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Strategic Partnerships Are Needed to Improve Health Outcomes

Shaking hands makes squiggly lines go straightMulti-party partnerships are increasingly the norm for advancing health outcomes across a geographic area. Organizations must come together for solutions that can’t be discovered or deployed from a singular vantage point.

More health care organizations and community-based organizations (CBOs) are partnering to address both the clinical and the social determinants of health. In a 2017 Partnership for Healthy Outcomes survey, more than 70 percent of the 200 plus health care organization and CBO respondents indicated that their partnerships involved more than two partners.

Using corporate alliances as a gauge, the number of alliances increases by 25 percent a year. Those alliances account for nearly a third of many companies’ revenue. Partnerships offer the possibility of achieving more together. They take all shapes and sizes, often forming out of a previous relationship or history of collaboration. For accountable care organizations (ACOs), 81 percent involved new partnerships between independent health care organizations which already had existing positive relationships.

Policy drives partner relationships

Policy influences the nature of partnerships in health care. Their provisions can stimulate or restrict relationships. Sometimes policy aims to advance collaboration. Sometimes it tries to foster efficiency through economies of scale or streamlined government contracting.

In the Partnership for Healthy Outcomes survey, partnerships most commonly provided services to impact immediate-term, patient-level clinical health needs, such as reducing hospital admissions, length of stay, or emergency department use. All of these measures have strong policy drivers as CMS and insurers levy penalties for over utilization. For 65 percent, the partnerships realized cost savings.

Some organizations come together to meet minimum population requirements to qualify for participation in programs, such as the Statewide Health Improvement Partnership (SHIP) and Community Transformation Grants. North Country Health Alliance (NCHA) is a three-county partnership in northern Minnesota to support communitydriven solutions.

NCHA also joins with Beltrami County to manage 51 partner sites for SHIP projects, including 23 workplace partners, 21 schools, five health care partners, and four tobacco free living partners.

“This funding allows us to do a lot more and to partner in new ways with schools and health care to make a difference,” said Marissa Hetland, director Clearwater County Nursing Service/Public Health/Homecare/Hospice and NCHA administrator. “Our partnerships are so valuable to keep things going. Our family home visiting program is flourishing, in part because partners like the Leech Lake Band of Ojibwe help us reach a lot more families.”

Partnerships evolve

Partnerships and alliances change over time. Harvard Business Review reported the failure rate for corporate alliances at 60 to 70 percent. Alliances often fall apart when they struggle with the right level of integration. And when the cost of partnership is too high, including loss of autonomy and control; shared cost of failure; loss of resources or technical superiority; potential conflict over goals or methods; and coordination challenges.

They also dissolve because of external factors. 2019 will be the last year that Southern Prairie Community Care (SPCC) will serve as a Minnesota Medicaid Integrated Health Partnership (IHP) ACO. SPCC came together as 12 counties in southwest Minnesota trying to impact health, care, and cost for people in its region.

“Through 2017 to 2018, it became apparent that the IHP program was not designed in a way to give us the financial and operational sustainability we need,” said Dr. Norris Anderson, SPCC executive director. “Most of the counties have chosen to move forward with a PrimeWest Health expansion, as a way to continue the local influence on health, care, and cost.”

SPCC spun off its population health arm into an independent nonprofit. The Center for Community Health Improvement Inc., (CCHI) in Willmar, was created initially to provide more flexibility and freedom to experiment with initiatives on a community level and access different funding sources.

The groundwork of partnership

Time and energy need to be spent upfront building relationships between partnering organizations. Members of allied organizations need to understand each other’s organizational structure, policies and procedures, and culture and norms. Trust and alignment are key practices for effective partnerships, which this quote from the Partnership for Healthy Outcomes survey so aptly captures, “Our work moves at the speed of trust.”

Motivations for partnering differ. Health care organizations aim to improve care quality and reduce cost, often focused on addressing acute needs, while CBOs aim to address underlying socioeconomic needs by addressing social determinants of health. These key differences can be leveraged to create value.

CCHI aims to do just that as it experiments with developing a community health worker (CHW) hub model. A CCHI staff will serve as its central point, interacting with CHWs, to build a stronger base of authority and legitimacy within the larger community. In its first year of independence, CCHI focused on relationships and building the local business case for CHWs. For example, Rice Regional Dental asked for help establishing Somali contacts as patients. Working with the community, a CHW discovered people were confused by the dental clinic’s appointment system and feared hidden costs. New processes and better communication have resulted in a large increase in Somali patients for the dental clinic.

The next phase is getting community buy in and willingness to invest resources in the CHW position. Carris Health is interested in financially supporting a CHW. The health care system wants the position to fit within its larger care team and to have a level of control over the position. “That could be helpful for meeting certain outcomes,” said Kristin Anderson, CCHI executive director. “And, partnering with us will allow a community health worker more flexibility and let them be accountable to the community first and foremost.”

Outside facilitators can foster partner alignment. Lake Superior Quality Innovation Network, led by Stratis Health, mobilized 1,182 organizations to improve care coordination and transitions in 27 community collaboratives across Michigan, Minnesota, and Wisconsin. Through the work of 57 locally-led problem-solving workgroups, these communities collectively avoided 73,546 hospital admissions and readmission, at a cost savings of $868.82 million, from 2014 to today.

A coordination of care team in the Twin Cities west metro is working to reduce readmissions by 10 percent and bring its rate below state and national averages. “I’ve been in health care almost 30 years now. This was the first opportunity to work with so many people doing the same work from different organizations,” said Peg Lusian, vice president Fairview Partners. “It’s brought us under one roof where we are not competitors. We are collaborators sharing best practices.”

Partnerships of the future

Policy researchers have talked about a future with “population health organizations” that drive better health for geographic populations. These coalitions would serve as integrators at the community level that bring together clinical care, public health programs, and community-based initiatives. They would focus on the underlying behavioral and social determinants of health. Education, housing, transportation, public safety, public health, and related sectors would all be involved. Some have commented “the belief that they could exist may seem excessively optimistic.”

Don’t tell that to the unicorns, like Health Care Collaborative (HCC) of Rural Missouri. HCC serves the role of a population health organization for its rural geographic service area, which covers more than 88,000 people, with 34 percent who live below 200 percent of the federal poverty level. This rural health network, comprised of more than 55 member organizations, wraps social service support around patients.

The HCC board—with representation from the local public health department, critical access hospital, community mental health center, dental school, and nursing school—brings different perspectives to projects while taking the position that the community owns the programs and services.

In the ongoing search for ways to deliver quality health care and social services, HCC looks for new, untried approaches to push innovation. For example, to reduce recidivism and promote health, people on medications newly released from prison are assigned to a registered nurse who serves as their community health worker. The nurse makes sure the patient has a plan to manage their health and medications.

“Network organization members are expected to work on issues with different organizations and communities and to try new approaches, learn, and improve together,” said Toniann Richard, HCC CEO. “Acting collectively through the network, board members are not afraid to approve of calculated risks.”

The future of health and health care will rely more and more on these kinds of strategic and creative partnerships.

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Read the Rural Innovation Profile for HCC of Rural Missouri, Rural Health Network Thrives on Innovation in Whole-Person Care (February 2019).