Collective Health ReSET Jan.22.2014

2014 Collecuve PealLh LLC
Rick Brush | rick@collectivehealth.net | 860.712.2242

collectivehealth.net
Impact Thinking for
Better Health & Financial Outcomes

reSET Social Enterprise Trust Design Lab ! January 22, 2014

identify
1
invest
2
improve 3 return
4
Health
Impact
Bond
SM

Health-
impact
investing

2
3
What matters to health?
4
A
c
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e
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s

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o

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g
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-
q
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a
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y
,

a
f
f
o
r
d
a
b
l
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h
e
a
l
t
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c
a
r
e

physical health

mental health

Health Care
3
A
c
c
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s
s

t
o

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=

1
0
%

6
Living and
Working
Conditions

General Socioeconomic,
Cultural and
Environmental Conditions

Social and Community
Networks

work environment

safety

social cohesion

physical health

participation

medical home

education

policies

market dynamics

employment and
economic
opportunity

water, sanitation, air
quality

neighborhood design
and built environment

housing

mental health

transportation

food systems

Lifestyle Factors
Health Care
Genetics
Community Conditions
2013 Collective Health LLC
Community: a better investment in health

r
e
a
l
l
y

7
Living and
Working
Conditions

Cultural and

Networks

work environment

safety

social cohesion

physical health

participation

medical home

education

policies

market dynamics

employment and
economic
opportunity

quality

neighborhood design

housing

mental health

transportation

food systems

Lifestyle Factors
Health Care
Genetics

education
College graduates live 5 years
longer than those who dont
complete high school. If all
Americans had the same good
health as college grads, wed avoid
$1 trillion of costs annually.
(RWJF Commission to Build a Healthier America. Issue Brief 6:
Education and Health. Sept. 2009. Nat. Longitudinal Mortality
Study. 1988-1998.)
r
e
a
l
l
y

8
Living and
Working
Conditions

Cultural and

Networks

work environment

safety

social cohesion

physical health

participation

medical home

education

policies

market dynamics

employment and
economic
opportunity

quality

neighborhood design

housing

mental health

transportation

food systems

Lifestyle Factors
Health Care
Genetics

education
Study. 1988-1998.)
relationships
The inuence of relationships on
the risk of death are comparable
with well-established risk factors
such as smoking and alcohol
consumption, and exceed the
inuence of risk factors such as
physical inactivity and obesity.
(Holt-Lunstad, Smith, Layton. PLoS Med. 2010; 7[7].)
r
e
a
l
l
y

9
Living and
Working
Conditions

Cultural and

Networks

work environment

safety

social cohesion

physical health

participation

medical home

education

policies

market dynamics

employment and
economic
opportunity

quality

neighborhood design

housing

mental health

transportation

food systems

Lifestyle Factors
Health Care
Genetics

education
Study. 1988-1998.)
relationships
community
A $10 per person annual
investment in community-based
prevention over ve years could
produce 5% reductions in type 2
diabetes, high blood pressure,
heart and kidney disease, and
stroke with ROI of $5.60 for
every dollar invested.
healthyamericans.org/reports/prevention08/
r
e
a
l
l
y

10
Living and
Working
Conditions

Cultural and

Networks

work environment

safety

social cohesion

physical health

participation

medical home

education

policies

market dynamics

employment and
economic
opportunity

quality

neighborhood design

housing

mental health

transportation

food systems

Lifestyle Factors
Health Care
Genetics

community
A $10 per person annual
investment in community-based
prevention over ve years could
produce 5% reductions in type 2
diabetes, high blood pressure,
heart and kidney disease, and
stroke with ROI of $5.60 for
every dollar invested.
healthyamericans.org/reports/prevention08/
socioeconomics
housing
transportation
food access
sense of control
education
Study. 1988-1998.)
work environment
built environment
natural environment
public safety
economic development
relationships
child development
local jobs & training
active participation
health-in-all
policies
r
e
a
l
l
y

