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 Welcome to this Week in Health, it influence where we discuss the influence of technology on health with the people who are making it happen. I. Today we have a great conversation around the social determinants of health and really improving the health of our communities by addressing the social determinants of health.

And there's a really neat partnership between Intermountain and a lot of organizations. Specifically, we're talking with the United Way, who is. Who has partnered with Intermountain on that and they talk about scaling that program up and the things, the challenges and the, the ways they're going about addressing it.

Great conversation, great topic. I hope you enjoy it. My name is Bill Russell, former healthcare, C-I-O-C-I-O, coach, consultant, and creator of this week in health. It a set of podcast videos and collaboration events dedicated to developing the next generation of health leaders. As we get to the end of the year, I really want to call out our sponsors who have partnered with us on our mission to develop the next generation of health leaders, not only Sirius Healthcare, who has partnered really strongly with us for this year, but also our channel sponsors who we couldn't do this without.

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So a lot of exciting things going on as we, uh, approach the end of the year. So, uh, without any further ado, let's talk about this great topic. . All right. Today we have Mikel Moore, the SVP and Chief Community Health Officer at Intermountain and Bill Krimm, the president and CEO of United Way of Salt Lake.

I would say good morning, but it's uh, afternoon for you guys, isn't it? It is. Hi Bill. Thanks for having us. Well, welcome to the show. I'm, I'm, I'm really looking forward to this conversation. We're gonna, we're gonna cover a fair amount of ground. What's interesting, I was introduced to this work probably two years ago.

Uh, CEO for Intermountain. Mark Harrison came to the JP Morgan conference and I, I think he was really new in the, in the role, and he, he talked about addressing social determinants and he talked about partnerships you guys were doing in, in. In that market. And at that point where I, I reported on this and I talked about it on the show.

I said, we're gonna keep an eye on this. This is really exciting work. So I'm really, I'm really excited to, to come back to it. So, Mikail, I guess I'll start with you. Give us a, a little history of the, of the work that you're doing in partnership and in the communities and, and specifically around social determinants at Intermountain.

And, and out of that we conceived the Alliance for the determinants of health, we call it. That pilot's been in operation for about two and a half years now in two counties in Utah. And the idea was this, that if we could organize around all of the services that people might need that are getting in the way of them, um, really activating improvements in their health and coordinate services for an individual and.

And come to understand some of those underlying contributing factors, we could probably make a difference. And so that's what we've been doing. We have a digital platform for community health workers to use to connect people from their social needs, their health needs, their mental health and substance use needs, all in one kind of care management platform.

And allow that communication to occur to ensure that we get people the services that we need, and it appears that we're making an impact on their use of the emergency department. Helping to solve problems that, uh, fall between the gaps of, of one program or another that might be a part of our social services agencies.

And we're learning a lot to help us scale this more broadly in our state, but hopefully across the country as well. Yeah, that, I mean, that's, that's some really exciting work. And you guys, uh, it feels to me like there's, there's a lot of leadership going on here in this.

So.

But Bill, I wanted to come to you and, and, and let's talk about the mission of the United Way and how it, it fits into this partnership that you're, you're doing right now with Intermountain and others. Yeah, thank you. Our United Way is, is really focused on, on two things. The first is, is we connect people in Utah to the very resources that Mikel just described that they need.

So through the 2 1 1 infrastructure, which is a NA nationwide . Use of the phone number two one one to connect people to resources. We operate that in partnership with others in our state. And so as, uh, they were standing up the alliance for the determinants of health, it became clear that being able to efficiently connect people to those resources, knowing what those resources are, having a database of the 10,000 different resources in Utah that people, uh, might access, that's important to this process.

The other thing that has become clear over time. Is that it? It's not simply a technical challenge of passing information from a healthcare provider to a social service provider. There's a human challenge to help that transfer of information result in a better outcome for a. For the patient. And so we've been involved in that process doing something we call a coordination center, which is coordinating between the providers and the community-based organizations to make sure people get where they need to go.

The second thing, and, and maybe the, the larger challenge is. Related to our mission to build partnerships that solve problems at scale. So for the last 10 years, we've been focused on transforming the educational environment for Utah kids. The, the health environment is something that's very much related to that, much as there are social determinants of health.

