What We Can Do Locally — Ideas From the SSU Initiative Conferences

Note: Gathered and developed by Skip Robinson Ph.D., given serious editing and sequencing attention by Adele Amodeo MPH, edited, added to, and critiqued by Georgia Berland M.A., Tom Moore, and Carolyn Epple Ph.D.

I. COORDINATE PRIMARY AND SECONDARY PREVENTION AND COALITION-BUILDING

A    Integrate and broaden public health efforts in coordination among health plans and private provider institutions, including nonprofit hospitals with community benefit obligations — such efforts to include primary and secondary prevention, health education, health

"Coordinate [more] among health care and social service and housing providers to integrate health and social services and case management, and to identify and fill gaps in health care access for the uninsured. This would include Sonoma County projects such as Frequent Users of Health Services Initiative (FUHSI), Health Care for the Homeless clinic development, and possibly the Social Security Benefits Assistance Project (if it is funded) among others." Georgia Berland

B    Plan and operate a collaborative — multi-institution "full court press" with prevention/early intervention/health education/health promotion on [at least] three highest cost primary chronic conditions (including in their case management and cost management), such as coronary, respiratory problems, and diabetes by community public health departments and agencies, employers, health plans, community health groups, media, schools, churches/synagogues/ mosques/meditation halls working together to foster shared priorities.

C    Significantly expand community/stakeholder/academic dialogue to increase coalition-building. [Consider funding year-long or multi-year educational and developmental programs.]

D    Do collaborative community-wide studies: What components of a community tend to make the community especially healthy/unhealthy? Practically, what can the community and its systems do to promote and improve community health?

"Such a study and a related community action project (identifying many such components and selecting water issues as [one] first action priority is underway by the Center for Social Change of the Sisters of St. Joseph; and considerable prior work on identifying such components was done by Memorial Hospital's Community Benefit Division, building on the Healthy Communities movement nationwide." Georgia Berland

E    (Question: How is public health and health care changed in an age of Jihad, 5 point hurricanes, 8 point earthquakes, and self-destructive governments?)

F    Foster community-wide study among campus, community, media, and public schools about food grown and food served.

"The issue of food grown and served in schools is being addressed through various programs of UC Cooperative Extension at the County, as well as in the Master Gardeners' program. Also, the Quantum Agriculture Project circulates information on more holistic approaches to agriculture. Certainly discussions of the effects of budget cuts are and should be taking place everywhere, and coordinating responses and advocacy is always a good idea. The new North Bay Spokescouncil is a group [beginning to try] to coordinate such efforts across disciplines." Georgia Berland

G    Include study of effects on health and mental accuity of the severe cuts in school PE, cuts in community facilities, cuts in county public health department programs, cuts in community health group funding, cuts in other critical community resources.

H    Develop budget models to show possible designs and costs.

I    Support Sonoma County's exciting "model" children's health project coalition.

II INTEGRATE AND STUDY QUANTITATIVE FACTORS

A    Include significant independent actuarial review of health plan renewal pricing and offers. Integrate this into employer and multi-employer negotiation with health plans.

B    Employ sophisticated "utilization analysis" to understand patterns of care and find most-needed changes in local approaches. Use "small area analysis".] Analyze "ambulatory-care-sensitive" hospital discharge data.

C    Collaboratively study, upgrade, and institute systems to prevent unnecessary hospitalizations, including thorough review of emergency room procedures/issues/plans, according to recent research findings.

D    Implement "adjusted risk-sharing across 'total' populations" to assist in modest moderating the volatility of risk "unknowns."

E    Explore government-subsidized re-insurance programs as one way to assist in bringing high-risk populations more safely into group or county insurance "pools" and in developing an adequate full-inclusion equation.

F    Explore "direct contracting".

G    Explore a variety of administrative cost savings, including more standardized insurance protocols to prevent unnecessary health service delays and simplify providers' "back office".

H    Better quantify the costs and methods for completing health care "access". Develop a draft master equation given x and y designs. Take action.

I    Consider methods for "more equitable adjustment" of care reimbursement rates, especially "costs" reimbursed/paid to hospitals, doctors, and other health professionals who require reimbursement for services performed (for example, reimbursement rates from health plans to small hospitals and doctor reimbursement rates for "public" patients). [Continue to push for more urban rather than rural Medicare, etc. reimbursement rates.

J    "Consider changing hospital fee-for-service funding to 'budgeted system' in which payers pay same amount for same service."

K    In public schools and non-profits, explore dropping use of "TSA in lieu of medical" and other cash versus medical options so as to optimize the risk pool.

III DEAL WITH PRESCRIPTION DRUG EXCESS COSTS

A    Investigate programs for significant prescription drug cost reductions/ discounts, including possible "re-importation" of prescription drugs from Canada, et al. Study currently operating models in such states as New Hampshire, Minnesota, Wisconsin, and Massachusetts, and in their cities, such as Springfield. Continue to explore "piggy-backing" on Federal group discounts. Analyze emerging data on other means of significantly reducing prescription drug program costs.

