Guest Commentary: April is National Child Abuse Prevention Month

Ruth S. Gubernick, MPH

In 2009, approximately 3.3 million child abuse reports and allegations were made involving an estimated 6 million children. More than five children die every day as a result of child abuse and approximately 80% of those children that die from abuse are under the age of 4 (Source: http://www.childhelp.org/pages/statistics/).

April is National Child Abuse Prevention Month. The Blue Ribbon Campaign and Prevent Child Abuse America (PCAA)’s Pinwheels for Prevention® campaign have shifted to positive messages of supporting families and strengthening communities to prevent child abuse and neglect. But while blue ribbons and pinwheels may raise awareness, there is little evidence to suggest that health promotion alone can change behavior! As a QI Advisor, I facilitated pediatric primary care teams in implementing Practicing Safety, a child abuse and neglect prevention intervention (http://www2.aap.org/qualityimprovement/quiin/PracticingSafety.html ). We identified key strategies to help pediatricians intervene with families at risk of abuse and neglect. This work was supported by a grant from the Doris Duke Foundation to the American Academy of Pediatrics and our research identified strategies that practice teams could successfully implement. The practices we worked with as a result of Practicing Safety would:

• Discuss crying with all new parents, not just those with expressed concerns. Help parents be aware of their baby’s temperament. Teach new parents how to swaddle their infant.
• Screen all new moms for post-partum depression using a standardized screening tool, such as the Edinburgh, and conduct follow-up for moms found to be at risk.
• Encourage parents to read to their baby. Practice enrollment in the Read Out And Read (ROAR) program provides free books in multiple languages and appropriate age levels that can be given to families.
• Talk about child development at each well-child visit, starting at 6 months, to help parents understand each stage of their child’s development. This can help parents keep their perspective as their child goes through developmental changes. Discuss establishing routines, modeling behaviors and that discipline equals teaching, not punishment.
• Provide stickers and potty charts for parents who are toilet-training their toddlers, making it a more positive and rewarding experience. Personal Note: My adult daughter was toilet trained that way and she still uses a chart and star stickers to achieve a personal goal!

When working with primary care practices I often start a learning session on the topic of abuse and neglect by describing a story about villagers who spend much time and resources rescuing babies that have fallen into the river as they flowed down to their village. Then one day a villager traveled upstream and figured out how to prevent the babies from falling into the river. I encourage us all to go “upstream” and test and implement strategies that focus on prevention! By ensuring that parents have the knowledge, skills, and resources they need to care for their children, we can help promote children’s social and emotional well-being and prevent child maltreatment within families and communities.

Ruth Gubernick is a JSPH doctoral student.

TechSolve in Cincinnati, OHIO

This past week I had the distinct pleasure, and honor, of speaking at the TechSolve series of health policy events, at their headquarters just outside of Cincinnati, Ohio. TechSolve is a 25-year-old, not for profit, consulting company that specializes in process improvement in healthcare. According to their own materials, "TechSolve collaborates with healthcare organizations to implement business improvement solutions. These solutions reduce process variation and eliminate wasteful activities - leading to increased capacity throughout and improved patient care and satisfaction"... All music to my ears!! I spoke for four hours about the history of the quality and safety movement in our country and its direct connection to health reform under the ACA. TechSolve brought together many of its key customers and we had an awesome interactive session. They also purchased scores of copies of DEMAND BETTER and I stayed to autograph every copy. TechSolve is a gem...and I am hoping that our school will be further engaged with their ongoing work. I am also convinced that some junior staff at TechSolve will want to join us in our growing on line Masters Degree in Healthcare Quality and Safety. It's a great potential partnership for sure. Stay tuned for more news about the good work of our colleagues at TechSolve and visit them at www.techsolve.org. DAVID NASH

Guest Commentary: Connecting to a sense of purpose in Washington

Pavan Ganapathiraju

When I first joined the one-year accelerated Master of Public Health program at Jefferson, I walked in with a variety of interests. Most students you ask about me will say emergency preparedness. However, I have always been interested in health policy.

After enrolling in PBH 509: Public Health Policy and Advocacy, our class was notified of the Annual Health Education Advocacy Summit sponsored by the Coalition of National Health Education Organizations and Partner Organizations that was held in Washington, DC. The agenda for the summit included training on advocacy, discussing priority public health issues, and meeting with Congressional representatives to lobby/advocate for such issues. After hearing about it, I knew I had to take advantage of this experience; it would be a great opportunity to develop new skill sets in advocating and networking.

When I returned from the conference, I was beyond happy. Not only did I get to see the Capitol of our great country for the first time, but I had the pleasure of talking to the offices of senators and representatives from my home state of Illinois. I was skeptical at first, as were most people. As my fellow classmate Alexander Yang , who also went to the summit, said, “We have this assumption that Congressmen are these invisible people you see once in a while on television, but they actually are human.”

Alex’s cynicism is actually very true. When you walk into a legislative office and tell them you are a constituent from their district that gives you the power above them. They are actually very willing to listen to you about issues. This experience proved to me that the system works; our congressmen do listen to our concerns.