There are social determinants of educational achievement and they're very much related. And so we've been focused on that for 10 years, building partnerships across sectors with, uh, health systems and businesses and community organizations and governments and schools to try to make sure that the education environment produces the best possible result for every child and.

This work fits very nicely into to that. It's an extension of the work that we've been doing to bring people together, figure out what the objectives of of collaborative work are, and then to work on those in a unified, aligned data-driven way. Yeah. It's, it's, it's amazing how many touchpoints there are.

It's, it's, we'd love to think that it's just a matter of getting the information around, but it really is inserting the right people, the right partnerships. I mean, it's the, this partnership brings together an awful lot of organizations. It's not just the United Way and Intermountain, is it Bill? No. No, not at all.

In fact, it's important to, to know of Intermountain's catalytic leadership role and their. Their embrace of the idea that we have to work collectively, that the systems that we're trying to align and, and integrate really are operated by many different organizations and they, they, and we have invited all of those systems and organizations to the table so that we can co-create a solution that works for everybody.

That's fantastic. We've, we've talked a lot about health, health, uh, inequities on the show. Mark probs, the former CIO for, uh, Intermountain talked about, uh, the different zip codes and the disparities. Dr. Klasko was on talking about the same thing in Philadelphia. He was talking about the mortality rates.

Someone born in this hospital will live almost eight to 10 years longer than somebody who's born in. Philadelphia, how do those inequities arise and and what leads to the health disparities in our communities? Well, it's, it's interesting. This is exactly what prompted us to look at this bill and. We first in our communities, it's about a 10 year life expectancy difference between a West side community and an East side community, if you will.

And for a long time, I think Intermountain thought the key to solving this was to create access to healthcare, right? We, we did a lot of work to ensure that our financial assistance policies were understood by the safety net providers in that community. We put clinics in those areas. We did a lot of things to ensure health access that isn't.

It, it's gotta be deeper looking at the conditions in which people are living, the safety that they're experiencing, their opportunity for education. And Bill knows this. I think he's, he's way ahead of us because of his work in education, but understanding the, um, how all of those things are different Geographically, our, our poverty rates vary.

And and are geographically clustered, educational attainment, income, et cetera, and it's correlated. Race often, and so we've really begun to think about how does you know this, this alliance that I speak of, our work operates at multiple levels. We have to ensure that the individual we're, we're meeting and getting to know today has.

The help that they need. But then we're also looking at how do we contribute to the way our communities are designed, built, and managed to influence those other outcomes that are determinants then of health. And then how do we redesign those systems if they're, they're just not working. And I think we're finding that there's more system work to do here.

Far more than we thought. Yeah. So has the, has the, I mean, you guys are on the ground and, and you're watching this. Has the pandemic impacted these communities more severely than, than others? Are we seeing that kind of disparity as well? We are, and unfortunately it is playing out over a long period of time.

At the beginning of the pandemic, we. Because essential workers were staying in the workforce while others worked from home, they were at greater risk, and that seemed to disproportionately affect poor minorities and vulnerable populations. But that's continued even as we've resolved. Having personal protective equipment, having safe practices in employment settings.

The disparities both in the way people are contracting covid, and then whether they live or die from it, does seem to vary by income and by race and by geography, and it, it's. It's complex. So one, we're finding that people who feel vulnerable or disadvantaged by the healthcare system are less likely to come for care sooner.

They wait longer, so they're sicker when they come in for care. They're also more fearful and they have language barriers, cultural barriers that make it more difficult for them to understand the treatment options that are available. Many of them are experimental, they. A lengthy education and, and understanding of, of that treatment.

And so as the pandemic has played out, we've had to shift and be responsive to that. At first, it was making sure we were making testing available and easy and, and perceived as safe in. In those communities. Then it became having community health workers explain the research protocols and the experimental treatments that were available in their language in a culturally appropriate way, in a safe way.

Now it's really putting pulse oximeters in the hands of the community health workers and teaching people the importance of getting care. Soon and whom to call and having a culturally appropriate connection to make that first call. So, uh, it's evolving because the disparities are real, and I think they're giving us great insight into the disparities that exist in lots of health conditions.

