What is care model innovation?
For my MBA capstone project, I set out to examine care model innovation in maternity care. My assignment was to put together a syllabus for myself, and then to teach myself from that syllabus over the semester. The first “lesson” in my class-of-one was to dig in to the broader healthcare landscape to see what frameworks and lessons I could find there. Here’s what I gave myself to learn from:
- A re-read of two of my favorite healthcare articles of all time: Atul Gawande’s 2011 classic, “Hot Spotters,” and Don Berwick’s brilliant 2008 lecture, “What Patient-Centered Should Mean: Confessions of an Extremist”
- Watching the video of a newer lecture from Berwick, “H4”
- A new book I was eager to read by Yale public health researchers, Betsy Bradley and Lauren Taylor, “The American Healthcare Paradox”
- An article from the management literature, “Four Ways to Reinvent Service Delivery” by Kamalini Ramdas, Elizabeth Teisberg, and Amy L. Tucker.
Two major themes emerged in these readings: the concept of health creation (also known as salutogenesis) and the related notion that wellness or illness is far more a function of how we live our lives than how we access healthcare. To understand how to approach care model innovation, we need to unpack these themes a bit…
Health Creation: The forgotten goal of our healthcare system
“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
Both Berwick and Bradley & Taylor ponder this definition from the World Health Organization, and the yawning gap between this vision and what the U.S. healthcare system is designed to deliver. In “H4,” Berwick pulls the curtain back on the ever stronger evidence that the three realms of health — physical, mental, and social — are highly inter-connected, and that you can’t achieve the former without attending to the others.
Our medical care system’s exuberance for fighting disease and infirmity have left the promotion of “physical, mental and social well-being” to the margins — easily dismissed as “woo.” And while there may be plenty of woo in so-called alternative medicine, there is quite a bit of science to support the role of stress reduction, social cohesion, and healthy diet and exercise in creating, maintaining, and restoring health.
Berwick argues these should be central to our healthcare system, but they are all but absent. He quotes physician Wayne Jonas to say:
Salutogenesis should be the defining concept for a new healthcare system. We must facilitate healing processes that focus on people’s resources, on their capacities to create health. Salutogenesis is the missing complement to pathogenesis.
What really impacts health: how we live
Bradley & Taylor examine why we’re not creating much health with our massive expenditures on healthcare in the United States, and offer a novel explanation and plenty of evidence to substantiate their hypothesis: it’s because healthcare isn’t really what creates health. Social care does.
It turns out that the ratio of health care spending to social spending is a far better predictor of a nation’s health than the level of healthcare spending alone, and the United States is far behind most of our peer nations in investments in social services like housing and food assistance and employment programs.
In a diverse set of case studies in their book, along with the innovative programs depicted in Gawande’s “Hot Spotters,” we begin to see signs of hope in programs that completely dismantle the walls between healthcare and social services, and orient care and support totally around the individual. We see dramatic examples of healthcare’s elusive “Triple Aim” — better health, better experience, and lower costs.
Most importantly, in the models these authors and scholars describe, we see lives transformed and health created, even where hopelessness and despair had previously flourished.
Approaching care model innovation through a new lens
The master orator that he is, Berwick weaves science and personal narrative to eventually arrive at a history lesson about the significance of “H4,” the title of his talk. In the 18th century, John Harrison, invented several clocks over many years, incrementally improving precision and reliability from so-called “H1” to “H2” to “H3”. But eventually he rethought the very foundation of his inventions, and this ability to transform his vision rather than iterate on his invention led to improvement of leaps and bounds in quality, reliability, and efficiency: “H4”.
How do we get the kind of innovation that bears almost no resemblance to the status quo? How do we get from H1 to H4 in healthcare?
A management framework for transforming care delivery
To answer this question, the management literature offers a helpful framework. Ramdas and colleagues suggest examining four factors and asking a series of questions to unearth assumptions and practices that limit service quality or efficiency.
1. The Structure of the Interaction:
- Does creating shared experience or shared information among clients add value for them?
- Do your clients need tight communication among multiple providers?
2. The Service Boundary:
- Does a segment of your clients use a very similar set of complementary services?
- Do problems with complementary services affect customers’ outcomes?
3. The Allocation of Service Tasks
- Does employees’ expertise match their tasks?
- What tacit assumptions influence task assignments?
4. The Delivery Location
- Does the location limit clients’ access or success?
- Have communication and information needs changed?
My project eventually touched on all of these questions. The structure of the interaction: Why not offer group prenatal visits to help expectant parents learn and connect? The service boundary: Why not extend the role of doulas to help families access services, learn skills, and bolster their support systems? The allocation of tasks: Why are we one of the only industrialized nations relying on obstetricians rather than midwives to deliver the majority of maternity care? The delivery location: Why not assess, support, and care for women in their own homes and communities?
This is reposted and mildly edited from a series I did on care model innovation in maternity care, which includes an exploration of how payment reforms can help achieve the elusive “triple aim” for women, babies, and families.