Quality Matters: You weren't a novice when you entered the Practice Change Leaders program. You were already doing some heavy lifting setting up medical services in homeless shelters and medication management programs for patients whose medicines cost more than $1,000 per month. How did the leadership training and mentoring change what you were doing or how you achieved it?
DeCubellis: For me, one of the main benefits of the program was learning how to build support for health reform by demonstrating that everyone is in a position to gain from improvement. We did a lot of work presenting the business case for our initiatives so that we could take what we do, put some numbers behind it, show its impacts and costs, and demonstrate how to test the model and spread parts that are successful. The program really helped me to balance clinical ideas with business decisions that need to be made, which is critical when pitching proposals to the federal and state government or to other funders. I've been able to share these skills with nonprofits and community providers across Hennepin County. I take the same direct approach the program's advisors took with me. I tell them that Hennepin County has reinvestment dollars to spend and will spend them on atypical programs provided they help reduce costs and improve outcomes. At this point we are targeting a 30 percent return on investment from these programs.
Quality Matters: That's a pretty high bar. Has it changed the quality and ambitiousness of proposals landing on your desk? If so, what are some examples?
DeCubellis: It is a high bar, but I think it's helpful in demonstrating the scale of opportunities for improvement that exist in health care. I suspect that threshold will come down over time, but for now there are so many options for achieving it—especially in programs that encourage now-separate organizations to create systems of care rather than work in isolation. A good example is the sobering center, a proposal we created with the help of local emergency departments that had identified chronic inebriates as a challenge to the work we were asking them to do. The sobering center program is designed to provide an alternative place for the chronic inebriates to go, and a place where they can receive support from community-based organizations. The program is projected to reduce the cost of providing services to this group by 80 percent. Another example is a program that makes vocational services available in primary care practices for individuals who are experiencing high levels of hospitalization and/or detox episodes. This is not the population that I would typically assume would be work-ready, yet there is a subset for whom the lack of employment is the very trigger that keeps them cycling in and out of crisis and if we can break that cycle, we have dramatically improved someone's life and reduced system costs. We start with small numbers to test concepts and, when outcomes are realized, we can grow from there.
Quality Matters: Has the Practice Change Leaders program also changed your interaction with the variety of partners in Hennepin Health?
DeCubellis: The business case exercise has helped to bring partners to the table—and stay at the table. For example, it helped to get hospital administrators to buy into the idea of reducing admissions and emergency department visits. Our approach with this has been to ask where they are losing money elsewhere in the system so we can help them mitigate those losses. One thing we found was that many patients were stuck in medical beds because there were challenges finding them placements in the community. Some were patients with chemical dependency issues; others were patients with traumatic brain injury. The hospital wasn't getting funded because, medically, the patients were stable. We brought social services and the state to the table to help move these patients out and asked that in turn they work with us to reduce ED visits. This type of win–win approach helps us all move forward together.
I also replicate the Practice Change Leaders' business case exercise every time I go before the county board to ask for policy changes that impact other departments. Examples include engaging housing in efforts that impact health costs and outcomes. For example, we have asked that the county give greater weight to low-income housing projects that allow us to place people coming out of hospital beds. So we can encourage developers: if you are going to bring us a 70-unit building, are you willing to set aside four or five spots for patients with high health needs? Often when pitching these sorts of programs, there's a lot of concern that health care costs would go down, but social service or other county costs would go through the roof. We have to demonstrate that these sorts of initiatives would save the county money when all other costs are factored in—in this case, reductions in costs at the hospital for an individual who is medically stable but stuck in a bed due to lack of placement.
Quality Matters: Are there other ways agencies are coming together to address some of the social and/or institutional barriers to efficiency and health?
DeCubellis: We're testing a number of approaches. We've been working with the corrections department to make sure that detainees who are being released already have their health care benefits established and appointments set. Otherwise it can take six weeks to get in to see a behavioral health provider. We're watching to see if that drops our recidivism rates. We also looked at ambulance runs from homeless shelters and discovered that they were staffing their front desks with clerks, but for the same cost they could have EMS staff who can help us figure out when an ambulance needs to be called and when basic care can be provided in the shelter. That has reduced ambulance runs.
Quality Matters: Your work with Practice Change Leaders required you to extend the Hennepin Health approach to older adult Medicaid beneficiaries. What impact did this have?
DeCubellis: When I went into the program, I was mainly focused on childless adults in the Medicaid program, so it forced me out of my comfort zone. I had to query what we were doing across the county for seniors, and I realized we don't have the same targeted efforts for this population, which is starting to boom. The advisors in the program connected me to groups in my own community that were already working on some of the issues I was concerned with. It was a little startling to learn from folks in D.C. about what was going on close to home. The program also made me aware of what was happening across the nation, and areas that fit for Hennepin County that we could grab on to. An example would be the awareness that we have a senior population in our shelters—with growing medical concerns and vulnerabilities. We needed some focused efforts on housing these residents to ensure proper supports were in place.
Quality Matters: Is there any advice would you give others about leading community-wide change?
DeCubellis: Probably the importance of getting your arms around people's basic social service needs before trying to increase their attention to their health care needs. Our patients' medical charts were constantly saying "referred, noncompliant” or “nonadherent to medication." There were a lot of negative terms around the individual, as opposed to us asking, "What's broken with the system? What kinds of support do people need to get their attention to their health care?" Hennepin Health has been a success because we have been able to make the case that everyone—housing groups and agencies, homeless shelters, jails, and hospitals—has a role in the overall health of the community.