Overall, I had a surreal experience being on Capitol Hill and advocating for something I believe in. This experience was very rewarding and I felt like I had a sense of purpose. In my future career, I hope to do some more lobbying/advocating.

Any public health student at Jefferson needs to take advantage of this opportunity when it arises again.

Pavan Ganapathiraju is a student in the Master of Public Health Program at the Jefferson School of Population Health.

Guest Commentary: A Different Perspective on Patient-Centeredness

Stephen Wilkins, MPH

Running concurrently with the recent Population Health & Care Coordination Colloquium in Philadelphia was the Fourth National Medical Home Summit, at which I was privileged to speak. Patrick Monaghan of the Jefferson School of Population Health noted in his recent post that “patient-centered care appears to finally be at the heart of the way healthcare is delivered in this country. And if it’s not, it’s certainly on the way.”

Now you would think that at a conference on the Medical Home, the care delivery model for value-based care and all things patient-centered, the topic of patient-centered care would be a topic of discussion….but you would be wrong. In fact, I was one of the few speakers that substantively addressed the challenges associated with the concept of “patient-centeredness.”

To be sure, patient-centeredness has arrived at the health care policy level. Health care markets too have discovered the benefits of being patient-centered. Like patient empowerment and patient engagement, the term patient-centered is ubiquitous in both the health care and popular media. The one place you apparently do not find things patient-centered discussed is at conferences dealing with Patient-Centered Medical Homes.

Of course there were presentations about EMRs, embedded care coordinators, population health management, and patient advisory committees. Yes, these are all prerequisites for PCMH certification– but there is nothing inherently patient-centered about any of these things. What was missing at the Summit, and from the current discourse about Medical Homes, is any meaningful discussion of what the providers of care (or the sponsors of PCMH pilots) are doing to engender a patient-centered orientation into the way they communicate with and care for patients.

Perhaps the biggest disconnect between the reality and the promise of patient-centeredness is found in the way physicians communicate with patients. As defined in Crossing the Quality Chasm, patient-centered care begins with the provider understanding the patient’s perspective, e.g., their fears, concerns, expectations, and previous health experiences.

However, many primary care physicians, including those practicing in Medical Homes, still communicate with patients using the same physician-directed style they were taught in medical school. Like the medical interview itself, a physician-directed style of patient communication does not allow much time for the patient’s story or for that matter identifying all the reasons why the patient wants to consult with their doctor. As a result, the patient is the subject of the medical exam…not an active participant.

Patient-centered communication has been the subject of research going back 30 years, including detailed descriptions of effective patient-centered communication techniques. The use of patient-centered communication is directly correlated with improved outcomes, quality, and patient satisfaction. When employed consistently over time, it probably even saves time. Yet the use of patient-centered communication in the Medical Home is not a priority for providers or accreditation agencies.

To bridge this disconnect and eventually realize the promise of patient-centered care, professionals in both the Medical Home and Population Health arenas need to focus more on the true meaning of patient-centeredness and how to integrate the philosophy of patient-centered care and the commensurate communications skills into everything we do.

Stephen Wilkins is the CEO/Founder of Smart Health Messaging, a communication firm committed to improving the quality of physician-patient communication. He is also the author Mind the Gap, a blog dedicated to the same subject. Mr. Wilkins was a contributor to Disease Management and Wellness in the Post-Reform Era, (Chapter 3 - Disease Management & the Medical Home) published in 2011.

Guest Commentary: Advocating on Capitol Hill

Jeffrey A. Nafash

Skepticism. Nervousness. Inferiority. These are all words that came to my mind when I prepared to venture to Washington, DC to advocate for an issue on Capitol Hill. Who am I? What do I know about issues? Why would my Senator or Representative want to hear what I have to say?

But, that is just it. I do have a voice. I do have an opinion. And, what I have to say matters.

During the weekend of March 9, I was fortunate enough to be an attendee at the Mid-East Regional Conference for the United Nations Association of the United States of America (UNA). UNA members from Pennsylvania and neighboring states came together and spent all weekend preparing for an advocacy visit on Capitol Hill and learning about the needed support for the United Nations. On Monday, teams of advocates marched to their Congressional representatives’ offices and made appeals for support of the United Nations.

The “ask” (what you are posing to your legislator to support) that we had on these particular Hill visits was for the United States Congress to have continued support for the United Nations and their efforts around the world, specifically to maintain funding for necessary programs, ratifying treaties, such as the Convention on the Law of the Sea. These are key issues that our leaders need to be made aware of!

As a Jefferson Master of Public Health Student, I was surprised at how well I was prepared to talk about Global Health issues as they pertain to the United Nations. Thanks to two classes I’m taking this semester – Public Health Policy and Advocacy, and Global Health – I knew the issues and felt prepared to share my stories. We live in a great nation, which has power on the international stage, and need to compel our leaders to ensure our stance in the future. For example, can you imagine a day where American support and funding to the United Nations is either shrunk or completely defunded? The implications would be dire; the United Nations is a great peacekeeping body on the Earth. The United States’ national security and influence in international issues would become a figment of the past.