11
Health
Determinants
Health Context &
Behaviors
(90%)
Health Care
(10%)
S. A. Schroeder We Can uo 8euer - lmprovlng Lhe PealLh of Lhe Amerlcan eople,"
!"# %&'()&* +,-.&)( ,/ 0"*121&", 337 (2007): 1221-28.
What the return on $2.9 trillion?
12
Health
Determinants
Health
Spending
Health Context &
Behaviors
(90%)
Health Care
(10%)
Health Care
(97%)
(3%)
Prevention
!"# %&'()&* +,-.&)( ,/ 0"*121&", 337 (2007): 1221-28.
CenLers for Medlcare and Medlcald Servlces, nauonal PealLh LxpendlLures" 1able 1,
(WashlngLon, uC: CMS, Cmce of Lhe AcLuary, nauonal PealLh SLausucs Croup, 2012).
13
Health
Determinants
Health
Spending
Health Outcomes
(
"
better, # worse)
Health Context &
Behaviors
(90%)
Health Care
(10%)
Health Care
(97%)
(3%)
Prevention
" Late Stage Interventions
# Infant Mortality
# Life Expectancy at Birth
# Diabetes
# Obesity
# Heart Disease
# COPD
# Disability
!"# %&'()&* +,-.&)( ,/ 0"*121&", 337 (2007): 1221-28.
CenLers for Medlcare and Medlcald Servlces, nauonal PealLh LxpendlLures" 1able 1,
(WashlngLon, uC: CMS, Cmce of Lhe AcLuary, nauonal PealLh SLausucs Croup, 2012).
unlLed SLaLes compared Lo 16 "peer" counLrles, nauonal 8esearch Councll, uS
PealLh ln lnLernauonal erspecuve: ShorLer Llves, oorer PealLh" (WashlngLon, uC:
nauonal Academles ress, 2013).
14
$2.9 trillion
health illness costs
Focus on symptoms,
not causes
Pay for treatment,
not prevention
Operate in silos,
not integrated teams
Create
temporary xes,
not sustainable impact
What drives health care spending?
13
$2.9 trillion
health illness costs
Focus on symptoms,
not causes
Pay for treatment,
not prevention
Operate in silos,
not integrated teams
Create
temporary xes,
not sustainable impact
What drives health care spending?
$ $ $ $ $
greater need
a vicious cycle
16
How can we make a greater impact
(and investment!) in health?
a

v
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r
t
u
o
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s

c
y
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identify
1
invest
2
improve
3
return
4
Health
Impact
Bond
SM
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What initiatives
and service
providers are
evidence-based?
Can the savings
be validated,
shared and
reinvested?
What are the
causes of poor
health and
who is paying?
What is the
required
investment and
risk/return?
4
1 2
3
ongoing learning ! iterative/adaptive ! sustainable reinvestment
Health-impact investing:
how it works
Health-
impact
investing

1. Known causes of signicant and costly health issues that can be
prevented or improved
2. Evidence-based interventions and service providers with
demonstrated results
3. Net savings potential and method for measuring/validating
actual cost savings (e.g., RCT using insurance claims data)
4. Payers that agree to share/reinvest savings:
Government health plans & commercial insurers
Self-insured employers
Providers with aligned incentives (Accountable Care Organizations,
Patient-Centered Medical Homes, capitated)

