Rae Woods: From Advisory Board, we are bringing you a radio advisory. My name is Rachel Woods. You can call me Rae. COVID-19 forced stakeholders to actually work together in new and different ways. In the last year, we've seen better care coordination, more cooperation, and more efficient resource deployment than perhaps ever before. Rae Woods: This act of systemness was a long awaited, but honestly elusive goal for health care leaders. The question now is how do we keep those practices going and apply them to strategies beyond the crisis? To talk about how systemness is driving population health efforts, I've brought Dr. Alisahah Cole, the System Vice President of Population, Health, Innovation, and Policy at CommonSpirit. Rae Woods: Welcome to Radio Advisory, Alisahah. I feel like I've been seeing your voice and your name lots of places. But have you ever been on a podcast before? Alisahah Cole: I have actually been on a podcast before, so this is really exciting. Thank you for having me. Rae Woods: How many? I feel like I'm the 10th in the list at this point. Alisahah Cole: No. I think you're actually still in the top 10. Rae Woods: Okay. You are joining us from a unique organization, right? CommonSpirit Health is one of the largest not-for-profit health systems in the entire country. Level set with me for a minute. How big are we talking here? Alisahah Cole: Yes. Thank you, Rae. And being that it's still a fairly new organization, I still get the question a lot, where is that? Who are you? Just to level set, CommonSpirit Health is the strategic partnership of Dignity Health and Catholic Health Initiatives. And so with that combination, we are now actually in 21 states. We have over 137 hospitals. But we are a fully integrated care delivery system. So we have over 1,000 care sites in pretty much almost half the country. Rae Woods: And you mentioned that the partnership is new, but I also think your role is new, right? I think you're the first System VP of Population Health. And this role did come out of, like you said, a major merger. What has that been like? Alisahah Cole: Yeah, so I'm actually the first of many firsts. Because the Population Health Division was an intentional creation of the new organization. And so there are a couple of New System Vice Presidents. My role is over innovation and policy. But we have a whole entirely new division and it was an intentional and strategic decision to put this work at the corporate level. Rae Woods: Exactly. Because it sounds like to me that the result is more structure, right? A more formalized approach to population health and even broader health equity- Alisahah Cole: Yes. Rae Woods: ... than it sounds like either individual organization had before. I want to ask, would this have been possible without resources from both orgs? Alisahah Cole: So the great thing about both organizations is that they were already doing amazing work in this space, both from a population health and a health equity standpoint. But the combination did allow for this intentionality, for it to really become a root of our foundational operational structure. And really for us to move our new mission forward, which is to care for the vulnerable. And without having the additional resources that the organization was able to create by coming together, this wouldn't have been possible. Rae Woods: When it comes to population health, how would you describe the goal of CommonSpirit? And what makes the kind of strategy and operations of pop health different at CommonSpirit compared to what we see with other organizations? Alisahah Cole: Yeah. So I would say one of the biggest things that sets us apart is our scale. Rae Woods: Yeah. Alisahah Cole: And our size and our scope. And quite frankly, the diverse populations that we do serve. Rae Woods: In fact, it's probably the most diverse population that a health system serves. Alisahah Cole: Yes, since we serve everything from urban to big academic medical centers, to small, rural, critical access hospitals and everything in between, right? We have to take geography into account. We have to take a very diverse from a race, ethnicity, age, gender. I mean, every market for us is so different. And so how do you ... For us in population health, we really look at how do we standardize certain elements and how do we bring certain resources across the entire enterprise, but allow for that local market autonomy? Alisahah Cole: Because we really do truly believe that healthcare at the end of the day is local. Rae Woods: Yeah. Alisahah Cole: And so that's one of the goals that we have. We also are focused on really helping our organization move into more value-based care arrangements. And currently we have over 2.5 million lives that we serve that are in value-based contracts. Rae Woods: Yeah, you mentioned scale. And honestly, if I think about where we started, right, the size and scale of an organization like yours, I can honestly spin that as a positive or as a negative, right? Rae Woods: On the positive side, you now have this structure of a common mission and vision as it relates to population health and all of its manifestations. Whether we're talking about value-based payment, whether we're talking about health equity. Rae Woods: The downside, though, is size itself, right? Implementing any kind of common strategy is hard enough at one hospital, let alone at 137 hospitals and counting. Is that