To my classmates, friends, and the Jefferson community, I would suggest that you become an advocate. Whether you agree with my trip to Capitol Hill or not, pick what interests you and be a voice. Note that not all advocates are going to Capitol Hill and meeting with our Nation’s leaders. We live in a great city that is ripe with issues to be addressed by our local, city government, and at Jefferson we have the support and resources to make a difference.

Jeffrey A. Nafash is a student in the Master of Public Health Program at the Jefferson School of Population Health.

WHYY RADIO TIMES with Marty Moss-Coane

I’m very much looking forward to Wednesday, March 28th at 10am, when I will be a guest on the acclaimed NPR program Radio Times with Marty Moss-Coane. The show is timed to follow this week’s testimony in the US Supreme Court regarding the constitutionality of health reform (known as the Affordable Care Act), particularly the individual mandate to purchase health insurance. Joining me will be the constitutional scholar Professor Theodore Ruger from the University of Pennsylvania and one of the nation's top political reporters, Dick Polman.

Although I don’t have the expertise to comment as to the constitutionality of the individual mandate, without it we cannot cover an additional 32 million Americans who do not currently have health insurance – it is really that simple. Also, the conversation about the mandate just obfuscates the real issues – we need to rationalize the approach to medical care by paying for value, not volume, reduce medical error and coordinate care. Most importantly, we need to practice population health by engaging in more preventive care and create incentives to change unhealthy behaviors. It promises to be an interesting dialogue…I hope you will have an opportunity to listen, and perhaps call in to share your views.

DAVID NASH

Guest Commentary: Reflecting on The Twelfth Population Health and Care Coordination Colloquium

Paul Terry, PhD

There were two intrepid features of The Twelfth Population Health and Care Coordination Colloquium that I found refreshing. First, the notion that population health and care coordination leaders can leave their respective worlds to present each other with a cogent case for better integration certainly is timely.

As much as one presenter joked that an ACO is an HMO misspelled, I’d venture that most who chose this conference came with an abiding belief that improving population health while reforming health care delivery are overlapping, if not mutually dependent, movements that will require the kind of transformative leadership Dr. Nash brought to this discussion. The ACO movement may eventually be viewed as the turning point for collaboration between public health and medically trained leaders.

Second, I appreciate that this was a colloquium, Latin for discussion, not a conference. An open sharing of ideas will be required if we are to discern what components of an ACO can foster innovation and avoid ACOs becoming HMOs warmed over.

My presentation at the colloquium focused on the role of financial incentives and the policy issues emanating from section 2705 of the health reform act, which provides for medical premium reductions for employees attaining a health standard such as a healthy BMI. I’ve published elsewhere on “progress based incentives” which StayWell believes represent a fairer and more effective strategy for supporting behavior change than the outcomes-based approach enabled by this new legislation.

It was easy to exchange ideas about the best use of incentives for employer health management programs in my session because we had examples to work from provided in presentations earlier in the day. The medical director from Perdue Chicken disavowed use of incentives in his employee health programs and asserted that his 80% participation rates were a function of smiling nurses and a caring, high-touch approach. He acknowledged the chickens in their “disassembly plants” weren’t quite so lucky. In contrast, a human resources leader from ARAMARK food services described how incentives increased health assessment participation rates to 60% from 20%. Though she didn’t explain whether they based their communications on behavioral economics principles, their employee communications about the loss of premium credits for non-participants suggest they were playing to the principles of “a bird in the hand” and “loss aversion” that I explained in my session.

Finally, Johnson and Johnson, the “granddaddy” of wellness programs, showed how their $500 incentives were yielding consistent 80-85% participation in a range of wellness offerings, which was up from the 26% participation they experienced in the years prior to incentives. For a deeper dive into the science behind best practices in the use of incentives, StayWell has produced a white paper on “The Role of Incentives in Improving Engagement and Outcomes in Population Health Management.”

Each of these progressive company presenters had inspiring success stories to share backed up with impressive metrics. But what I found most attention-getting about these presentations was that they were featured as examples of employers building a “culture of health.” Yet, all of the metrics shared were traditional participation rates, biometric outcomes, or other measures related to individual choices.

We lack a common language for describing our workplace culture of health, not to mention tools for measuring the same. Therein resides a challenge for those of us ready to embrace Dr. Nash’s daunting idea that population health can intersect with care coordination. Culture is defined by how we communicate with each other, our daily rituals, foods we eat, how we treat each other, and what we value and believe in, just to name a few potential measures.

We’re getting increasingly sophisticated about designing individual-level incentives to increase engagement. And as the ACO movement foretells, we’ll continue innovating with pay-for-performance systems and cost-sharing schemes. Our greatest challenge yet will be to define a “culture of health,” invent metrics that quantify its progress, and create incentives that compel organizations to build environments that inspire and support healthy living.

Paul Terry, PhD, is CEO of StayWell Health Management.