5. ROI/IRR: acceptable investor risk-return and payback period
18
whats required
Preventable/manageable chronic disease (heart disease, asthma,
COPD, diabetes)
Superusers of emergency department/hospital readmissions
Mental illness (especially with comorbidity)
Addiction/recovery
Preventive oral health
Onsite/location-based clinics and telehealth
At-risk maternity/prenatal care, and early childhood development
19
potential applications
20
(with a few complicated charts)
21
Asthma in Fresno: A Crisis for Children and Community
20.2% children 5-17 diagnosed with asthma*
Every day, 20 go to the ER and 3 hospitalized for asthma
$34.8M per year for asthma-related ER and hospitalizations
* signicantly higher for some race/ethnicity and socioeconomic groups
22
Asthma: A Business Case for Prevention
Asthma Control: Home-Based Multi-Trigger, Multicomponent Environmental Interventions
Home-based multi-trigger, multicomponent interventions with an environmental focus for persons with asthma aim to reduce exposure to multiple indoor asthma triggers (allergens and irritants). These
interventions involve home visits by trained personnel to conduct two or more activities. The programs in this review conducted environmental activities that included:
Assessment of the home environment
Changing the indoor home environment to reduce exposure to asthma triggers
Education about the home environment
Most programs also included one or more of the following additional non- environmental activities
Training and education to improve asthma self-management
General asthma education
Social services and support
Coordinated care for the asthma client
Summary of Task Force Recommendations & Findings
The Community Preventive Services Task Force (/about/task-force-members.html) recommends (/about/methods.html#categories) the use of home-based multi-trigger, multicomponent interventions with an
environmental focus for children and adolescents with asthma based on evidence of effectiveness in improving overall quality of life and productivity, specifically:
Improving asthma symptoms
Reducing the number of school days missed due to asthma
The Task Force (/about/task-force-members.html) finds insufficient evidence (../about/methods.html#categories) to determine the effectiveness of home-based multi-trigger, multicomponent interventions with an
environmental focus for adults with asthma based on the small number of studies identified and the mixed results across the outcomes of interest.
Task Force Finding & Rationale Statement for review of interventions for children and adolescents (rrchildren.html)
Task Force Finding & Rationale Statement for review of interventions for adults (rradults.html)
Economic Review
The Task Force finds that home-based multi-trigger, multicomponent interventions with a combination of minor or moderate environmental remediation with an educational component (rrchildren.html#range)
provide good value for the money invested based on:
Improvement in symptom free days
Savings from averted costs of asthma care and improvement in productivity
Results from the Systematic Reviews
Twenty-three studies qualified for the effectiveness review.
Children and Adolescents:
Asthma symptom days: median decrease of 21 days per year (6 studies)
School days missed: median decrease of 12 days per year (5 studies)
Acute healthcare visits: combined median decrease of 0.57 visits per year (10 studies)
Hospitalizations: median decrease of 0.4 hospitalizations per year
Emergency department visits: median decrease of 0.2 visits per year
Unscheduled office visits: median decrease of 0.5 visits per year
Pulmonary function: overall, no significant improvement (7 studies)
Adults:
Three intervention studies reported one or more outcome measurements in adults. Although two studies observed improvements in quality of life or symptom scores, the results for health care utilization, and
productivity outcomes showed borderline or no improvement. No studies in adults reported any physiologic outcomes.
Applicability
The reviewed multi-trigger multicomponent intervention studies were conducted:
Mostly in the homes of US urban minority children
By a wide range of organizations including:
State and local health departments
Health care systems
Community organizations
By a wide range of trained personnel including:
Community health workers (most common)
Nurses
Respiratory therapists
AsLhma ConLrol: Pome-8ased Mulu-1rlgger,
MulucomponenL LnvlronmenLal lnLervenuons
"#$%$&'# ()*')+
CosL-beneL sLudles show ,)-.,% $/ 0123 -$ 04526 for each $1 lnvesLed.
www.LhecommunlLygulde.org/asLhma/mulucomponenL.hLml
++
Pediatrics Pediatrics
pediatrics.aappublications.org
Published online Published online February 20, 2012 February 20, 2012
Pediatrics Vol. 129 No. 3 March 1, 2012 March 1, 2012
pp. 465 pp. 465 -472 -472
(doi: 10.1542/peds.2010-3472)
Article
Community Asthma Initiative: Evaluation
of a Quality Improvement Program for
Comprehensive Asthma Care
Elizabeth R. Woods Elizabeth R. Woods, MD , MD, MPH , MPH
a
, , Urmi Bhaumik Urmi Bhaumik, MBBS , MBBS, MS , MS, DSc , DSc
b
,,
Susan J. Sommer Susan J. Sommer, MSN , MSN, RNC , RNC, AE-C , AE-C
a
, , Sonja I. Ziniel Sonja I. Ziniel, PhD , PhD
c
,,
Alaina J. Kessler Alaina J. Kessler, BS , BS
a
, , Elaine Chan Elaine Chan, BA , BA
a
, , Ronald B. Wilkinson Ronald B. Wilkinson, MA , MA,,
MS MS
d
, , Maria N. Sesma Maria N. Sesma, BS , BS
e
, , Amy B. Burack Amy B. Burack, RN , RN, MA , MA, AE-C , AE-C
b
,,
Elizabeth M. Klements Elizabeth M. Klements, MS , MS, PNP-BC , PNP-BC, AE-C , AE-C
f
, , Lisa M. Queenin Lisa M. Queenin, BA , BA
b
,,
g
,,
Deborah U. Dickerson Deborah U. Dickerson, BA , BA
b
, and , and Shari Nethersole Shari Nethersole, MD , MD
b
,,
h
Author Affiliations
ABSTRACT
OBJECTIVES: OBJECTIVES: The objective of this study was to assess the cost-effectiveness
of a quality improvement (QI) program in reducing asthma emergency
department (ED) visits, hospitalizations, limitation of physical activity, patient
missed school, and parent missed work.
METHODS: METHODS: Urban, low-income patients with asthma from 4 zip codes were
identified through logs of ED visits or hospitalizations, and offered enhanced
care including nurse case management and home visits. QI evaluation focused
on parent-completed interviews at enrollment, and at 6- and 12-month
contacts. Hospital administrative data were used to assess ED visits and
hospitalizations at enrollment, and 1 and 2 years after enrollment. Hospital
costs of the program were compared with the hospital costs of a neighboring
community with similar demographics.
RESULTS: RESULTS: The program provided services to 283 children. Participants were
55.1% male; 39.6% African American, 52.3% Latino; 72.7% had Medicaid; 70.8%
had a household income <$25000. Twelve-month data show a significant
decrease in any ("1) asthma ED visits (68.0%) and hospitalizations (84.8%),
and any days of limitation of physical activity (42.6%), patient missed school
(41.0%), and parent missed work (49.7%) (all P < .0001). Patients with greatest
functional impairment from ED visits, limitation of activity, and missed school
were more likely to have any nurse home visit and greater number of home
visits. There was a significant reduction in hospital costs compared with the
comparison community (P < .0001), and a return on investment of 1.46.
CONCLUSIONS: CONCLUSIONS: The program showed improved health outcomes and cost-
effectiveness and generated information to guide advocacy efforts to finance
comprehensive asthma care.
KEY WORDS KEY WORDS
asthma cost analysis community health worker
emergency department visits health disparities health outcomes
hospitalizations nurse case management pediatrics
return on investment
Abbreviations:
AAP
Asthma Action Plan
CAI
Community Asthma Initiative
CHW
Community Health Worker
hup://pedlaLrlcs.aappubllcauons.org/conLenL/129/3/463.absLracL
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23
Asthma Impact Model for Fresno (AIM4Fresno)
identify
1
Value: reduce ER 30% & inpatient 50%