challenge something that you've experienced? Alisahah Cole: I would be lying if I said no. And I think all systems that are going through these mergers and strategic partnerships and combinations are experiencing the same thing. We refer to it as systemness. Rae Woods: Yeah. Alisahah Cole: How do you build in that systems thinking while at the same time, like I said, allowing for that local market autonomy? Rae Woods: You perked my ears because you said one of my favorite words. And anybody who's read anything that we've done at Advisory Board knows that there is a lot of focus on systemness. And I kind of think about that as an organization's ability to kind of overcome challenges and make progress because of its scale. Not in spite of it. Rae Woods: And people talk about systemness in a whole host of different ways, but in my mind, and I'm curious what you think about this, the ultimate execution of systemness is being able to inflect the outcomes of an entire population. And a population that quite literally is coast to coast. Do you agree with that kind of definition? Alisahah Cole: Yes, that is spot on. I couldn't have explained it better. Thank you for that. And we are really being thoughtful about how do we encourage systemness? How do we really embed that thinking? Because it is a different way to think for a lot of people. So how do we embed that thinking? Rae Woods: Yeah. It's not just an abstract concept, right? It requires a systemized approach- Alisahah Cole: It does. Rae Woods: ... to actually implementing systemness. If I can say two confusing words at the same time. From our perspective, one of the foundational elements of how you do systemness well, comes down to leadership and the kind of leadership structures themselves. How does the structure, when it comes to population health, work at CommonSpirit? How does it cascade across so many different areas? Alisahah Cole: Yes. We have a corporate kind of an enterprise level population health function. But we also have connections all the way down to every local markets. And so, one of the things that we realized as we were all coming together, and again brand new. And most of us knew from outside of either of the legacy organizations. Alisahah Cole: Making those connections and building those relationships with local leaders was critically important. And we wanted to make sure that we did that in a strategic way. And so, one of the frameworks that we set up was an establishment of different councils. Alisahah Cole: For example, I have a Vulnerable Population Council that I set up that is made up of a physician of a clinical and administrative leaders all across the entire spectrum of the organization. Rae Woods: Wow. Alisahah Cole: Corporate all the way down to local. And our focus is really about how do we take better care of our vulnerable populations? Whether that's from a policy issue, from a process issue, from a clinical care delivery issue. And so we meet on a monthly basis to really talk through the strategy around our vulnerable populations and the operations and execution. It's one thing to have the strategy, but you have to have that local market buy-in in order to execute. Rae Woods: And I imagine one of the big conversations at one of those council meetings has to be, how do we decide what to do next? Especially if you have representation from local leaders and the corporate office. And again, prioritizing is difficult at any institution, let alone one of this size. How do you actually surface kind of best practices from the local areas and decide which ones do we want to make consistent across our whole market? Alisahah Cole: Yes. So there's a couple of different ways. And again, this is one of those areas where I do think it's important for the local market leaders to be the ones helping to drive those conversations. Because often, or I would say what we've found, is that nine times out of 10, what one market may be dealing with is another market is also dealing with it, as well. Maybe just with some nuances, differences. Rae Woods: Even with all the diversity that you described. Alisahah Cole: Even with all the diversity. For example, right now, equitable COVID vaccine distribution. Rae Woods: Yup. Alisahah Cole: Is something that has been very consistent across every market. Now it may be for different reasons, right? In our rural markets, it's tending to be our elderly population that we're trying to make sure that they have access to getting the vaccine. In some of our urban markets, it may be some communities of color that we're really trying to encourage. And there may be other barriers, right? The barriers may be a little bit different, but the issue as has been consistent across all our markets. Rae Woods: Or maybe the process is consistent. Whereas the people that are identified as being maybe resistant to getting a vaccine or have legitimate hesitancy, like you described with communities of color. It's a matter of setting up a process that would identify those people. Even though it might be different organization to organization or area to area. Alisahah Cole: Well, yeah, the people, the process and even our own internal process. I think that's been one of the things, even when we have seen that, for example, in certain markets, communities of color aren't hesitant. They weren't hesitant. Rae Woods: Yeah. Alisahah Cole: It was just they couldn't get on to the website