into the mix of what makes up health and health care. Most of our attention today is on brining the electronic health record on line as a way of sharing and using information to carry out the traditional work of health care. Seeing the broader health care landscape and making it become interactive will use the technology to the fullest extent of its potential and create new markets some of which will be driven by profit and many which will match need with ability to give. Imagine a local network that lets individual and organizations identify their needs and also what they can offer to others. An early version of just such a system existed in Spokane Washington a decade ago and made an impact on health status.
The fourth thing that will be needed is a vision of how a community and its health might be different. This vision does not need to be perfect at the outset, in fact it can’t be, because this is a complex undertaking and can’t fully be understood until it would be created in each distinctive community. What is needed is a place to begin, perhaps a snapshot of problems and challenges, resources that could be used and people that might be involved. The question should be “what sort of health and health care do we want in our community”? We know a great deal about how to structure such conversations and these will need to be convened in order to get real involvement by all in the community. Synthesizing and netting meaning out of these discussions will be a challenge, because direction will not emerge all at once. This will mean that each community that engages such an undertaking will need a convening institution or group or they will need to create one. There are many health care foundations and local community foundations that could take on such a responsibility. These convenings should not be hosted by any of the powerful incumbents. They need to participate and they can support, but they should not be the convener. The initial vision will really be a direction, coupled with some values and informed with a few aspirations. It should be thought of as a place to begin, not end.
Finally, efforts of these sorts fail when they do not translate into actions. There will be no one best first step, just as there cannot be a perfect vision. But the effort should identify a dozen or more projects to begin with. These might be a refined map of resources, an intervention to design a new care model for a critical population, richer public information systems, a leadership development program, public score cards on critical indices, a revitalization of school clinics, or the creation of a new educational program. The undertakings should be varied and rich.
We do not have any natural ways of thinking about the entire community when it comes to health and health care. Even public health has been segmented in its work over the past few decades. The health care reform provides and opportunity to think expansively and inclusively about what people need and what keeps them healthy. The real promise of this epochal change won’t be realized without such reflection and action.