Potential: 16,000 children with poorly
controlled asthma covered by Medi-Cal

Target top 10%: $8 million net savings
24
identify
1


Value of reducing emergency room (ER) by 30%
and inpatient hospital by 50%
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$16.0
2012 2013 2014 2015 2016
Medical Costs (millions)
Post-intervention
P
re-intervention
Savings
3*4 3*45(6 3*4 7*/4

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Figure 4. Preventing asthma: projected savings.
Potential: 16,000 children (3-19) covered by Medi-Cal had an
ER or urgent care visit for asthma in past 12 months

Target top 10%: 1,600 x $5,000 = $8 million net savings
)
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23
invest
Phase 1: 200 children
" current demonstration
project is grant-funded
Phase II: scale-up TBD
" health-impact investment
2


identify
1
26
improve 3


invest
2
identify
1
27
return 4
Validation: third-party
health insurance actuary
" actual savings achieved
ro[ecL lead & evaluauon:
8C1 uslng lnsurance
clalms daLa
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2012 2013 2014 2015 2016
Post-intervention
Pre-intervention
Savings
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improve 3
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Validation: third-party
health insurance actuary
" actual savings achieved
ro[ecL lead & evaluauon:
8C1 uslng lnsurance
clalms daLa
! #$%& '())*+,-* .*/)01 22'
$0
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2012 2013 2014 2015 2016
Post-intervention
Pre-intervention
Savings
3*4 3*45(6 3*4 7*/4

!"#$%#&'( *&+ ,-./01*2 3-.1.
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return 4 improve 3
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29
30
Health-impact investing
at the community-level
Five places. Five metrics. Five years.
Population 100,000
Invest in system-wide efforts to
generate sustainable health and
nancial impact
More to be announced
HICCup.co
31
32
What are the opportunities for impact
thinking & investing in Connecticut?
33
('#I J,.7<
rick@collectivehealth.net | 860.712.2242
Web: collectivehealth.net
1wluer: @collectivehlth

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Rick Brush | rick@collectivehealth.net | 860.712.2242

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