2015

With a new year, we all consider our resolutions and opportunity to change. Well, the NC Foundation for Advanced Health Programs (NCFAHP) has been giving this a lot of thought in recent years. Our founder, Jim Bernstein, embraced change and the innovation required to bring it to fruition. Many of our “friends and family” encouraged us to change our name, saying: “It’s too hard to remember.” Over the past year, we sent surveys to our partners and friends, held focus groups and at last reached a consensus on a new name. Beginning January 1, 2016, NCFAHP will become the Foundation for Health Leadership and Innovation, with the tagline: Moving People and Ideas into Action. Our website address will also change to foundationhli.org. Thanks to each and every one of you that gave us your time and ideas. We look forward to staying in touch and continuing to live up to the challenge our new name suggests and the legacy of Jim Bernstein.

Aging in North Carolina is another topic we have spent a fair amount of time discussing with our board and staff. Much attention has been given to the “silver tsunami” yet we are still woefully unprepared to care for the very individuals in our country that have so gallantly contributed to our own well-being. It reminds me of James Taylor’s song, “Secret of Life”:
[box type=”bio”]

The secret of life is enjoying the passage of time. Any fool can do it, there ain’t nothing to it. Nobody knows how we got to the top of the hill. But since we’re on our way down we might as well enjoy the ride.

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As we change, age and consider what this means, how can we help our seniors “enjoy the ride”? Here are some of our state’s facts on aging:

NC ranks 9th nationally in population 60 and over
By 2025, 89 counties are projected to have more people 60 and over than 0-17
NC ranks 6th in the number of grandparents responsible for grand children under 18
48 percent of older adults have two or more chronic diseases
In 2010, more than 170,000 people aged 65 and over had Alzheimer’s disease or other types of dementia. By 2025, this number is projected to increase to 210,000.

Attention to population health provides a perfect opportunity for us to consider the “ride” and not the crash!! What are the things we can do in our communities that reflect value not just loss? In February 2010, The Economist published an article “The Silver Tsunami”, discussing the management of an aging workforce. Small changes in production lines helped maintain productivity. Designing and modifying housing to support progression in age is critical to aging in place. A report prepared for The Duke Endowment: “Aging in the Carolinas: Demographic Highlights, Programmatic Challenges & Opportunities” presents a thorough review of our opportunities. Jim Johnson concludes in the final paragraph of his report:

“What is needed in this space is a centralized hub for successful aging in place ideas and practices. Such an entity should serve five specific but interrelated functions: mobilize collective ambition, leverage intellectual capital, facilitate new venture creation training, foster social innovation, serve as a clearinghouse for information dissemination, and engage in succession planning.”

As we pause to honor 2015 and the new year, let’s not forget the shoulders we stand on in order to face the future.

-Maggie Sauer

CEO & President

Neftali
Psychologist Neftali Serrano remembers when the concept of integrated care—the combination of behavioral health and primary care—clicked with him.

Dr. Serrano was working in a health center, down the hall from the primary care physicians. He only had two or three patients a day. “I was open for business and had no one coming in,” he said.

Out of that futility, he said he started spending time with providers instead of sitting alone in his office. This evolved to walking into exam rooms and working with patients directly.

“Within 30 seconds, patients were opening up about their behavioral health issues and getting to things that would usually take hour long visits or even a series of visits,” said Serrano.

Dr. Serrano said he connected faster to patients in a primary care setting. “They trusted their primary care doctors and they extended that trust to me,” he said.

Dr. Serrano now works with the Center of Excellence for Integrated Care, a program of the Foundation that trains health care professionals and providers to treat behavioral and physical health in one setting.

[box type=”bio”] “They trusted their primary care doctors and they extended that trust to me.”[/box]

Integrated care can work especially well among the aging population. Two out of three Americans aged 65 and over have chronic illnesses, which are often coupled with mental health distress. The Centers for Disease Control and Prevention estimates that 20 percent of adults over 55 have a mental health concern. Decreased mobility, isolation and health complications can cause anxiety, depression, and severe cognitive impairment among our aging community members.

