We’re Reducing Heart Attacks in San Diego. Here’s How.
The Rippel Foundation’s ReThink Health initiative has partnered with Be There San Diego to develop a payment model, and serves as a technical advisor to Be There and other California communities in their work with the California Accountable Communities for Health Initiative. We were thrilled to learn of Be There’s results from its efforts to reduce heart attacks and strokes, and invited Katherine Bailey, executive director, to share some of the reasons for the group’s success with our readers.
Since 2010, a group of ambitious health care leaders interested in transforming health in San Diego County has been working together to end heart attacks and strokes. Our initiative is called Be There San Diego. The American Journal of Managed Care just published the outstanding results of our first effort together. Our collaborative learning and action led San Diego County to avoid 2,735 hospitalizations from heart attacks from 2011 to 2014, saving $61 million. Given the 13,849 hospitalizations for heart attacks that did occur in San Diego, plus the hospitalizations related to heart attacks in all other California counties, the authors calculated that more than 20,000 hospitalizations could have been avoided statewide over the same time period.
The potential for improved health and decreased costs is astounding. If San Diego County, with its highly competitive health care environment, can get such phenomenal results, then it’s worth investigating how we might spread them across the golden state and to other communities throughout our nation. As a start, Be There San Diego has been reflecting on the approaches that have most contributed to our success. Below are our five top lessons for communities that are ready to go.
Lesson 1. Position clinical leaders to design the way forward, so they want to do the work
In 2009, the California Department of Managed Care found that many of the medical groups across the state were not always using the best practice protocols proven to reduce heart attacks and strokes, and as a result, were not achieving the highest quality rankings. These included controlling blood pressure and cholesterol. In response, a group of experts with a grant from the National Institutes of Health came to San Diego and convened our medical groups and health planswith a call to do better on these outcome measures. At first, all the health care organizations in town felt they must send someone to participate.. When the experts provided a clear opportunity for these clinical leaders to design the pilot program for addressing the problem, suddenly everyone wanted to be there.
This motivated early clinical champions to lead the way in San Diego. Dr. Jerry Penso, at the time the medical director at Sharp Rees-Stealy Medical Group, suggested the creation of a “University of Best Practices” (UBP), which has continued to this day. Medical directors from across the region come together monthly, share what is working best in their organizations to reduce heart attacks and strokes, and also invite expert speakers from around the country. As a forum for medical directors, the UBP has created trust, relationships, and a place to set common goals rooted in what’s being learned together. To broaden impact beyond sharing best practices, the clinical leaders decided to launch a campaign to end heart attacks and strokes—this was the beginning of the Be There San Diego initiative.
Lesson 2. Provide neutral leadership to build trust
Another early champion was Dr. Anthony DeMaria, from the University of California San Diego, who, at the time, was the editor for the Journal of the American College of Cardiology. Dr. DeMaria was able to provide neutral leadership for the effort as well as expert medical guidance. Given the competitive nature of the health care organizations involved with Be There San Diego, having a neutral voice to chair the meetings and provide leadership allowed the group to move quickly into a mindset of competing against the disease instead of each other.
As Be There San Diego moves into new areas of work, beyond the UBP, sometimes participants need additional approval from their organizations to stay involved. When this happens, my colleagues and I, who are now responsible for managing Be There San Diego, are often asked to reconfirm that there aren’t any hidden agendas at work. They seek transparency, especially as they judge whether they want to invest their energy in the effort. Be There San Diego addresses these concerns proactively. We communicate regularly with the clinical leaders who already trust the participants and process, and support them in developing the talking points they need to discuss the work with their colleagues. They know better than we do how to navigate their internal structures to build support for the agenda they helped create.
Lesson 3. As the work evolves, keep the meetings relevant
There was a high level of enthusiasm for the UBP meetings and Be There San Diego in the early years, and our challenge has been to maintain this enthusiasm as the years go on. To overcome this, we work hard to keep the UBP relevant for the clinical leaders. We’ve been able to secure leaders’ ongoing commitment by updating the format to focus on actions taken as a result of the meetings, varying the number and types of speakers, and inviting professionals from other fields (e.g., pharmacists) to join the meetings.
