Many of you probably saw the recent Sunday New York Times Magazine story about home- and community-based health care, called ?What Can Mississippi Learn From Iran.? Basically, it describes a still rudimentary and not fully funded vision of creating ?health homes? using community health workers to reach the medically underserved in the Mississippi Delta, particularly those with chronic diseases. The idea is based on a similar program in Iran.
There?s a lot I liked in this article by Suzy Hansen. The author is an American living in Turkey and she?s not a health care writer. She came to the subject ? and to the Mississippi Delta ? with fresh perspective. I liked her focus on chronic disease, disparities (black/white, rich/poor, rural/urban), prevention and wellness, the need for more and better primary care, the lack of care coordination and the rationale for more integrated delivery systems with primary care at its core. She did that well. Hansen also did include some context (I would have preferred a bit more) about some of the other delivery system changes unfolding through the Affordable Care Act, changes in the delivery of health care that my posts here often urge you to report on.
So the points I raise below aren?t because I think the article was bad ? as I said, I liked it. Rather it?s because I wanted to draw out a few points that will help you as health journalists read it a little more critically and then think a little harder about what?s going on in your own states or communities.
Hansen said in an interview that she first got intrigued about the Mississippi initiative after seeing an earlier report on it in 2010 AARP Bulletin. When I went back and read the 2010 article, and then re-read the Times piece several times I wasn?t really clear on how much the ?health homes? had achieved in the two intervening years. I emailed her and she said, ?It?s all moving slowly. They have implemented the HealthConnect program, they have trained community health workers, they have designed the health worker certificate program at Jackson State, and opened clinics in some of the schools. They are trying to demonstrate various aspects of the model in order to convince people to fund them.? But the to-do list is still long.
Given all the attention right now on changing health care to achieve precisely the goals that the Mississippi group is trying to achieve (wellness not sickness, better care coordination, fewer hospitalizations, reducing disparities, etc). I was left wondering what?s stuck here ? why isn?t this program accomplishing more. (It might have to do with Mississippi and local politics and personalities ? not purely ?health.?)
But that?s something you can look at:
- Who in your community seems to have a good idea and isn?t getting anywhere or is moving more slowly than anticipated? Why?
- What ? or who ? are the barriers, the change-resistors?
- Is there someone else in the same region with a similar approach that has gotten off the ground?
- Is there a community elsewhere in the country with a very similar idea that is either up and running or about to be?
- Why can town/city/county/health system X do this and town/city/county/health system Y can?t get past the ?talking about it? stage?
Hansen?s article did mention the shifts in health care the ACA aims to achieve. She noted, briefly, that the health law recognizes the need for all these changes contemplated by her subjects in Mississippi. She mentions the ?hot spots? that Atul Gawande, M.D., has written about, and has a quote from Richard J. Gilfillan, M.D., director of the Center for Medicare and Medicaid Innovation (CMMI) about encouraging more primary care-centered models and more preventive health. But there was still a bit of a disconnect ? that somehow this ?health home? model has to be imported from Iran. I know (from personal experience!) that editors often like ideas that sound counterintuitive and exotic: Pariah Iran can cure what ails the Mississippi Delta.
But there are scores of other programs across the country engaged in the same kind of transformation as this Iran-focused team in the Delta. Small patient-centered medical homes, school-based clinics (which is a part of what they are doing in Mississippi), community health centers that are trying to bridge social and medical needs (they vary ? there?s a fair amount of innovation going on in the best of them), growing numbers of integrated delivery systems, the ?hot spotters,? accountable care organizations, community health workers/health navigators, care transition teams and community-based geriatric teams trying to prevent newly discharged hospital patients from boomeranging right back into the hospitals, visiting nurses (not all of whom are quite as 9-to-5 and profit-driven as described in the article, although there are obviously significant problems in that industry). There also is a lot of work going on developing ways to use telemedicine and new technology to monitor frail or chronically ill people at home. There are many and they are growing all the time. (For an overview of such programs and more story ideas, see Susan Jaffe?s tip sheet on innovations in Medicare.)
Hansen?s article wasn?t designed to tell readers about all of them ? she wanted to focus on a particular community and the people trying to heal it.
?I was most interested in why this 80-year-old man who has been working in poor communities all his life turned to this concept, and what that revealed about American health care and the lives of people in Mississippi,? she emailed me. ?In the end, I felt that most average Americans are not aware of these various initiatives ? of any alternatives to American-style health care ? and that it was worth it to highlight this story as one example of thinking outside of the box.? (She also noted that, to many New York Times readers, Mississippi is almost a foreign country ? and vice versa.)
Hansen wasn?t trying to make the case that the Mississippi effort was the be-all of health reform. Which means she left plenty for the rest of us to write about.
Like the one in the Delta, the new models and initiatives aren?t all fully formed. They won?t all meet expectations, and some will probably fail. But there is a growing recognition ? and it?s spreading ? that new models are needed. (And they don?t have to come from Iran.)
Moving to these models doesn?t always require more money. It does require redirecting the money already being spent. Changing payment incentives ? and the flow of money to hospitals and specialists and acute care and emergencies instead of a more holistic community-focused chronic disease priary care-based management approach ? is not going to happen overnight. It will take years. But it?s a change that is under way ? in Boston and Philadelphia and Denver and Texas and Iowa and Camden and Alaska and the Bronx ? and in countless communities in between.
How to find them? One way is CMMI. For instance, I searched for ?Mississippi? in the Center for Medicare and Medicaid Innovation Center main page and came up with 51 hits (some of the listings seemed duplicative, and some were run by out-of-state entities, like Duke), I looked at the CMMI Innovators map - and found zero in Mississippi (most were concentrated on the two coasts and the northeast).
I looked at the Partnership for Patients page at CMMI, and came up with three pages of Mississippi projects (just because they are there doesn?t mean they are all big, ambitious or successful, just that they?ve joined the initiative). The point isn?t that the Iran-model isn?t a good or interesting or smart one - it is interesting. It?s just that if you, as health journalists, look around you will find that there are a lot of other people who aren?t just yelling and screaming about health reform. They are also trying to make it happen.
One last thought ? not all the pilots and projects out there use as much home-based care as the Mississippi project contemplates for the non-elderly. If you come across a project using community health workers/health navigators let me know. I know of a few too?? maybe we can highlight them in a future post.
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