IV EXPLORE RE-DESIGNING HEALTH PLANS, HEALTH SYSTEMS, OPERATIONS DESIGNS

A    Improve coordination/management of chronic care "high utilizers". (Rule of thumb: 10-20 percent of health plan participants are responsible for 80-90 percent of health care costs. How can we change this locally?)

"The FUSHI project has been studying this issue for Sutter and Memorial for a year now. The very broad-based collaborative they developed has collected lots of excellent data, and their proposal for implementing response for this population — integrated case management across health and social services along with special training for clinicians and social service staff — is now being submitted." Georgia Berland

B    Institute and upgrade systems to prevent medical errors.

C    Consider implementation of "Point of Service" design (in general or in such special applications as for covered outpatient mental health services).

D    Explore expanded utilization of the "staff model" Health Maintenance Organization (such as Kaiser plus an IPA HMO).

E    Together, consider development together of a county-wide health care district, including potential for more rational regional planning.

F    Consider wider development of multi-employer and multi-sector health plans.

G    Plan, negotiate, and implement more sophisticated information technology systems both within institutions and across/between them.

H    Consider expanding use of "national model" County programs to treat such Sonoma County-sensitive problems as those with HIV-AIDS and the aged.

Example: "Sonoma County has a very focused HIV prevention and treatment effort, understood to be a national model." Georgia Berland

I    Improve access to health care for all the uninsured, immigrants, homeless persons, and similar populations. (Develop systematic cost and systems modeling to estimate costs and trades.)

J    Further develop health care language services for those for whom English is not a primary language.

K    Develop more adequate health care transport services for those who need them. (Figure out how to reinstate those recently cut.)

V REDUCE DANGERS OF ECOLOGICAL/ENVIRONMENTAL POISONING

A    Analyze and remediate local ecological environmental public health hazards.

B    Develop high-profile consumer resource access and training in ecological systems and problems, both in person and online.

C    "Assess and address toxicity exposure among homeless people, those living in substandard housing, and those of low income (sometimes known as 'environmental racism')." GB

VI ADDRESS ISSUES OF EDUCATION, TRAINING, AND ALLOCATION OF SCARCE RESOURCES IN THIS TIME OF CRITICAL SHORTAGES OF HEALTH PROFESSIONS PERSONNEL

A    Get information from the Office of Statewide Health Planning and Develop- ment on health manpower projections. Work with the Pew Center for the Study of the Health Professions at University of California San Francisco for key data.

B    Significantly increase "academic articulation" in health care curriculum, study, careers, and re-training planning and funding for very high quality (and sufficiently high quantity) training among public educational and health service institutions in and around Sonoma County, and within these institutions. Example: Specifically encourage increased study and dialogue within and between the Sonoma County Office of Education, Santa Rosa Junior College, Sonoma State University, and other educational institutions. Example: Increase dialogue among local hospitals, clinics, other health care delivery systems, and labor unions which can all work in tandem. Work with labor unions, including to assist in creating "career ladders". Overall, develop compelling strategies and tactics for retaining health care professionals here in Sonoma County.

C    Champion accelerated and intensified graduate and certificate study in and around Sonoma County — in the traditional fields of health care, in health care public policy development, and in complementary/alternative/integrative medicine.

D    Develop multiple strategies to significantly reduce hospital and long-term-care facility reliance on "registry" nurses.

"Offer specific training to clinicians and health and social service providers on such issues as pain management (planned by FUHSI), benefits access, etc." GB

VII FURTHER BROADEN THE SYSTEMATIC STUDY OF THE CRISIS AND ITS AMELIORATION

A    With adequate funding, do a systematic review of recent health care literature on "healthy communities" and "humane cost-containment" in the U.S. and abroad. Interview experts. Show how advances can be incorporated here and adapted to Sonoma County. Test ideas with local focus groups.

B    Consistently place all learnings in writing and graphics - and place these on local health care educational websites for community learning. Develop hypertext links between them. Consider CDs and print.

VIII FUND-RAISING

A    Through the Initiative Seed Grant, increase cooperation and planning among Sonoma County leaders and institutions in support for and solicitation of foundation and government funding - for developing and implementing advanced approaches to health care service and organization in right here in Sonoma County.

B    "Support existing collaborative efforts to develop needed programs and resources, such as the Sonoma Health Alliance, FUHSI, Health Care for the Homeless, Court Homeless Protocol Project, Center for Social Change, Volunteer Center's training and resource development assistance, Hepatitis C Task Force, Healthcare Workforce Development Roundtable, Area Council on Aging, Children's Health Access Coalition, Redwood Community Health Coalition, health care careers training initiatives in the Sonoma County Office of Education and schools, Santa Rosa Junior College, Sonoma State University, other educational institutions, and the efforts in many other local organizations and coalitions." GB