to go in and figure out how to sign up. Or they didn't actually have transportation to get to the mass community vaccination site. But really focusing on that work allowed us to figure out what really are the barriers in the markets that we have? Alisahah Cole: But what we agreed upon, as far as standardizing, was the data collection. For example, we're going to collect data around vaccine distribution in the same manner. We're going to stratify it by race, ethnicity, gender, and zip code. Looking at social vulnerability index and making sure that those community members were getting the vaccine as well. Alisahah Cole: That's just one example of where we at the kind of national population health level really helped out in regards to data and the standardization of the data. And then also the sharing the best practices. So when we ... For example, in our LA market, they held a mass community vaccination event with the NAACP in one of the historically black college and universities there. And that partnership really increased the number of community members of color who received the vaccine. We were able to share that across other markets to say, "Hey, have you reached out?" Rae Woods: Yeah, how did you share that? Because right, that best practice sharing is something that I think could be a massive benefit to an organization like this. If you can actually do it in a structured way. Alisahah Cole: Yes, yes. We have regularly scheduled meetings for our leadership that happen on a monthly basis. And one of the things that we also did was create a website. And so we have the CommonSpiritPopHealth.org website. Where it's open to the public to see some of the work that we're doing, but it also has a membership portion to that. Alisahah Cole: All of our providers, our leaders are able to sign in to that and then access toolkits and resources and data whenever they feel like it. Right? That's a 24-hour access to information. Because that was one of the things that we heard from our local markets. Was how do we learn about this and how do we do it in real time? So we may not necessarily have to wait until the next vulnerable population council meeting, for example. Rae Woods: Yes. Exactly. That way, I'm going to make up an example, but if a practice in the west coast is saying we're really struggling to re-engage our patients and get them to come back, they could go onto this website and find another practice that has figured out the marketing technique or whatever it is to get folks to reengage and say, "That's what I'm going to do next." Alisahah Cole: Yes, yes. And we even go so far to even offer if we've created certain patient materials, education materials, even marketing or collateral materials. All of that is located on that website. So people can access that and they don't have to spend time and energy recreating something. Rae Woods: You've used the word standardization a few times. And standardization is a necessary component of the systemness we're talking about. But I think there's also a fear that standardization can go too far. And you've even said that the normal variation that would happen at a local market is something that is not only necessary, but encouraged. How do you balance the need for standardization while also providing the variability that local markets might need and want? Alisahah Cole: Yeah. I think ultimately all of us who went into healthcare went into this industry because we want to help people get better and stay well. Right? And so, one of the things that we have found that's been really helpful is to always lead with kind of this patient first, community first mindset. And then really having conversations around what do we believe if we standardize X, Y, and Z? Will this drive improvement in health outcomes or our community outcomes, right? Alisahah Cole: And so by always kind of leading with that, that's been really helpful to frame conversations. But there are two areas that I would say we consistently continue to push around standardization and that's data. So the data integrity is so critically important. How do we collect data? How do we analyze it, et cetera? And then evidence-based clinical practices, right? And so we want to make sure that if we know there are best practices out there that are evidence-based that actually improve health outcomes, how do we make sure that those are being consistently applied across all of our care delivery sites? Because ultimately that's what we're here to do, right? Is make people better and keep people well. Rae Woods: Mm-hmm (affirmative). So said another way, there has to be a standard for standardization. And with the two examples you said in mind, that's a way to keep defending the standard approach, is actually the best approach for outcomes here for patients, for the community. Alisahah Cole: Yes. Yes. Rae Woods: I want to come back to this concept about prioritization. So you can prioritize efforts kind of at a national level, but you can also prioritize at a clinical level. And when I talk population health with a lot of organizations, they often tell me something like this. They say, "We have a couple of examples of where we do, say care management, really, really well. We do it really, really well in oncology or maybe even for just these clinical scenarios within oncology." Rae Woods: But their next question is how do we scale that across different clinical scenarios? Or