7

Reflections on the Day

In the final discussion, roundtable members and attendees reflected broadly on opportunities at the interface of health care and public health. Paul Mattessich of Wilder Health opened the discussion with his summary of what he heard as common themes throughout the presentations and discussions. Participants then discussed important takeaway messages from the workshop and considered future actions.

OVERVIEW OF COMMON THEMES

Mattessich highlighted 12 themes that he said emerged from the workshop discussions.

1. Collaboration is essential. The issues we are facing are complex, Mattessich said. Health is influenced not only by health care but also by environmental, social, political, economic, and other factors. A health-in-all-policies approach inherently requires collaboration, he continued. Health care and public health need to collaborate with each other and with other systems and departments (e.g., transportation, natural resources). Working in communities requires the involvement of different organizations that can help to bridge linguistic and cultural barriers. Collaborative action of organizations is also needed to ensure adequate and sustainable resources and funding.
2. There is success to build on. The workshops highlighted a variety of case examples of successful health care and public health collaborations. Mattessich observed that progress is being made not

2. only with service integration but also with payment approaches. Ongoing research is contributing to this progress and developing an evidence base.
3. Successful collaboration is being endorsed at the highest levels. The U.S. Department of Health and Human Services and others at the federal level, health care leaders, foundations, and academic leaders are endorsing collaboration between health care and public health, even if action and funding are lagging in some spheres, Mattessich said.
4. Leadership is a key element of successful collaborations. Across all of the examples, strong leadership was an essential element of success in collaboration. There is also empirical evidence of the critical role of leadership across partnerships (see Chapter 4).
5. Data and metrics are needed to assess impact. An often-raised challenge was the lack of data for strategic and operational planning for collaboration and for monitoring the success of collaborations. Existing data are often difficult to access or are not available at the appropriate level for analysis (e.g., data from electronic health record [EHR] systems, claims data). Some of the case examples demonstrated how the process of joint measurement has led to the building of relationships among collaborators. Community needs assessments can target the places where the need for services is the greatest, and then outcomes are monitored to determine whether the collaborative initiative is having an effect (e.g., reduced emergency department visits, hospital admissions, costs).
6. It is important to understand why collaborations fail. A challenge to moving forward is that failures are rarely reported, Mattessich said. Looking back at case studies over the past 30 years, it is very difficult to find failures in the literature, he said. To advance the field, it is important to study unsuccessful collaborations and discover why they fail.
7. Setting clear goals is essential. Many speakers stressed the importance of developing commonly accepted and understood goals to provide focus and orientation for the collaboration.
8. Do not just plan, implement. If we have a propensity to act, and not just to talk and plan, we will be more effective, Mattessich said. Nothing will ever be perfect; we have to move ahead when things are good enough. Focus on a smaller number of issues, build, and create momentum, and change will occur.
9. Understand the multiple layers. The examples discussed demonstrate that, to be effective, it is important to understand and involve various levels of management and operations within organizations and across systems. Mattessich cited the Boston Asthma Home Visit Collaborative as an example in which city-,

9. agency-, and community-level organizations were engaged in order for success to occur (see Chapter 5).
10. Innovation occurs naturally in unexpected and sometimes serendipitous ways. Once collaborations are under way, good ideas that would not have been thought of at the beginning often emerge, because people are creative and entrepreneurial, Mattessich observed. As examples, he recalled the availability of blood pressure cuffs for loan from libraries and protocols for screening and referral by barbershops as part of Million Hearts (see Chapter 3).
11. It is important to both build and build on relationships. Collaboration takes a lot of effort up front to engage and motivate extremely busy people and to explain how participating is in their interest. Developing the necessary relationships involves overcoming language and cultural issues across communities and disciplines. It was discussed that decisions and actions should be based on what patients and communities want, not what the collaborative thinks that they want. This effort requires interaction with the communities, professionals across disciplines, and other stakeholders. This could be more formal, such as community needs assessments or the result of ongoing informal conversations.
12. It is necessary to reach out to other systems. In order to create a culture of health, health care and public health need to collaborate not only with each other but also with other systems, such as schools, housing, employers, and others.

PARTICIPANT PERSPECTIVES

Moderator Mattessich asked roundtable members and participants to briefly suggest something they learned at the workshop that they would take back to their organizations, communities, professional groups, and so forth. The following topics were highlighted by individuals as takeaway messages.

Margaret Reid of the Boston Public Health Commission said that the payment issue is very complicated and observed that communities are at different places in their conversations about payment reform, with some more advanced than others. An Institute of Medicine staff member noted the synergy between the work of the Roundtable on Population Health Improvement and her work with a roundtable considering obesity solutions. Cathy Baase of The Dow Chemical Company made an observation about the rapid pace of change and the need to recognize that as we are moving forward, so are others. We need to keep reaching back out to people and expecting that things have changed, she said. A participant from

the Association of State and Territorial Health Officials (ASTHO) noted the need to revisit its list of partners and determine who is not part of the collaborative and how it might work with them. Another participant from ASTHO highlighted the value of the study by Prybil and colleagues (2014) in helping to measure the success of current collaboratives and identify potential failures and where quality can be improved. Several participants highlighted the importance of engaging people from other sectors in a meaningful way. They expressed hope that the successful examples discussed would lend credence to the collaborative approach, and some wanted to see more examples of successful collaborations that engaged other sectors. George Isham of HealthPartners mentioned that dentistry and oral health are among the sectors that are often omitted. Terry Allan of the Cuyahoga County Board of Health said some of the examples showed real change in the relationships and the level of engagement around the population health concept, which he felt was very motivating. George Flores from The California Endowment stressed that it is important, but not sufficient, to talk to or survey communities; they must also be involved in decision making. A participant suggested that the “certificate of need” process should be expanded in ways that bridge medical care and public health, and that federl agencies (e.g., Health Resources and Services Administration) could provide information about how they identify health care resource shortage areas.

CLOSING REMARKS

Getting healthy requires broad, multisectoral collaboration, said David Kindig of the University of Wisconsin School of Medicine and Public Health. He offered several thoughts for further consideration. What is the “glue” or resources that are needed to make collaboration happen? Does investment in this type of multisectoral collaboration provide a higher return than investment in other approaches to health and health care? Is there a need for more research, such as that described by Prybil and colleagues (2014), about who participates in the partnerships, how they are funded, which sector takes the lead, which is the anchor organization, and other questions?

A key question is where the money will come from for these collaboratives. Although there are examples of impressive and successful voluntary efforts, Kindig suggested that they are rare. This is too important to depend on informality and happenstance, he added. It is not clear where the responsibility for funding rests, and a variety of funding sources were mentioned during the workshop (e.g., community benefit dollars, Medicaid, foundations). Every community needs to identify some modest, sustainable resources to bring people to the table from across sectors, he concluded.