Chris Michael Kirk and William D. Neigher
Healthcare reforms and market pressures are rapidly moving U.S. healthcare systems from volume to value, from traditional medicine to population health. In this environment, a new set of skills will be required for organizational success. We believe that community psychologists are uniquely positioned to contribute to these efforts. The purpose of this paper is to explore the relevant practice competencies in the evolving context of health care in the United States. The article summarizes some changes in the U.S. healthcare system, discusses key competencies needed for success and aligns them with competencies identified by community psychologists. Using examples from a large healthcare system in the eastern United States, this article highlights ways in which the healthcare system of the future can benefit from the principles and skills practiced by community psychologists.
Keywords: community psychology, health care access
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Healthcare in the United States is changing. The passage and implementation of the Patient Protection and Affordable Care Act (PPACA) [P.L.11-148] is changing the incentive structure for healthcare delivery, moving healthcare systems toward an emphasis on prevention (Koh & Sebelius, 2010) and value based purchasing by payors. This move from reactive “sick care” to preventive health care, from volume (e.g. more tests = more reimbursement) to value (e.g. cost per episode of clinical outcome) is a fundamental shift for an industry that has been built around the “perverse incentives” of the fee-for-service system that rewards “how much care” over “how efficient and effective.”
This fundamentally new and emerging dynamic demands a new set of skills for healthcare organizations, competencies that have not typically been emphasized in medical training and health care administration. Importantly, many of the competencies of the emerging healthcare system fall within the set of skills and experiences common to community psychologists. As healthcare systems grow to emphasize prevention, promote patient empowerment, and impact health from multiple ecological perspectives, Community Psychologists are uniquely positioned to play an important role in this transition, with the opportunity to make a significant impact in the health status of communities. The purpose of this paper is to highlight the relevant community psychology competencies at play in the evolving world of health care, providing a brief theoretical overview and concrete examples from a large healthcare system in the eastern United States.
Moving Toward Population Health Management
As illustrated in Figure 1, the demands on the healthcare industry, initiated by health reform and market pressures, are causing a shift along two axes. In this model, health status on the x-axis presents the continuum of health, from terminal illness to thriving. The y-axis highlights the ecological context at which interventions may be targeted. These range from individuals to entire populations.
What doctors and hospitals currently do can be plotted in the lower left-hand corner of the Emerging Healthcare Model (Figure 1). Individuals with some degree of sickness are seen and treated. Physicians are reimbursed for their ability to properly diagnose a patient and prescribe the correct course of treatments that will cure or heal, or provide palliative care (i.e. the right side of the model). While this paradigm is vitally important for those who are ill, the financial incentives have encouraged healthcare systems to put most of their effort, energy, and capital into a system designed to favor the highest end of the case mix index [i.e., resource intense care].
Despite its successes, this model is incomplete and unsustainable. The PPACA increased access to affordable preventive services, holds Accountable Care Organizations [ACOs] accountable for providing these services, and formed the National Prevention Council. This group produced the first National Prevention Strategy (National Prevention Council, 2011), which represents a powerful tool for public health and healthcare organizations in thinking about chronic illness, health disparities, and patient empowerment within an ecological context. With Medicare penalties for hospital re-admissions, shared savings models, and the widespread availability of “free” screenings, the incentive structure is changing incrementally toward preventive care as a more valuable component of healthcare.
Population Medicine and Population Health Management
A second shift is illustrated on the vertical axis of the Emerging Healthcare Model (Figure 1). The emphasis on prevention means that healthcare systems can no longer focus only on patients, but must turn their attention to populations as they assume financial risk for cost containment. This not-so-subtle change is moving healthcare systems into the community, not just to market services and perform generic screenings, but to create measurable change in the health status of the populations they serve. This move is precipitated by many factors including increased evidence for the impact of the social determinants of health (Braveman et al, 2011), emerging business models that emphasize shared costs and risk mitigation, and evolving demographics.