how do we decide what's the next one that we need to expand to? How do you make that call and balance prioritization with pushing for more scale? Alisahah Cole: Yes, that's a great question. And I think it's one that we are actively still in the process of figuring out. But there are definitely some things that we have landed upon. The first thing I would say is that it is a multidisciplinary team that comes together to help make those decisions. And those decisions are being led by our clinicians. And so that's one of the key areas that has been wonderful to see. Alisahah Cole: And those goals are, once decided upon, they end up being board-level goals. So that's another thing when you think about accountability, you have to build that accountability framework into the work that you're doing, as well. But there are certain things, for example, we are looking at hypertension and diabetes. Because we know that those are two medical, chronic conditions that drive so many things, right? They drive poor health outcomes. They drive increased costs for both the patient and the community and also our health systems. Alisahah Cole: And so how do we really help support our community members who may have that diagnosis in keeping their blood pressure or their diabetes under control. And also how do we support others who don't have that diagnosis in keeping them well so they don't end up getting that. It's so many different layers to it. Alisahah Cole: One of the other things that we did was also establish a National Community Health Team. And so, I think that's another key, critical component because again, as we're speaking, we're moving toward value-based care. I think everyone in the country recognizes that. I hope no one still has their head in the sand. But if you're thinking about value-based care, we're really moving an industry from one that thinks about illness and disease, right, to one that really does have to focus on wellness and prevention. Alisahah Cole: And so having a really strong community health division or department to help you in that space, I think is also critically important. And that was one of the other corporate level functions that was established with the combination. Rae Woods: And by the way, I do think that most folks would agree with you and say that moving to alternative payment models, moving to more value-based care is something that is inevitable in the healthcare industry. But the reality that most leaders and most organizations, including CommonSpirit, have is a hybrid business model. Right? Alisahah Cole: Yes. Rae Woods: Then you have a lot of money tied up in value-based payments, but still in fee for service. I'm going to come back to prioritizing, scaling, making decisions on what to do next. How do you do that in a hybrid fee for service and value-based care business model? Alisahah Cole: Yeah. So the great thing about population health is that it actually works, whether you're in a fee for service model or a value-based care model. And that's really from a financial standpoint. One of the things that we've been really thoughtful about building those population health principles into our models. So it does make sense. Rae Woods: Give me an example of that from the fee for service perspective. I mean, I'm going to wear the hat of the naysayer that is, volumes have been depressed for the last 14 months, yet this is going to happen to me in the future. But I just need all my surgical beds full right now, because I need enough money to pay my doctors. Alisahah Cole: One of the great things that we have realized and that has actually been elevated during COVID, has been the need for patient navigation. Rae Woods: Yup. Alisahah Cole: And that's something that, from a population health standpoint, we have been supporting for many years. A lot of people are more familiar with that in the oncology space. But we were actually able to extend that to our maternal service and our orthopedic service. Alisahah Cole: To your question around, I need heads and beds. One of the things that we recognize with one of our virtual patient navigation tools was that we were able to decrease length of stay for our moms who delivered and for individuals who are coming in for elective hip and knees. And so, as we all know, if you're able to get the length of stay down, one, it's better. Especially as a lot of our hospitals from a joint perspective are in somewhat of a value-based model. But also, we're able to turn those beds over, right? So you have more availability for people who do need to come in or who do need to ... more people access, improving access to being able to have those, especially in our orthopedic space. Rae Woods: Or even getting people to come back to the same organization again and again. Right? I think that in the last episode we had with Ochsner Health, the CEO Warner Thomas rightfully pointed out that the healthcare industry is more fragmented than maybe ever before. Something like navigation is important for making sure that patient shows up for their second and third and so on dialysis appointment. But it's also important to make sure that young, commercial patient actually chooses your organization again and again. As opposed to CVS or the other health system down the street or the independent physician group or whoever. Right? Alisahah Cole: Right, right. And being able to provide the type of care that, that consumer, if