Integrated care can offer older adults a safe place to get help with these behavioral health issues.

“Some older adults are not as willing or able to go outside the walls of a primary care office to see a therapist,”” said Dr. Serrano. “Having a behavioral health consultant right there is a more culturally appropriate way to deliver care for folks who are more comfortable with primary care.”

[box type=”bio”] Integrated Care can offer older adults a safe place to get help with behavioral health issues.[/box]

Initial research trials among the elderly combined psychiatric therapy with primary care, and proved to be very successful, said Dr. Serrano. For example, cardiovascular health, a common concern for the elderly, can improve by treating depression. “There are clear links between heart health and depression,” said Dr. Serrano.

Another advantage of integrated care is the free flow of patient information. The patient’s medical history is on hand, and can better inform the behavioral therapist, instead of having to start from the beginning with every patient.

Integrated care can also help primary care physicians make better assessments for their patients. For example, depression is often masked by physical health issues. Patients with vague pain may be suffering from isolation or loneliness.

“Oftentimes primary care doctors will do a whole lot of work to address the physical problems but fail to address the root issues,” said Dr. Serrano.

There is also a certain threshold a patient must meet for referral to a mental health therapist. Many people that need behavioral health assistance may not have acute behavioral health issues, but would benefit from the input of a therapist in their primary care office.

Dr. Serrano said it will take a lot of broad training across specializations to prepare the medical profession for an older population. Mental health professionals in particular, according to Dr. Serrano, will need to reconfigure their mindset and work-flow. “Mental health professionals are more accustomed to sitting in an office by themselves than working on a team,” he said.

The Center of Excellence for Integrated Care (COE), a program of the Foundation, helps providers make this adjustment. They have practical training programs on all aspects of integrating the silos of behavioral health and primary care in any setting where health care is delivered. COE is also dedicated to reducing the stigma associated with behavioral health issues. Accessing therapy through a primary care doctor can help reduce any discomfort of feeling of shame about needing help. The integrated approach to elderly care is important to recognize and replicate as our population continues to age.

By 2025, 89 percent of NC counties will have a greater number of older adults than children. The aging baby boomers in combination with increased longevity of life will cause North Carolina’s older population to double in size in the next 15 years. This influx prompts us to think intentionally about how to support our older community members and their caregivers. As a state we are paying attention to the issues surrounding our aging citizens.

For example, in September 2008, the North Carolina Medical Journal, released an edition titled Healthy Aging in North Carolina. The journal introduces the challenge of healthy aging, in which older adults are able to live disease-free, maintain their physical and mental functioning and actively engage in their communities. The edition draws on the expertise of stakeholders across the state who offer a roadmap for preparing for an increasingly older population.

In addition, the North Carolina Institute of Medicine (NCIOM) is hosting two task forces related to aging that convene stakeholders and organizations on the health issues we face:

Task Force on Alzheimer’s Disease and Related Dementia
Task Force on Mental Health and Substance Abuse: Older Adults Working Group

NCIOM’s mission is to develop strategy and build collaboration around the greatest health challenges facing our state. The organization just wrapped up the task force on Alzheimer’s disease and related dementia. As our population ages, the occurrence of Alzheimer’s disease will become more frequent. The number of North Carolinians with Alzheimer’s disease and related dementia is projected to increase 31 percent by 2025.

Alzheimer’s disease is the most common form of dementia, which generally refers to a spectrum of symptoms associated with memory and cognitive function loss which can result in an inability to perform daily tasks.

“It touches so many people. Everyone knows someone who suffers from Alzheimer’s, or who cares for someone with dementia,” said Michelle Ries, who heads up the task force.

The task force was a seven-month collaboration to produce an actionable plan for the coming spike in Alzheimer’s disease and related dementia. The collaboration included the North Carolina Department of Health and Human Services, AARP North Carolina, Alzheimer’s NC, the Alzheimer’s Association and LeadingAgeNC.