While both areas comprising the upper quadrants of the model (Figure 1) are grounded in an epidemiological science base, we distinguish between population medicine (upper left hand quadrant) and population health (upper right hand quadrant). Population-based medicine is focused on identifying risk factors and finding new ways to manage chronic disease (Peters & Elster, 2002). The Medicare Shared Savings Program and Accountable Care Organizations are grounded in this quadrant, trying to find cheaper and more effective ways to help patients and families, providers and insurers consume fewer inappropriate resources.
In contrast, population health management takes a broader approach that includes prevention. Defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the groups” (Kindig & Stoddart, 2003), population health’s focus on a broad range of “health outcomes” creates many opportunities for affecting the health status of populations, not just those who are sick. Much of the recent emphases of public health institutions to improve the built environment (Prevention Institute, 2004), address health policy, and extend evidence-based primary prevention initiatives fit firmly within this quadrant.
Competencies for the Next Generation of Healthcare Delivery
As healthcare shifts toward prevention and population health management, the competencies of the workforce must also shift. While there will always be a need for practitioners adept at the diagnosis of injury and illness, effective treatment planning and delivery, effective patient communication and regimen adherence, new competencies will be required. Table 1 highlights the some of the key competencies needed for success within each quadrant.
Preventive medicine requires a set of competencies that are distinct from the daily practice of many physicians and other providers, and the policies and strategies of healthcare institutions, organizations and systems. While some practices do an excellent job, an emphasis on screening, immunization, and health education for patients has often been neglected, reduced to a difficult-to-read flyer or a hurried conversation. The incentives of the traditional healthcare model did little to reimburse them to keep their patients healthy. By incentivizing preventive care, healthcare reforms are trying to push practices to adopt these competencies, and providers will have to adapt either by building these competencies themselves (e.g. valuing screening) or adding people to their teams who possess these skills (e.g. health educators).
Population medicine requires grounding in epidemiology and risk analysis combined with the ability to develop and apply interventions to help the chronically ill manage their diseases more cost-effectively. At the same time, institutions that work in population medicine must find ways to communicate effectively both to patients (or beneficiaries) and to healthcare providers, helping both groups understand evolving processes and take necessary steps to obtain more cost-effective care.
Population health management, as defined here, requires three basic competencies for success. First, healthcare workers in this quadrant must find ways to engage the community, understanding that much of health and healing occurs outside of the medical environment. Second, interventions (including policies, built environment, and programs) must be developed emphasizing primary and secondary prevention. Without this investment, healthcare systems will have difficulty adjusting to the wave of people with serious, but preventable health concerns including diabetes and obesity. Finally, population health management policy needs to embrace the values of inclusion and find ways to empower people to control their own health and wellness. We argue that community psychologists are especially equipped to play a significant role in this shift toward population health.
Community Psychology Competencies
Recent efforts at defining a set of competencies for community psychologists have yielded a beneficial list of 18 skills that are common to the field (Dziadkowicz & Himenez, 2009, Wolff, 2011). The goal of this effort was to highlight the unique contribution made by community psychologists, a field that is often unknown to many in the world of practice, and to construct and validate a value proposition to distinguish us among similar professions to prospective employers (Elias, M.J., 2009). By outlining a set of competencies, the field can better inform the education and employment of community psychologists around the world. The 18 competencies can be divided into five categories: 1) foundational principles, 2) community program development, 3) community and organizational capacity-building, 4) community and social change, and 5) community research.
While the contributions of community psychologists are not mutually exclusive from those of various theoretical orientations, the complete constellation of identified competencies highlighted have great use in various settings, including the emerging world of healthcare. As healthcare reforms push health systems toward population health, we believe that over the next decade healthcare may become an opportunistic workplace for community psychologists. These settings are inclusive of traditional and emerging stakeholders, encompassing hospitals and health systems, Accountable Care Organizations, multispecialty group and primary care practices, payers [government and commercial], health policy organizations and foundations, public health organizations, and local, state and federal government agencies.
Atlantic Health System (AHS) in Northern New Jersey is an example of a healthcare system that is already incorporating the skills and experience of community psychologists. Serving a population of almost two million people, Atlantic Health System (AHS) is home to community psychologists in senior management, starting with the President and Chief Executive Officer, the VP and Chief Strategy Officer, and the Director of Mission Development with responsibility for community health at the system and hospital level. Listed as one of America’s Top 50 hospitals in two specialties and with one of the largest Medicare Accountable Care Organizations in the country, AHS is poised to be a leader in the future of healthcare and the shift from traditional medicine to population health.