you will, is interested in versus maybe a boomer who is like, "No, I want to go in and see my doctor face to face." Alisahah Cole: And so, one of the other things that we were able to support revving up from a pop health standpoint were the virtual visits. Right? And so that was something from an innovation standpoint we've been pushing for a while. And one of the things, the good things, if you will, that has come from COVID has been this ability to accelerate delivering care virtually. Rae Woods: Yep. Absolutely. Throughout our conversation, we've been talking about population health specifically. Which is a small slice of some bigger initiatives that I know that you and ultimately CommonSpirit are focusing on. Right? You mentioned value-based care as one of them. But there's also things like a larger social determinants of health strategy and ultimately a larger health equity strategy. How does the work you're doing in population health connect back to those larger initiatives? Alisahah Cole: Yeah. One of the reasons that I joined CommonSpirit Health was because of their commitment to equity and justice and this intentional thought process around how do we better care for our vulnerable populations? Alisahah Cole: And so as a practicing family medicine physician, that has been my whole career. I've worked in underserved areas, both rural and urban. And so that's what I have always felt called to do. And so coming to an organization that, one, has health equity built into its strategic priorities is just amazing. And part of that work is focusing on social determinants of health. In a couple of different areas, right? So the first one clinical, being a physician, I'll start there. How are we assessing our patients for social determinant of health? Rae Woods: Something that definitely requires a systemized approach. Alisahah Cole: Oh, my goodness. Yes. And then how are we making sure that if we are screening or assessing and something is positive ... Always, my physician colleagues are like, "Well, what do I do if it's positive?" We always want to be able to do something, right? Rae Woods: Yeah. Alisahah Cole: What resources do we have in place to be able to refer patients and make sure that the connections are made? And so, one of the things that our Community Health Division has really been strong is developing something called our Connected Community Network. Which really does do exactly what I said. If we're screening, something's positive, these networks are in the local communities. They're built upon the resources that are available in those communities. And so it's a way for me, as the physician or the clinician, to make that referral to a community based organization. And often hear back to say, "Oh, the patient was able to keep the referral," or, "They did go to the food bank and was able to receive food." Alisahah Cole: And then ultimately our goal would be, as we are continuing to assess and refer connect and hopefully improve on that social determinant, we also start to see changes in health outcomes. In that patient with diabetes, for example, if they're food insecure and we're able to get them food secure, do we see an improvement in their blood sugar control? Alisahah Cole: There's clinical, but then there's also ... And this is one of the things I really strongly encourage all hospitals and health systems to think about. There is also the role of us in communities as anchor institutions. Often we have been in those communities for many, many years. And not only do we have this healthcare delivery responsibility, we often tend to have an economic impact, right? We sometimes tend to be the largest employers in those areas. Rae Woods: And therefore the entity that is, I'm going to use the word responsible, for supporting the broader community. Whether we're talking about patients or not. Or whether we're talking about patients that are in your physician office or not. Alisahah Cole: Right. Right. And definitely for non-profits, we have been supporting the community through our community benefit work for forever, right? And then with the need to do community health needs assessments. We've been doing those for a couple of years now. And so we have that information, all that robust information from the community members themselves saying, "This is what we need help with." Alisahah Cole: So how do we as large, economic drivers, if you will, within local communities have more intentional partnerships with community organizations to really improve the social determinants that we're hearing from the community that they need help with? Or if we're doing the screening, we're able to look at that data, as well, and say, "Well, our patients in this market are really struggling with food insecurity or housing insecurity." How do we now take our economic framework or impact, if you will, and apply it directly to housing or apply it directly to food? And so that's work that we're also doing. Rae Woods: I want to take it to a broader equity framework for a moment. Your CEO, Lloyd Dean, has been pretty blunt here. Right? And actually expressed a goal of confronting racism in healthcare. What do you see as your department's role in combating the way that, that institutionalized racism manifests in health? Alisahah Cole: Yeah. So a couple of different things that we're working on in that space. One is just education and awareness, especially for our