The group hopes to increase awareness and reduce stigma about the disease, which is a prevalent problem.

“People don’t want that label because it may affect their employment or even personal relationships,” said Ries. This reluctance causes problems for data collection and efficient delivery of care.

Another aim of the task force is to support people with dementia and their families with improved services. “What we’ve found is that it’s very helpful for caregivers to stay active and connected in the community,” said Ries.

Caring for a loved one with Alzheimer’s disease or related dementia can be very taxing. The report targets specific goals for supporting the estimated 444,000 North Carolinians who provide unpaid care for their family member with dementia.

The task force’s action plan will be published in March 2016, and will provide our state with tactical directions for preparing for an aging population in North Carolina.

The work of NCIOM and their partners exhibits North Carolina’s commitment to understanding and preparing for our unique challenges. The message is clear from the North Carolina Medical Journal: “We all need to work together and share the responsibility to increase the quality of life for all North Carolinians.”

To learn more about the work of the task force, visit:
http://www.nciom.org/task-forces-and-projects/?task-force-on-alzheimers-disease-and-related-dementia

Oral health disparity affects all age groups, but is particularly difficult for the elderly. The complications of frail and failing teeth are compounded by the inability to access care. Insurance coverage for oral health is spotty, and Medicare, the public insurance available to the elderly, does not cover oral health.

Many of our aging community members, especially vulnerable and underserved populations, did not grow up with the benefit of water fluoridation, and 25 percent of adults aged 60 are missing many of their original teeth. Besides the painful side effects of oral health issues, missing or weak teeth affect nutrition, as older adults choose softer and potentially less nutritious foods. Twenty-three percent of the elderly population in the U.S. also suffer from gum disease, which is more common in disadvantaged populations.

In North Carolina, we are fortunate to have caring organizations working to collaborate on solutions to the problem of oral health disparity among the elderly. One of these organizations is Access Dental Care, a dentist office on wheels. Access Dental is a non-profit organization that travels to long-term care facilities to meet the needs of elderly patients.

Zulayka Santiago, director of the NC Oral Health Collaborative, reflected on the experience of a day with Access Dental:

“As a newcomer to the world of oral health, I had heard great things about the work of Access Dental Care. Given that words so often fall short in communicating the impact, it was important for me to witness their work in real time. I met them at Rex Health and Rehabilitation in Apex, a new site for them. It was a cloudy Monday morning, but what I witnessed that day would brighten most any day.

I met the van in the parking lot and helped them unload all of their equipment. In just a few minutes a full dental office set up in one of the dining areas! The ease and flow of process signaled to me that those three individuals had performed this routine many times. Providing dental care to individuals who are frail, elderly or who have intellectual or developmental disabilities is not easy (to state the obvious). My brief time with Access Dental Care definitely affirmed this fact. But more importantly, what the experience illuminated for me was that this type of work requires a certain strength of character and commitment to ensure that each patient receives the care they need with compassion and a lightness of heart.

Dr. Bill Milner (dentist), Betsy White (dental hygienist) and Rhonda Little (dental assistant) made a big impression on me that day. As we work to ensure access to optimal oral health for all North Carolinians, it is essential to celebrate the models that are working well and doing a good job of reaching the most vulnerable. I applaud and am inspired by the work of Access Dental Care. I am grateful to have such strong partners within the NC Oral Health Collaborative.”

The Foundation, through the expertise of the NC Oral Health Collaborative, acts as a convener for oral health disparity issues in the state. We work with partners like Access Dental Care to develop strategies and action plans to improve the oral health status of all North Carolinians. For more information on the Oral Health Collaborative, click here.

To learn more about Access Dental Care, visit http://www.accessdentalcare.org/

The Foundation would like to congratulate the Bernstein Fellows Class of 2013-2015 on their completion of the fellowship program.