This is, uh, it, I'm listening to you talk, and this is a gnarly problem. I mean, you keep talking about culturally appropriate care and culturally appropriate,

right? People in the right setting together. And, and, and Bill, I want, I wanna come back to you. And how do you, how do you organize that? How do you bring that together? I mean, that's, it's one thing to say, Hey, we're, we're gonna get the volunteers that really have a heart for this and that organizations that, that can do this.

But then you have to match. The right setting. It's not just throw, throw people at it. It's appropriately selecting the right people and putting them in the right place. Yeah, I, I think it is a gnarly problem. And, and there isn't a textbook solution to it. There's no, there's no playbook for this because it's so contextual.

So. The principle that that one has to use is the idea of co-designing with communities, bringing the voice of affected populations to the table, to hear their experience, to understand their challenges, and to co-design the solution with them. And I, I think if, if you start with the assumption. That we think we know.

Those of us who are in professional roles think we know a lot. Yeah. But unless we have lived the challenges that people of color in low income communities. Our living, then we are likely missing some important information. And so trying to co-design a system together with them is, is I think, the starting point for dealing with that complexity.

So help me understand what that looks like. So a, a co-designing session, is that, is that going out into the community and doing like town halls? Is it. Is, is it surveys? Is it one-on-one? Is it bringing people together in a design session? What, what does it look like? It's, it's all of the above and multiplied over and over again.

I think. So there are trusted organizations that, that work in these communities. There are people, community health workers, Mikel mentioned community health workers are, by definition connected and close to the community. They're not, they're not white. 53 year old guys that that go, I. In their car to a neighborhood and try to figure stuff out.

There are folks from the neighborhood who are trained to be community health workers and to connect with people that they know. There are networks of, of informal organizations. There are great community-based organizations that are, are doing daily work with these populations. So that's one piece of it.

Listening to people through 2 1 1 is another piece. We collect data every day through calls and interactions with folks online who are, who need help. And if we step past the initial sharing of information to understand more about, about the lives and experience of those folks, that's a piece of this. I think then it, it's also, we invest resources in building the capability and identifying.

The informal leaders in communities and bringing them to the table. So at some point it is about co-designing with them. It's about having people at the decision.

Shoulder to shoulder with the, the executives of a health system and the CEO of a nonprofit and, and the CEO of a business trying to do that together. And, and I, I, I wanna emphasize that last point that co-designing across sectors is super important. I think our, our country probably, certainly our, in our community, there's a, a tendency historically to design in silos.

Government programs get designed in silos and, and everybody kind of. Works in their own sphere. There's nothing mal intended about that, but we don't get the best thinking unless we put everybody in the same room over a long period of time working together. Yeah. The, the further you are away from the problem, it's, it's hard to.

It's hard to really, uh, understand how, how it's impacting. And one of the things we have always looked at as healthcare is that we, we wanna keep people outta the er, but you know, if we don't know that they don't have heat, if we don't know that they don't have the right living environment and, and those kind of things, we, we we're treating a, a address.

So coordinating the activities, coordinating the information, the information flow is, is this something that you guys just give the community community workers access to? And is it an Intermountain program that you've, that you guys support and maintain for the, for the larger community

context? Tied to what Bill just said. When we, when we define our aspiration in this way, we listened to what gets in the way. Sectors working together, and one of the first things we heard in our listening to our process was we need a way to communicate with one another. We have this great resource in 2 1 1 where each of our services are listed, if you will.

There's a great directory. People know those resources exist. We don't have a way to know that when we refer Bill to bank, the we're. Some job retraining. We don't know if those issues get solved. We only stay in our silo. We ask for something, we refer something, and then we continue to follow the issue we're managing.

And so what our colleagues asked us for Mother Sectors was, give us a way to communicate. That also protects the privacy of the person that we're serving because if we ever violate the privacy of the individual, we're trying to help, then we're not, we're we're, we're cut off from our opportunity to help.

So we partnered with Unite Us to bring a platform to our communities. They have a lot of experience doing this and it essentially a. Builds on the knowledge that exists in the 2 1 1 directory resource, but then puts each of the service providers in on onboard that network so that they can communicate with others in the network.

