By: Paul H. Dworkin, MD

Connecticut Children’s was proud to serve as the Presenting Sponsor for the first-ever D.C. Forum hosted by the Connecticut Health Council, which is an initiative of MetroHartford Alliance. The forum was designed to promote Connecticut as a center of excellence for collaboration and innovation with regards to population health.  Connecticut Children’s President and CEO James Shmerling, DHA, FACHE, delivered the forum’s opening remarks.  Paul Dworkin, MD, executive vice president for community child health at Connecticut Children’s, served as a panelist for a presentation by Meena Seshamani, MD, PhD, who is the director of the Office of Health Reform for the U.S. Department of Health and Human Services.  Ann Taylor, JD, executive vice president and chief administrative officer for Connecticut Children’s, also participated in the forum.  Here’s a look at Dr. Dworkin’s message to forum attendees:

Successful transformation of health services is critical to promoting optimal population health. Furthermore, the shift to such financing mechanisms as value-based purchasing incentivizes the development of programs and services to promote health and wellness.   Our experience within the Office for Community Child Health of Connecticut Children’s suggests that our State’s unique capacity for collaboration, innovation, and system building makes Connecticut an ideal driver of change deserving of private (and public) investment.   Promotion of children’s optimal healthy development has undeniably critical implications for workforce development and economic stability (e.g., as publicly embraced by Governor Peter Shumlin of Vermont) and, as proven by the research of Nobel laureate economist James Heckman, the return on such investments are unequalled across the lifespan.  However, the capacity to achieve short-term, scorable savings in child health expenditures is relatively modest compared to adult, and especially aged, populations.  As a result, such initiatives as those included within the Center for Medicare and Medicaid Innovation’s growing portfolio of payment and service delivery models that aim to achieve better care for patients, better health for our communities, and lower costs through improvement for our health care system are primarily focused on adult populations.  Numerous other examples illustrate the focus of the federal government on adult medicine.  Nonetheless, many innovations in the child health sector have direct applicability to adult health services and can serve as useful prototypes.

While child health innovations offer important implications for population health and child health services transformation, we should acknowledge certain structural differences between child and adult care systems.   For example, while health insurance coverage issues are of major relevance for health care transformation, they are less of an obstacle in the child health sector, since well over 90 percent of children have coverage via private insurance, Medicaid, or the Child Health Insurance Program.  In child health care, the far greater issue is access to specialty care, given the limited supply of pediatric specialists, the concentration of such specialists in major urban centers, and the curtailed availability imposed by some specialists in response to the inadequacies of public program reimbursement.  In contrast, adult specialists are, in general, in far greater supply and compete for publicly-funded (i.e., Medicare) patients.  As a result, the “solutions” are quite different, with a focus on expanding insurance coverage for adults, in comparison to expanding the capacity of the primary care medical home and facilitating referrals to specialists for children, especially those with chronic and complex medical conditions.  Furthermore, given the extraordinary influence of such non-medical determinants of health as social/environmental, genetic, and behavioral factors, health care transformation for children and adults alike must occur within the context of comprehensive system building promoting access to the wide array of critical community-based programs and services.

Notwithstanding these differences, the shared goal for health care transformation for both children and adults-the promotion of optimal health and development-demands the diffusion of evidence-based innovations that strengthen the capacity of the medical home, decrease the cost of specialty care, and enhance access to community-based programs and services, all in the context of comprehensive system building.  Our work with child health transformation in Connecticut speaks to our strong capacity to design, implement, and diffuse evidence-based innovations throughout the State and across the nation in the context of comprehensive system building and strong family and community engagement.  In fact, these efforts have resulted in considerable private investment in the form of grants and gifts, as well as other revenue streams and public support that promote sustainability.