We have also focused on moving from a “lunch and learn” format to a meeting structure where learning is focused on taking actions to improve patient care. For example: after learning at the UBP about a new cardiovascular disease risk calculator that stratifies risk by race, one of our clinical leaders whose practice is comprised largely of African Americans started using the tool during patient visits. He found the tool compelling given the higher risk levels for African Americans and said it worked to motivate his patients to make important lifestyle and behavioral changes.
Lesson 4. Ask clinical leaders to set the target goals and analyze progress together
In 2012, after two years of meeting together, clinical leaders had built enough trust in one another to form a second collaborative group within Be There San Diego—the “Data for Quality Group.” In this forum, the health care organizations share their aggregate intermediate outcome data for comparison and improvement. They have also set targets for the entire county, such as 80% blood pressure control for diabetics with hypertension. The data group has seen impressive improvements, with all of the established targets successfully met by 2016. These improvements were a result of keeping the focus on specific goals, sharing what was working, and impressive internal efforts inside each of the health care organizations.
As with the UBP, maintaining the Data for Quality Group requires constantly looking to improve. This means continuously reviewing the way we collect, analyze, and report back on the data. Given today’s environment, in which health care organizations are required to report so many measures to multiple entities, we are especially challenged to determine which data are really worth examining as a group. If involvement in the group requires too much extra work that doesn’t add value, it could quickly lose its appeal and attendance would wane. To this end, in 2017, the group–based on a growing awareness of the Social Determinants of Health (SDoH)–decided to combine clinical data with SDoH data at the zip code level. Examples of SDoH data include education level and income level. We’ve had some interesting discussions and continue to be intrigued by the possibilities in combining these two data sets, but are not yet convinced that the “juice is worth the squeeze.”
For 2018, we are interested in getting better access to race/ethnicity data, which are not currently reliable in most of our health care organizations. Other 2018 goals are to include more outcomes data (e.g., complications from diabetes) and a broader set of intermediate outcomes data. We are always working with the clinical leaders to determine what data provides the greatest value in pursuit of the target goals they set together.
Lesson 5. Work with trusted community-based organizations to engage patients
From the beginning, the clinical leaders recognized that, even if everything goes right at the physicians’ offices, we will not reach our goal if individuals don’t access care or are unable to follow preventive treatment recommendations. Preventing cardiovascular disease really requires a community-wide effort. Our name, Be There San Diego, is based on the concept that we can motivate individuals, families, and communities to make behavioral changes (such as taking their prescribed medications or helping family members get to appointments) in order to “be there” for each other.
This recognition of the vital role of community organizations, which already have the trust of many potential patients, led us to pursue partnerships with faith-based organizations (FBOs). We looked at relevant outcomes data and decided to start our work in Southeastern San Diego, a city neighborhood disproportionately impacted by heart attacks and strokes. We believed that the African American FBOs could help their congregants connect their desire for spiritual living to the benefits of recognizing and treating cardiovascular risk to prevent heart attacks and strokes.
Given the history of broken trust between the medical community and the African American community, we faced many challenges in building these partnerships. These were addressed through honest conversations about racism inside the medical and research community, including the infamous Tuskegee experiment. To build trust, we worked with the community to develop a data stewardship agreement that outlined our shared approach to ownership and handling of data collected in the project. The partnerships have proven so successful that the FBOs have been nationally recognized for their work developing heart health in their congregations.
In San Diego, we attribute our success to convening, building trust and relationships, setting shared goals, tracking our progress, and asserting neutrality while also focusing on the broader community. These actions develop the buy-in of the clinical leaders, patients, and community—and the ongoing commitment so many of them have decided to make to one another. Without their energy, time, and desire to make patient care better we would not have achieved such rewarding results. We look forward to continuing and improving our efforts, well into the future.