Table 2 lists the key community psychology competency groups with their application to healthcare settings and specific examples of examples of how AHS is applying these competencies within our settings. While much could be written on each of these initiatives, the purpose of this paper is to highlight alignment opportunities for community psychologists.
The foundational principles of community psychology include the “values and perspectives” that are common to community psychologists. These include: 1) ecological perspectives, 2) empowerment, 3) socio-cultural and cross-cultural competence, 4) community inclusion and partnership, and 5) ethical, reflective practice. In the emerging world of healthcare, these principles are increasingly aligned with the needs of healthcare systems. For example, as the focus shifts from patients to populations, an understanding of multiple ecological levels is vital. Further, the coming emphasis on prevention requires a passion to empower diverse groups of people to control their own health and healthcare. By holding and applying these values, community psychologists already speak the language that is currently being learned by many in the healthcare workforce.
One area in which we are working to find ways to create empowering environments for our patients and communities is our health literacy initiative. Defined as “the capacity to obtain, process, and understand basic health information and services to make appropriate health decisions” (Ratzan & Parker, 2000), health literacy is a function of both the skills and abilities of individuals and the complexity of the healthcare system. In short, most healthcare communication is too complex for the average person and the outcomes associated with limited health literacy include hospitalization, emergency department usage, lower quality of life, and premature death (Agency for Healthcare Research and Quality, 2011).
Working with doctors, staff, and community groups, we are leading a system-wide initiative to create a more health literate healthcare system and to design community-based programs to increase health literacy in vulnerable populations (Brach et al., 2012). The principles of empowerment and socio-cultural competence provide the framework for leading this effort, and our ecological understanding allows for the analysis of health literacy from multiple vantage points. Combined with emphasis on shared decision-making and patient engagement, health literacy is a great opportunity for community psychologists to apply their foundational principles in a way that has the potential to dramatically affect the health of individuals and communities.
Community Program Development
Community psychologists also maintain competencies in developing programs and preventive interventions. Building on the strong value base of prevention and health promotion, community psychologists in the changing world of healthcare delivery have the opportunity to develop initiatives designed to keep populations healthier. As mentioned, these skills have not been consistently applied by those in traditional healthcare delivery. By bringing the ability to develop, implement, and manage evidence-based programs that will affect community health, community psychologists can provide a valuable service to healthcare systems.
At AHS, we are realigning the departments of Community Health at each hospital with the National Prevention Strategy and the identified best practices in prevention and health promotion. In the past, much of hospital-based community health has been grounded in clinical practice (screenings, immunizations) and the marketing and public relations plan of the hospital. In contrast, we are setting up a process that emphasizes data-based decision-making, evidence-based best practices, and sets the metric for success as total population health. Community psychologists who possess these skills have the opportunity to make a significant impact in community health departments in a number of delivery settings. We explore some of these opportunities next.
Community and Organizational Capacity-Building
Healthcare systems range in size and scale, from small community hospitals to large national corporations, both not for profit and proprietary. Regardless of size, leadership is challenged to move these organizations forward in order for them to survive in a world of value-based purchasing. Building on the competencies of 1) community leadership, 2) small and large group processes, and 3) consultation and organizational development, community psychologists have the opportunity to shift organizations toward the future, engaging multiple stakeholders including patients, communities, organizations, staff, physicians, and payers.
With the unanimous support of its Board of Trustees, AHS has recently changed the vision of our organization from an emphasis focused on nationally recognized quality medical care to an emphasis on community health: “Empowering our communities of the healthiest in the nation.” More than just changing the vision, it is part of an effort to involve the system and the community in becoming directly involved in population health. More than 17,000 AHS staff, physicians, volunteers and Board members will reach out to our communities in a multi-element initiative to engage them in proactive change.