The programs of Connecticut Children’s Office for Community Child Health exemplify Connecticut’s unique capacity to pilot and implement evidence-based population health innovations locally and statewide, as well as in other jurisdictions across the nation. Select examples include:

• Our Help Me Grow^® National Center, which provides technical assistance to a network of state affiliates around the country. In Connecticut, Help Me Grow^® is a program of the state’s Office of Early Childhood that promotes the early detection of young, vulnerable children at risk for adverse developmental and behavioral outcomes and “demedicalizes” such issues through the linkage of such children and their families to community-based programs and services through United Way of Connecticut’s Child Development Infoline;
• Educating Practices in the Community (EPIC), a program conducted in partnership with the Child Health and Development Institute of Connecticut that provides child health provider training on critical contemporary issues and strengthens practitioner performance through the process of practice-based “academic detailing;”
• Co-Management, which employs referral guidelines, management protocols, and facilitates access to specialist support to expand the capacity of the primary care medical home to manage a wider array of common conditions;
• the Care Coordination Collaborative model that improves collaboration among care coordinators from diverse sectors including child health, mental health, early care and education, and family support and is being disseminated across the State by the Department of Public Health;
• and Mid-Level Developmental Assessment, a new model for assessing children with mild or moderate developmental delays to determine which services would be most beneficial to them that is being spread under the auspices of the Office for Early Childhood.

The programs and services comprising such innovations are also instrumental in encouraging comprehensive system building and illustrate our capacity for collaboration, innovation, and “all sectors in” system design.  The latter is particularly important, given the impact of social determinants of health, behavior, and the environment in determining health outcomes.   For example, these innovations engage such diverse and important sectors as child health, early care and education, and family support, as well as child welfare, food & nutrition, housing, economic development, workforce development & employment, neighborhood health & safety, transportation, arts & culture, and faith-based initiatives.

Connecticut’s success in supporting innovation and system building to promote population health illustrates the benefits of embracing key policy concepts critical to achieving the outcomes we desire.   Examples of such key concepts include:

Promote the healthy development of the entire population

1. While a focus on individuals with the most complex conditions offers the greatest opportunity for short-term cost savings, address the needs of vulnerable individuals at-risk for adverse outcomes to maximize both impact and return on investment over the longer term.
2. Optimize access to and utilization of community-based programs and services that promote the health and safety of residents in a variety of settings.

Create integrated systems of care with strong linkages

1. Integrate support for families to ensure cross-sector coordination of health, education, human services, and other critical services.
2. Support community-based efforts to identify and address resident needs as early as possible and ensure that early detection leads to referral and linkage to services.
3. Connect community-based programs and services to each other to decrease duplication and streamline services for families.
4. Strengthen the interface between place-based initiatives and system building to achieve efficacy and enable economies of scale.

Make better use of existing resources

1. Strengthen the capacity of care coordination to access and synchronize existing services within and across sectors.
2. Strengthen the effectiveness of person-centered medical homes as health neighborhoods to enhance access to community-based programs and services.
3. Achieve cost efficiencies through the blending of administrative and financial resources of departments and agencies.
4. Employ such innovations as linkage to community-based programs and services to demonstrate real-time cost-effectiveness through “demedicalization.”
5. Encourage the Congressional Budget Office to extend the financial scoring of interventions from several to multiple years and even decades (“dynamic scoring”) to capture and value a long-term return on investment.

Build a strong evidence base and use data more effectively

1. Use data, both state and federal, to document gaps and capacity issues to inform advocacy and to emphasize the need to strengthen health and community services.
2. Demonstrate the efficacy of innovations through the use of both direct and indirect outcomes (i.e., mediating factors, proximate measures).
3. Embrace the evidence-based Strengthening Families Protective Factors Framework to inform design and evaluation in all programs, systems, and policy efforts.
4. Pursue opportunities to develop common indicators and data sets to share and integrate data.
5. Establish a comprehensive resources and referrals database to coordinate care, monitor outcomes, and evaluate cost savings.

Connecticut’s efforts are distinguished by going beyond the usual call for health care transformation’s triple aim to that of achieving population health and healthy development.  We believe that a focus on the former is too narrow and not an end in itself.  Rather, a focus on the longer-term, highly desirable, admittedly elusive outcomes of a healthy population and a broadly-defined return on investment stimulate true innovation worthy of private and public support.  We, in Connecticut, are embracing this approach.

Paul H. Dworkin, MD, is the executive vice president for community child health at Connecticut Children’s, the director of the Connecticut Children’s Office for Community Child Health and the founding director of the Help Me Grow^® National Center. Dr. Dworkin is also a professor of pediatrics at the UConn School of Medicine.  Learn more »

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