And then there's a consent process for the individual that we're looking to serve. They have to consent to have their information shared. And then community health workers are using that platform to connect the others involved in care and coordinating services. And it allows us to do a couple of things.

One, we get to coordinate for that individual. We also get to understand our network. How often do we have people? Aligned with the work that are needed to solve the problems we've identified, and when do we have to find someone that we're not already working with closely. And then we can actually over time measure the performance of that network and making that leap in healthcare to thinking about how we manage a network of skilled nursing facilities and specialists and primary care physicians and hospitals that are all involved in the continuum of care.

We're now beginning to manage a network, if you will, of cross-sector partners in serving a community. And that gives us different ways to think about how we redesign that network to better meet the needs over time. Well, I, I wanna come back to you shortly and I wanna talk about. The, the, the goals and the partnership from a metrics standpoint, from a health systems metrics standpoint, what you're looking at to say this is successful.

Bill, I wanna talk to you a little bit about scale though. First, and one of the greatest challenges that we have is scaling out these really good programs. We might be able to do them in a single community and do them effectively. But, uh, you guys are attempting to do this pretty much statewide, which is, which is pretty exciting.

'cause if you're able to do it statewide, there's no reason why you couldn't at least do it across all of Intermountain service area, which would take you into a. What, what are some of the challenges you, you face as you, as you scale this up? Well, I, I think they fall into two categories. There's the technical challenge of just getting everybody to e everybody's data systems to talk to each other.

So one thing that's important to mention is that Intermountain has. Has started this platform and or is using this platform in this initial process, but other health systems have other ways of managing social determinants, like kind of work like this other. Yeah, other systems use other technologies, so Right.

So really the problem be the first scaling problem is about data interoperability. I think it's, does my system talk to your system and does the data we're putting into it exchange freely and securely across systems? So from a patient standpoint, it doesn't matter exactly where you start, that you're getting the same kind of service.

A community based organization standpoint, you're not trying to populate 10 different systems with the same information. And so that's the, it's a technical challenge. On the one side, I think the, the more complicated challenge, and that's hard enough, like getting everybody to, to work out the data technology.

Part of this is hard on me. I think the, the larger scaling challenge is the human behavior challenge in a decentralized, multi-sector system. So the number of organizations in the Utah 2 1 1 database exceeds 25 oh. Those are, for the most part, independent organizations that, that have to voluntarily agree to work in a new way to make that side of things work.

And then there are a number of health systems that have to voluntarily agree and people have to be trained in new workflows. People have to buy in and want do it. People have to then adapt to their own processes. And all of that is, is kind of a human in, in a decentralized world. Where there is no single CEO to say, we have a new process today.

Here's your training. Let's get it going. In a decentralized world, that is a person by person, organization by organization kind of conversation to get everybody on the same page, rowing in the same direction. And so Mikhail coming back to.

And actually I wanna talk about this first from a, from a health system perspective. What, what kind of metrics are you looking at from the health system? And then I wanna, I wanna talk about from the program, what, what kind of goals and objectives, uh, do you think are, are, are, what are the targets for the entire program?

So let, let's system. Hey, this has been this. This is making an impact. Well, when we thought about the why for doing this, we knew we wanted to improve overall health outcomes and reduce total cost, and yet measuring health outcomes and total cost over a time period that would be beneficial for communicating results and making decisions is really challenging.

And so we. Scale our metrics down to really focusing on two process metrics and one outcome metric for the duration of our timeframe. So we're focused on how many key partners do we get aligned successfully on the platform? Um, so engaged in the network. Then how well do we adopt a change in workflow in the clinical setting where

To what degree do we adopt a screening mechanism for assessing social needs and then change workflows. So we're connecting people to resources, and then our outcome metric is to what degree do we impact avoidable emergency department visits for this population compared to the population that's, we're doing this in a couple of geographic.

Experiment design that we can use to see if we're making a greater impact in this population versus the other. And interestingly, we have found it far easier to get community partners engaged in the network than to change our own work processes. Though we're now catching up on that. I know you laugh. We, we thought it would be the case, but we had no idea how true it.

