One of The Rippel Foundation’s most important contributions to the field of population health is the ReThink Health Dynamics Model—a tool that helps stewards of regional health ecosystems grapple with the possible consequences of actions they are considering in order to influence complex health drivers. These stewards often wonder: will the outcomes of the decisions we want to make be what we intend? The Model helps them investigate the answers they seek, without them needing to become expert in modeling themselves because the Model is a simplified, but realistic, representation of real world dynamics. We call it a “regional health ecosystem in a computer.” Over and over again, we’ve seen how it can reveal lessons, ideas, and inspiration for practitioners regardless of their level of experience or roles.

The online Model has been freely available and widely used since its launch seven years ago. Despite its broad utility, we have always wanted to make the platform more user friendly. In response to growing demand, we invested in a new set online features that make the Model even easier to use. Now, anyone may set up their own individual or group accounts, save and compare scenarios within or between groups, and scale the Model’s population size to better represent the number of people in their own region of the country. Stewards may then choose from over two dozen initiatives and financing options (a.k.a. potential decisions they could make) to create possible future scenarios and explore the likely impacts on a range of health system indicators including measures of health, care, cost, equity, productivity, spending, and return-on-investment.

To illustrate the range of applications the Model offers, we’d like to share a few stories about how it has contributed to learning in three settings: a multisector partnership, a hospital system, and an academic institution.

Making Strategic Health Care Investments

Five years ago, the Dartmouth-Hitchcock (D-H) health system in New Hampshire began its journey toward achieving the Triple Aim through an increased focus on population health. Early on, a key sticking point preventing a full commitment to this new approach was lack of knowledge about whether D-H could make a higher level of investment in community conditions to support health and well-being in a way that would be sustainable over the long term. The D-H board of trustees engaged with ReThink Health to use the Model as a means to exploring scenarios that would provide more information.

ReThink Health designed a model-based strategy lab for senior leaders to explore the likely consequences of various investment scenarios. The trustees especially wanted to understand the potential added value of upstream investments, such as community-based efforts to enable healthier behaviors, when combined with downstream reforms to deliver higher-value care under global payment.

After studying these scenarios and learning that combining upstream and downstream interventions is likely to produce far greater health and economic benefits over the long term, D-H designed its first-ever Population Health Innovation Fund. This ingenious financing structure allows D-H to continue to fund traditional healthcare programming while reinvesting gains in excess of the endowment’s investment targets into upstream health interventions. Today, through the fund, D-H is is able to support community programs working on substance use, mental health needs, the health and well-being of older adults, and access to well-coordinated care. One of the first of its kind in this country, this typeof “windfall reinvestment fund” is an example of how other hospitals could better leverage their endowments to yield much greater value.

Developing Community-Driven Strategy

In 2010, Pueblo County, Colorado had among the worst health outcomes in the state. A group of regional health leaders decided that pursuing the Triple Aim offered a framework to begin to address the region’s poor health outcomes, and formed the Pueblo Triple Aim Corporation (PTAC). Its first action was to take a step back and ask why the region’s current investments in health were not delivering better outcomes?

ReThink Health worked with PTAC to develop a process for collecting local data, and used the information gathered to help build a customized version of the Model that reflected the regional landscape. These efforts revealed that there were many disconnections between different parts of Pueblo’s health system, particularly in the area of primary care. By experimenting with the Model’s financing components, PTAC learned that a relatively small investment of 1% of total health care spending in Pueblo could create hundreds of millions of dollars over time for programs to improve health, and could be shared between both the community and providers.

Matthew Guy, the first executive director of PTAC, says of the Model:

The ReThink Health Model helped the Pueblo Triple Aim Coalition move away from the short-term, and even mid-range, thinking about our work to a broader and longer perspective. PTAC really came to understand the long-term game we were participating in, and that some of the trends we were trying to change were going to take years and decades to stop and reverse. The Model also helped our health care entities see how other groups had a large and valuable role to play in changing health outcomes (environment, crime, poverty), which improved their willingness to collaborate. The health care entities also saw a benefit from savings accrued from improved health system actions around the social determinants of health. They realized sharing a portion of the savings with organizations focusing on the upstream elements of health and well-being would positively impact both their outcomes and bottom lines.

The final plan that PTAC developed after working with the Model reflected this new appreciation for social determinants of health and long-term thinking. Its portfolio of investments in population health included a diverse mix of interventions like coordinating care, increasing adherence to treatment, recruiting primary care providers to serve low-income populations, supporting healthier behaviors, and providing economic opportunities for those from disadvantaged backgrounds. This plan helped PTAC attract significant funding to support its agenda. The 2016 County Health Rankings revealed that progress on Pueblo’s health outcomes are being made, including a nearly 50 percent reduction in preventable hospital readmissions among seniors and significantly reduced teen/unintended pregnancies. PTAC continues to use the Model, and is working closely with the Institute for Healthcare Improvement and other partners to continue to implement the plan and transform health for the region.

Influencing the Future of the Field

At Dartmouth College, over the past six years, the ReThink Health Model has become an integral part of the master’s of health care delivery science program, which prepares health care leaders to envision, implement, and lead change across the delivery spectrum. In particular, the program’s Sr. Associate Director Ano Lobb and Assistant Professor Eric Wadsworth note that it is a critical tool for teaching students about the potential for “radical redesign” of the current health system, and the challenges and opportunities therein. They wrote to us saying:

The Model is especially effective for synthesizing concepts of strategy and population health, and inspiring creative thinking about which partners, investment opportunities, and other sources of cost savings, sharing, and revenue are currently underutilized. The ability to provide immediate feedback on the simulated effects of a variety of investment strategies on a vast array of measures, over a long period of time, can be transformative…. The importance of community collaborations to address social determinants of health consistently emerges as a central theme.

Over the years of observing students interact with the Model, Lobb and Wadsworth have concluded that the opportunity for deep and reflective learning offered by the Model is so great that they have expanded the time allotted to activities using the Model from a one-day immersive opportunity to a full week.

Where will the Model be Used Next?

Population health is a complex system with myriad interlocking drivers that can improve or hurt health outcomes. It is challenging to understand how these different forces interact with each other, and it becomes even more difficult when trying to predict how actions on those drivers today will change the health ecosystem years or even decades in the future. We believe expanding access to the Model will contribute to current and future stewards’ development of a nuanced and systems-oriented understanding of our health ecosystem. How can YOU imagine using the Model to improve decision making in your region? Please let us know in the comments below.

The personal views and opinions expressed in this blog (and in any comments) are those of the original authors only, and do not reflect the opinions of The Rippel Foundation or ReThink Health. Neither The Rippel Foundation nor ReThink Health is responsible for the accuracy or validity of any of the information contained in the blog or any comments. All information is provided on an “as-is” basis.

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