providers. Just recognizing the history of medicine and race in this country. I'm still amazed, but then I tell people all the time, I didn't get that training in medical school. Rae Woods: No. Alisahah Cole: I had to learn that myself or ... Fortunately I went to a residency program that was focused on urban underserved. And so my curriculum there really had a health equity foundation. But that's not a consistent or a standardized curriculum, if you will, in both undergrad or med school. I think there's that opportunity. And we're actually ... That's one of the things we're working on with our partnership with Morehouse School of Medicine, is culturally competent education. And how do we, again, inform our providers of the history, but then also what are some of the things that you can do differently when engaging with different community members that may not look like you? Rae Woods: Yeah. How does bias play out in the care delivery process? Alisahah Cole: Yes. Rae Woods: Right. It's something hugely important for caregivers and the clinical workforce to understand today. Alisahah Cole: Yes. And at the same time, how do we continue to increase the number of diverse care providers? Rae Woods: Absolutely. Alisahah Cole: And so that's the other part of our relationship with Morehouse, is creating these regional medical campuses so that we can continue to grow the number of underrepresented minorities in medicine. There's that work that's happening. And at the same time, there is the uncomfortable conversation that we sometimes have to have around there are people who experience care differently in the healthcare system at large, when they come through our care delivery walls, right? And sometimes that is based on how they look or where they come from. Alisahah Cole: And to your point, we have to recognize this unconscious bias that exists. But this is an area where I think standardization can be really helpful to help mitigate that. If we have- Rae Woods: Back to systemness. Alisahah Cole: Back to systemness. If we have standard evidence-based clinical protocols that say every patient, every time, that should help mitigate that. But one of the things that we have to do is then make sure from an accountability standpoint ... and this goes back to data. As you can see my two favorite things here. Make sure that those standards are being delivered consistently, right? Alisahah Cole: And so, I think there is clearly so much that we can do. And so excited to work for Lloyd who is just an amazing CEO. Who's really pushing us, right? Rae Woods: Yeah. Alisahah Cole: He's calling us out and he's pushing us in this space. Rae Woods: Well, I think CommonSpirit is definitely an organization to watch here. Before I let you go, I do want to ask you the final question that I ask all of my guests. Based on this conversation, is there one takeaway or one action item that you want our listeners to focus on? Alisahah Cole: Yes. So one of my favorite Edward Deming's quote, and many people listening will know him some as the father of quality improvement. He stated that every system is perfectly designed to get the results it gets. Every system is perfectly designed to get the results it gets. Alisahah Cole: We have, in this country, systems that were designed to perpetuate inequity. And I think we have to be really honest about that. We have a healthcare delivery system that's been built on treating illness and treating disease, right? And what we really need to do, we are at this moment in time where we have to redesign systems. Alisahah Cole: We can't keep leading in these broken systems. We really have to take an innovative, bold approach to redesign systems for equity. To redesign systems for justice. And ultimately, to move into systems that really do promote health and wellness. Not just for our patients, but for the larger community. That's my challenge. Let's stop leading in these broken systems and start really redesigning and recreating systems that ultimately improve the health for all of us. Rae Woods: I could not agree more. Thank you so much, Alisahah, for coming on Radio Advisory. Alisahah Cole: Thank you, Rae. Rae Woods: We'll be right back with what our research team is watching this week. Rae Woods: Of all the questions we're getting asked right now, the biggest one has to be when will this pandemic end? Well, we're starting to enter a phase in which pandemic progress is actually likely to stall. Just as Brandy and I predicted, we're starting to have more supply of doses than demand to get vaccinated. And while the U.S. has made clear progress, we are still nowhere near herd immunity. And across the world, vaccination challenges continue. Rae Woods: We think the next step is a hybrid approach. If we have any chance of getting to herd immunity, vaccine strategy is going to have to be hyper-local and more global than ever. That means leaders must focus their efforts in areas where people in their community are still resistant to vaccination. Especially in areas where demand is lacking, like in rural communities. And at the same time, we need to focus on where supply desperately lags behind demand. Which is across the world. Because unchecked global surges like the one we're seeing in India and emerging variants across multiple countries, will limit everyone's ability to reach herd immunity. So no matter where you're listening from, remember we are here to help.