Our graduated Fellows include:

Sarah Brill Thach, MPH: The Center for Healthy Aging at the Mountain Area Health Education Center
Joanne Rinker, MS: Director of Training and Technical Assistance at the Center for Healthy North Carolina
Marian Sadler Aldridge, MPH: Community Development Specialist at the Buncombe County Department of Health
Jill Boesel, MPH: Project Coordinator for Physician Practice Services with Community Care of North Carolina
Amelia Mahan, MSW, Behavioral Health Program Manager at Community Care of North Carolina

The Foundation is pleased to welcome its newest class of Bernstein Fellows. Five dynamic professionals will participate in the fellowship program through October 2017, they are:

Pete McQuiston: Director of Food and Nutrition at Swain Community Hospital in Bryson City, NC
Rod Jenkins MHA: Deputy Health Director for Cumberland County, North Carolina
Erin Hultgren, MPH: Program Manager at Gaston Family Health Services, Inc.
Catherine Parker, MA: Director of Hertford County Student Wellness Center, a division of Roanoke Chowan Community Health Center.
Jamie Cousins, MPA: Program Manager for the Catalyst for Health Eating and Active Living

We’d like to thank retiring program Director, John H. Frank, for his leadership in the program since 2010. During his time as Director, he strengthened the curriculum, increased the number of programmatic partnerships, and guided thirteen Fellows through completion of the fellowship. The Foundation is extremely fortunate and grateful for John’s leadership and dedication to the Fellows Program.

We also welcome Tom Bacon, DrPH, as the new Director of the Fellows Program. Tom is the retired Executive Associate Dean and NC AHEC Program Director, and he continues to work as a part-time Research Fellow at the Cecil G. Sheps Center for Health Services Research at UNC-Chapel Hill. The Foundation is excited and grateful for Tom’s commitment and leadership in continuing and developing the Fellows program.

Omisade Burney-Scott joined the Foundation for Health Leadership & Innovation as partnership manager on the Rural Forward NC team in October. She brings years of experience in community engagement to Rural Forward. Read more to learn about Omisade:

Q: What experiences or jobs have led you to work at the Foundation for Health Leadership and Innovation?

I think my ability to hold transformative spaces and support individuals, organizations and communities in navigating growth and deep change in an intentional and grounded facilitated manner brings me to the Foundation. My professional experience of working in rural communities around a myriad of issues such as community development, economic development and leadership development over the past 15 years is also a key factor. Additionally, I had the opportunity to support healthy eating and active living projects across the country in my previous role as a Program Officer with Active Living by Design (an intermediary of the Robert Wood Johnson Foundation).

Q: What role do you play in the Foundation?

I am a Partnership Manager with the Rural Forward NC team. I work with the director and associate director to design, organize, and implement capacity-building services for Healthy Places NC in rural central and eastern North Carolina.

Q. What is most rewarding about your job? What is most difficult?

The most rewarding part of my work is seeing community members and groups become self-sustaining in the ways they come together to do their work (self-facilitated, clear lines of communications and accountability). It’s also rewarding to see the long-term impact of shared leadership processes that lead to innovation and tangible outcomes. The most difficult part of my job is learning the alphabet soup of new health field lexicon (lol)

Maggie-Sauer Over the past year, our newsletters have focused on the efforts of the Foundation and state and national leaders to transform health care. Success in these efforts will, in part, be measured by the transformation of our current and future workforce. Recently, NCFAHP hosted a national webinar with 3RNET, the National Recruitment and Retention Network discussing workforce needs in the current environment, New Models of Care and their Impact on Rural Workforce.

Dr. Erin Fraher, Ph.D* framed the conversation with her presentation: “The Workforce Needed to Staff Value-Based Models of Care”. According to Dr. Fraher, new roles are emerging to provide enhanced care functions.

Dr. Fraher suggests that two of the common new roles are:

Roles that focus on coordinating care within a health care system
“Boundary spanning” roles that coordinate patient care between health care system and community-based settings

Improving patient care and population health is dependent on “boundary spanning.” It’s one thing to create a descriptive title for the process and quite another to engage the workforce in the process. Change is never easy. Yet, to Dr. Fraher’s point we need to “Plan to provide a workforce of health not a healthcare workforce.” Additionally, she makes the following points regarding boundary spanning roles.