A media campaign asks the question “if you could do one thing, and one thing only to improve the health of your community, what would that be?” Respondents will not only be asked to answer, but to become involved in the process. By participating in “community action teams” based on the priorities we received and consonance with a formal needs assessment survey by our community health committees at our individual hospitals [CHNA explained below], we hope to find more than one thousand new contributors to our efforts.
At the same time, we are refocusing our efforts internally. In an attempt to become more patient-centered, we launched a system-wide Healing Culture Council, designed to re-imagine and improve the patient experience (Neigher and Hakim, 2012). With extensive participation across all levels of the organization, this group has been able to identify areas for improvement and enact changes that are making AHS hospitals a better, more supportive experience for patients, families, and staff.
Examples include extending pet therapy [“Healing Paws”] to patients and staff [“Ruff Day”], healing messages for “on hold” calls, increasing access to integrative medicine services, encouraging “eye contact at eye level” for all patient encounters, more “quiet time” with subdued lighting on inpatient floors, increasing pastoral care availability, fostering better advance care planning, moving to unrestricted visiting hours 24/7, and a renewed emphasis on the healing arts.
These are examples of how community psychologists can help build the capacity of organizations for a more patient and family centered environment. The ability to understand organizational culture, facilitate groups, and lead organizational development processes are critical success factors.
Community and Social Change
To be successful in the future of healthcare, providers will have to look beyond the confines of their offices and hospitals to build solid partnerships with organizations across the communities they serve. Only a small percentage of healing occurs in a healthcare environment. Neighborhoods, workplaces, schools, playgrounds, and community organizations all have an impact on the health and well-being of the population. Thus, to truly affect population health, healthcare systems must embrace an ecological understanding of the multiple determinants of health and build strong partnerships with organizations across the spectrum. The competencies here include: 1) collaboration and coalition development, 2) community organization, and 3) community education.
The PPACA provided hospitals with a great opportunity to improve population health by engaging with the community. Part of the Act required non-profit hospitals to conduct a Community Health Needs Assessment (CHNA) every three years. While the requirements for this process are relatively open, one tenant is that hospitals must consult “community representatives” including those of low-income, minority, and/or chronically ill populations. While hospitals are not required to maintain long-term partnerships with these sectors, the mandate creates an opportunity in which those with the ability to effectively engage diverse community members, build coalitions, and establish collaborative partnerships can have a sustainable impact.
At AHS, we are conducting CHNAs across the region and have designed a process to develop partnerships with a broad spectrum of community representatives at each of our sites. We are finding great opportunities to partner with faith communities, non-profit organizations, businesses, and schools. One of the brightest opportunities is an increased connection with public health partners. We are finding common values and goals with many of our partners in county and municipality-based public health systems and are exploring new ways to increase opportunities for collaborative and efficient interventions.
Healthcare systems are a wonderful natural laboratory for applied and translational research. While research has a mission-driven role in academic and teaching healthcare settings, community psychologists bring skills in participatory community research and program evaluation that have the opportunity to emphasize strengths, empower people, and create actionable change. At AHS, we are working on a series of research projects to inform medical practice and community health.
For example, we are working to test a model of patient adaptability in multiple populations including surgical patients, Medicare beneficiaries, and employees. As shown in Figure 2 (Neigher and Hakim, 2012), this model defines adaptability as the ratio of resilience to vulnerability. This research will be used to test interventions to build resilience in patients and communities, allowing hospital systems to move beyond solely risk-based assessment. Other opportunities include evaluations of hospital initiatives and community-based programs. Healthcare settings remain a critical environment for community research and should interest community psychologists who are passionate about improving health while adding to the research literature.
The purpose of this paper was to highlight ways in which the competencies of community psychology are relevant to practice within U.S. healthcare settings. As shown, there is great overlap between many of the competencies that community psychologists embrace and the emerging needs of healthcare systems. We hope that in the future an increasing number of community psychologists will consider healthcare systems as a workplace setting, and believe that health systems (and the communities they serve) will benefit from the skills and values that community psychologists bring to the table.
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Chris Michael Kirk and William D. Neigher
Chris Michael Kirk is Director of Mission Development at Atlantic Health.
William D. Neigher is Vice President and Chief Strategy Officer at Atlantic Health.
Keywords: community psychology, health care access, gjcpp