But we're now gaining traction pretty equally in both, I would say, but it, it took some time and it was slower to come internally than externally. And we are seeing a decrease in emergency department use that. I'll tell you, COVID is clouding that data point quite a bit because we know emergency department use dipped significantly for a period of time there.

And so we're trying to work out the noise of, of the pandemic in the data, but it does appear like we're having an impact. Proportionally in this population. Yeah. Well, good luck taking that noise out of the data. That's, that's a pretty significant impact to the, to the data. So it'll be interesting to see, uh, where that goes.

I, I, I do wanna ask about funding a little bit because, uh, I, I feel like it, it's a, it's a gnarly challenging problem. A lot of health systems have mission driven. Focus and they wanna do these kinds of things for their communities, but at the end of the day, some of 'em just don't have the funds to do it.

And when you're talking about social determinants, where does the funding come from? Is it, is it government? Is it health systems? Is it, I mean, where, where's, what's the, what's the source of funding for this type kind of program? So I see. At least two key sources of funding that are important for this to be successful.

I think one, and, and most importantly, if we are shifting to value-based care, then it becomes the prudent thing to do, to think about how to make these investments, uh, because it will be better for people, better for total costs. If we do so, and in Utah we do have a managed Medicaid model. So we have accountable care organizations that are at least theoretically, already at risk for managing the total cost of care for Medicaid beneficiaries.

So. That's one ingredient. But second, there are a lot of things that are vague in current regulations around what you can pay for as, uh, a part of your Medicaid offering of services. And similarly, there's lots of other rules around housing and, and other resources. And so Intermountain did make a charitable contribution at the beginning of this alliance demonstration to.

A fiscal media who's really managing that money and ensuring that it's utilized by the alliance in ways that fill those gaps. So funding community health workers funding, housing voucher application fees, or driver's license, uh, fees. Other types of assistance that are in the white space. They're not covered by any existing program, but the objective is that we're through the demonstration showing our own Medicaid plan as whether as well as other Medicaid plans, the path for making these types of investments.

Now, I think it'll need to also be supported by. The development of technology that can support at a statewide level and some other things for which there are some federal and other resources we could tap into. So we're, we're studying that now. So I'm, I'm gonna give, I'm gonna throw out a, a closing question.

I'd love for both of you to, to answer. Fast forward a year, a year from now, looking back and we're having a conversa, another conversation. Uh, what, what would be just.

I think next year if we had a built out single system that any provider could plug into with an open API, so that we've got data crossing systems, and if we had a user interface that was available to patients so that they have a stake in this. I would say, and all, there's a lot that goes around, goes into making those two things happen and, and then other things that would've to happen as well.

But if we had those two things in a year, I think that'd be miraculous. I don't know if it's possible to do it in a year, but that's, that's, that's on the horizon. This partnership is rallied around the idea of creating a single statewide system that is interoperable.

Organization's data system and a user interface for individuals to directly sort of self-serve. You know what, you know what Bill? If, if you had said that, let's say a year ago, I would say. That is a long shot. But after this year, we've done so many things at such an amazing, at what, what some people now are referring to at at covid speed.

I mean, we've, we've just done things so rapidly that we've never done before, so it's, it's a very real possibility with the right, with the right focus and the right people aligned. It's exciting. Mika, you, you get the last word, . I would just add that we also, in a year, I hope we have data that tells us that this does make an impact on the cost of care and on quality of life for people that we're helping.

I think you're right, bill, that Covid has accelerated our understanding of the need for this. And so maybe that proof point is less relevant today than it would've been than we thought a year ago, but I think it still matters and it'd be important for us to contribute that to accelerate, um, what Bill described.

Absolutely. I. Not only coming on the show, but I, I, I wanna appreciate, I really appreciate the work that you're doing, and I, I hope to get you on the show next year and remind you of what we said and see, see how much progress we made. This is, this is exciting stuff, so I, I look forward to catching up with you.

That would be great. We're gonna count on it. Thank you, bill. Thank you. What a great conversation. That's all for this week. Don't forget to sign up for clip notes. It's a great way to support the show. It's also a great way for you to stay current if you're not familiar, clip Notes is an email that we send out immediately following the shows, actually 24 hours after the show airs, and it'll have a summary of the show, bullet points, key moments from the show, and also one to four video clips that you could just watch.

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