Workforce planning efforts that include workers who typically practice in community and home-based settings
Embracing role of social workers, patient navigators, community health workers, home health workers, mental health workers, dieticians and other community-based worker
Integrating health workforce and public health workforce and planning

Hmmmm, this sounds vaguely familiar… Our May newsletter focused on Accountable Care Communities, which are defined as: “a collaborative, integrated, and measurable multi-institutional approach that emphasizes shared responsibility for the health of the community, including health promotion and disease prevention, access to quality services and healthcare delivery. The ultimate goal of the ACC is a healthier community.” (Healthier by Design: Creating Accountable Care Communities)

At the Foundation, we are impatiently awaiting the release of the Accountable Care Community model by the CMS Innovation Center. Fingers crossed, it will provide the opportunity for uniquely partnering these “boundary spanners” together with a payment model to support the work.

Again, in a previous newsletter, Dr. Jerome Grossman and Dr. Jason Hwang’s “The Innovator’s Prescription: A Disruptive Solution for Healthcare” presents a compelling argument regarding the common sense of a “boundary spanning” workforce of health, “Consider this equation, 2 + 8,758. These numbers reflect the hours spent annually by each of us on healthcare during the year. Two hours is the amount of time people spend annually in a traditional healthcare provider’s office, versus 8,758 hours spent on self-care.”

In the article “New Project? Don’t Analyze‑Act!” from the March 2012 edition of the Harvard Business review, authors Leonard A. Schlesinger, Charles F. Kiefer, and Paul B. Brown make this point regarding new endeavors:
“We acknowledge that action before analysis, learning instead of predicting, can be, well, unpredictable—and messy. And we concede that it’s antithetical to the way most organizations work. However, in the long term, taking lots of small steps actually reduces risk, which makes such an approach ideal for tackling challenges and getting fledgling initiatives off the ground, particularly in today’s skittish corporate environment.”

Perhaps with “small steps” we can create a boundary spanning workforce of health. This newsletter describes some of the “small steps” at the Foundation. The team at NCFAHP strives to be entrepreneurial leaders. I would also call the Fellows boundary spanners in their own communities. Finally, from the same article:

“Entrepreneurial leaders are individuals who, through an understanding of themselves and the contexts in which they work, act on and shape opportunities that create value for their organizations, their stakeholders, and the wider society. Entrepreneurial leaders are driven by their desire to consider how to simultaneously create social, environmental, and economic opportunities. They are also undiscouraged by a lack of resources or by high levels of uncertainty. Rather they tackle these situations by taking action and experimenting with new solutions to old problems. Entrepreneurial leaders refuse to cynically or lethargically resign themselves to the problems of the world. Rather through a combination of self-reflection, analysis, resourcefulness, and creative thinking and action, they find ways to inspire and lead others to tackle seemingly intractable problems…The only way to lead in an unknowable environment is through action.”
The Bernstein Fellows are entrepreneurial leaders. In fact, Sarah Thach is the Fellow who directed me to the Harvard Business Review article. In closing, I think it’s only fitting to end with one of her quotes:

“Just try it…. early frequent failures keep you limber!”

Thanks Sarah, and our thanks to the Fellows current and past!

-Maggie Sauer

CEO & President

A flexible workforce is essential for the future of our health care system. A massive shift in the way services are reimbursed is coming. This prompts a similar shift in how we train the workforce that keeps our communities healthy. Federally funded insurance will pay providers based on the quality of care instead of the quantity. The Centers for Medicare and Medicaid is already funding pilot projects to encourage this change. These “value-based payment” projects are causing a bloom of experiments all over the country. The goal of these experiments is to provide patients with preventative and comprehensive care that is high quality and affordable.

It’s a big challenge. But it will be easier to manage if healthcare providers learn from each other. On August 18, the NCFAHP, Practice Sights, and 3Rnet hosted the first of many webinars to begin a national conversation on the creative models in action across the country. Rural areas, because of their small size and their unique needs, are excellent places for experimentation.

