Health Promotion

The National Impact of a Health System

By: Paul H. Dworkin, MD

At Connecticut Children’s, we have long appreciated the benefit of a health system extending beyond its geographic reach to make a national impact – in policy, system building and other areas. In our organization, we do this through Connecticut Children’s Office for Community Child Health (the Office), which offers programs and services in more than 30 states and advocates at the local, regional and national levels for child health services transformation.

We recognize the critical importance of studying best practices elsewhere. As we formed the Office, we learned about the important work of the Nemours Children’s Health System in advancing policy change around the country. Their approach had an indelible impact on the way we formed the Office and highlights the potential that health systems everywhere have to make a national impact through their work.

Pediatric Grand Rounds: Whole Child Health

To ensure we continue to learn from the best practice work at Nemours, I invited Daniella Gratale, the director of the Office of Child Health Policy and Advocacy, to present the annual pediatric grand rounds lecture named in my honor. Daniella oversees policy development and advocacy to advance Nemours’ federal agenda related to healthcare coverage, pediatric research, population health and other areas.

Her presentation, titled “The Provider Role in Promoting Whole Child Health,” covered Nemours’ work on the both local and national levels and highlighted best practices elsewhere. She focused on the imperative of providers addressing social risk factors in order to advance health outcomes and promote health equity. She also highlighted the need to address big picture community conditions such as raising the minimum wage and addressing poverty through changing laws and regulations.

Nemours’ National Impact

Specific to Nemours’ work on a national level, I had the privilege of participating in a convening organized by Nemours in collaboration with the Duke-Margolis Health Policy Center in late 2019. The purpose of the convening was to identify critical building blocks for transformative pediatric models that address social drivers of health and share best practices to inform future efforts. The publications that followed the convening have been instrumental in guiding the Office’s current efforts at the state and federal levels in advancing child health services transformation.

During her grand rounds presentation, Daniella detailed the building blocks identified through the convening, which included:

  • Multi-sector partnerships and alignment: To ensure financial sustainability, a best practice for consideration is a child health and wellness trust. In such trusts, partners collect and administer funding from different sources to invest in the common good for the community through work that is guided by the community. Such approaches provide opportunities for sustainable impact over time.
  • Data: Closed-loop referral systems are critical to providing data that documents the impact of cross-sector partnerships. Under such systems, providers refer children and families to helpful community-based services and those service providers circle back with providers to detail outcomes. While utilizing different closed-loop data systems can be burdensome for participants, North Carolina’s NCCare360 is particularly effective as a public-private partnership that allows electronic referrals through a common platform.
  • People: Having a workforce that reflects the community is important for transformative models that engage in place-based initiatives. Having the right types of positions in place, such as community health workers and social workers who can partner with patients to address their needs, is an important strategy. The Vital Village project in Boston is a good example of an initiative that is grounded in the community’s aspirations and elevates the voices of residents through community-driven solutions.
  • Payment: With a goal of paying for health, payment models should support transformative care delivery and enable the types of services that communities need. Over time, we should strive for sustainable, multi-payer financial models with aligned incentives and aligned outcomes. Successful examples include Massachusetts, which is testing social risk adjustment, and Arizona, which requires managed care organizations to reinvest profits into the community.
  • Policy: Policy change can be an enabler of all of these building blocks. New York and Oregon offer particularly strong examples of effective policy change that leverages federal funding streams layered with state legislation. New York’s First 1000 Days on Medicaid initiative and Oregon’s Coordinated Care Organizations both include contracting requirements for managed care organizations that address social drivers of health.

Nemours’ Impact in Delaware

Daniella also detailed how Nemours is leveraging the above-identified building blocks with state-level initiatives in Delaware, noting that small states can be great labs for testing new strategies. She offered the following examples:

  • Multi-sector partnerships and alignment: Nemours launched a pediatric-only clinically integrated network in Delaware in 2019, similar to one offered by Connecticut Children’s, to help create sustainable partnerships among pediatric providers across the state. Similar to Connecticut Children’s, the Nemours clinically integrated network offers its members access to different clinical pathways, care coordination services and case management services. It also negotiates contracts on behalf of members that move toward improving quality and enhancing value.
  • Data: Nemours offers a social needs screening tool to patients and has consistently found food insecurity and reliable internet access to be top needs over the past year. They are looking to better understand and utilize the data to inform future interventions for families.
  • People: Nemours employs care coordinators and community health workers to ensure the proper workforce is in place to address needs identified through screening tools, utilizing the EPIC Healthy Planet module to collect social data and the 211 system for referrals to community services.
  • Payment: Nemours is working to implement value-based contracts with Medicaid and commercial payers. One of their contracts offers incentives to providers for closing racial and ethnic disparities in key areas such as well child visits, immunizations and lead screenings.

Listen to the January 4, 2022 Pediatric Grand Rounds session featuring Daniella Gratale.

Lessons Learned for Connecticut

Following her lecture, Daniella met with several groups to expand on different aspects of her presentation. Conversations with our Office program leaders, the leadership of our clinically integrated network, and government relations reinforced our strong opportunity to share the key concepts that she clearly espoused with Connecticut state leaders, payers and advocates.

The day’s discussions emphasized how Connecticut’s State Innovation Model, led by the Office of Health Strategy, affords an opportunity to strengthen the evolution of person-centered medical homes and the design of health enhancement communities; encouraged the advancement of value-based payment models that could support interventions aimed at addressing social drivers of health; and encouraged advocacy in support of a child health services transformation first initiative. Daniella’s visit encourages us to continue to engage partners such as the Nemours Children’s Health System to exchange thoughts and best practices and advance our shared agenda. 

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

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