The webinar is titled “New Models of Care and their Impact on Rural Workforce.” The conversation was led by Erin Fraher, PhD, an expert on health workforce research at UNC-Chapel Hill, and representatives from three states presenting on projects in their community.

Erin Fraher set the stage for the discussion by explaining the difference between “old school” and “new school” workforce characteristics. In conventional, fee-for-service models, the healthcare workforce is trained to operate in isolated specialties instead of in coordinated teams. The “new school” workforce reaches patients in their community, rather than in a hospital or an acute care setting. This new workforce will maximize the responsibility of medical assistants, panel managers, dieticians, and health coaches. These teams will have a different work flow to accommodate new roles.

Fraher stresses that we will have to prepare and equip the 18 million members of our healthcare workforce for this change. Medical training will also need to include an emphasis on integrated care and include rotations with teams that are following a coordinated model.

The rural health centers from North Carolina, Oregon and Colorado are piloting a variety of projects in an attempt to launch value-based care. Every state is different, but all three are creatively addressing the unique needs of their community.

Chris Collins from the North Carolina Office of Rural Health & Community Care discussed the variety of loan repayment programs to attract medical workers to underserved areas, including therapists in integrated care settings. Collins also discussed the growth of telehealth services in North Carolina and the efforts to fill the gaps.

Melissa Bosworth of the Colorado Rural Health Center presented their work on creating a data bank to show the economic impact of their programs. Those programs include reducing the number of mentorship hours for nurse practitioners and introducing mediation services to improve office culture in clinics. The Colorado Rural Health Center is also pairing health IT students with rural clinics to help them transition to changing technologies.

Scott Ekblad from the Oregon Office of Rural Health highlighted the 16 coordinated care organizations across the state. Fourteen of these organizations are rural. These organizations have a “global budget,” and are given the creative power to meet needs. They have an incentive to keep Oregon citizens well using community health teams. Medical assistants, dental hygienists and community paramedics have more responsibility and are well connected to patients in a community setting.

Practice Sights and the NCFAHP will continue the conversation on the efforts of states that are moving to value-based care. Stay tuned for the next webinar!

Neftali The Center of Excellence for Integrated Care adds another level of expertise by welcoming Neftali Serrano as Associate Director. The Center of Excellence aims to integrate patients’ physical and behavioral health across health care settings. Serrano has years of experience doing just that, and we asked him a few questions to get to know him better:

What attracted you to the Center of Excellence?
After 14 years as a clinician and program developer I was looking for an opportunity to train a behavioral health workforce in primary care in a more efficient, scaled fashion. The Center of Excellence provides this opportunity to engage an entire state in developing an integrated care workforce. This is a really exciting opportunity.

Where were you before accepting this position?
Before coming to the Center of Excellence I was the director of behavioral health at Access Community Health Centers in Madison, Wisconsin where I developed a primary care behavioral health program that is one of the most mature and successful programs in the country. The team there is great and one of my proudest accomplishments professionally is that when I left the program was a strong as it ever was and will continue on in perpetuity as a result.

What are your hopes for the position?
I hope that in five years or so we are all able to look back and reflect how we were able to train hundreds of behavioral health professionals to provide integrated care to thousands of patients across the state of North Carolina and set a model for how to do so in a sustainable fashion for other states to follow.

In your experience, what’s been the best strategy for successful behavioral health integration?
The keys to successful integration are actually pretty simple. First, it is essential to have a relatively healthy organization. No project of any kind thrives in a dysfunctional organization. Second, it is essential to have clear that one of the main goals of integration is to support the day-to-day work of primary care clinicians. In other words, whatever you do should make life easier for the main cogs of your workforce. Third, you need behavioral health professionals who are truly able and willing to adopt a new professional identity related to primary care. Mental health professionals who work in primary care become a new breed or type of professional and embracing this is core to working through all the inter professional issues that will arise. And of course it is essential the mental professionals remember the first key, which is the primary care clinician is their first customer.

Leaning into Change…