Insights / Quality Improvement / Uncategorized

Beyond Models: The Compassionate Intersection of Clinical Medicine, Sociobehavioral Health Determinants, and Delivery System Transformation

Abhishek Dalal and Uyen Phan

 

In the September 2018 issue of Healthcare: The Journal of Delivery Science and Innovation, meet Amy Boutwell, MD, MPP and read this blog post for an enhanced understanding of the significance of Dr. Boutwell’s thought leadership and the field of delivery science in a manner aligned with social medicine’s vision.

Boutwell, President of Collaborative Healthcare Strategies, is shaping delivery system transformation at the state and national level. Her sweeping interview begins with her outlook on the evolving intersection of healthcare policy with market structures and its desired and developing effects (e.g., implementation of organizational innovations) on healthcare outcomes.

Boutwell advocates for an integrated approach to healthcare at the systems level and down to the point of care. She details how the sociobehavioral determinants of health and its logistical aspects should be paid attention to by providers themselves and in collaboration with other health professions and how health facilities can evolve to support these endeavors. Boutwell expands her point about healthcare treatment not simply being biomedical to how healthcare treatment is not the purview of an individual health facility and solely at the point of care. She provides real-world solutions to the health system’s fragmentation, which underscore lessons from other industries where poor interorganizational integration leads to crucial cognitive and material resources (i.e., in healthcare, resources to manage the social, behavioral, and logistical aspects of health) dissipating for strategic outcomes, and operational requirements shifting the remaining resources to managing “just in time” (i.e., healthcare treatment viewed as the purview of an individual health facility solely at the point of care) [1].

Boutwell is an action-oriented leader. She, through working on large scale initiatives, has developed “methods” rather than “models”. Boutwell works with hundreds of teams nationally and develops methods by identifying the common elements of success and of failure. An architect of delivery science, Boutwell accomplishes drawing “generalised lessons from local experiences” and “building theory around the processes of implementation and increasing understanding of the complex change processes involved.” [2] In other words, Boutwell has spearheaded the learning needed to drive improvement by creating granular information “about what works, for whom, and in what contexts.” [3] Her work preserves small scale or quality improvement’s best aspect which is “directed at securing change.” [4] Advocating “methods” and not “models”, Boutwell says “Models are made to be broken by the next team in a different environment, working on different patients, with different resources.”

Coinciding with the release of Boutwell’s interview, Boutwell and colleagues at the New York State Medicaid program announced the incredible success of a state-wide application of rapid-cycle continuous improvement (RCCI) method to enhance the care of the acute care setting high utilizers  (now called multi-visit patients, or “MVPs”).[5] Boutwell designed the “MVP method” and led the implementation of 3 years of serial implementation cycles; now, over 80 MVP teams have launched across New York state. Boutwell had also developed the “ASPIRE+” methodology to reduce all-cause, all-payer readmissions by implementing interventions that matched the root causes of acute-care returns for complex need populations in a data-driven manner. Over 85% of teams in a 2-year implementation of ASPIRE+ achieved measurable reductions in their acute care utilization measures.[6] “ASPIRE+” and “MVP method” were designed for scale – to be applicable in a variety of settings, for a variety of target populations, and with a variety of resources. Leading delivery system transformation, Boutwell has put forward the important “evidence, strategies, and methods needed to support translation of first-rate ideas into broader practice.” [7]

Boutwell’s work is unique, especially when considering the admonishing words on the state of health system strengthening by Jim Yong Kim, President of the World Bank since 2012 and a physician-anthropologist: “Downplaying execution has sometimes been seen as proof that our minds are focused on high ideals, not bogged down in the mundane mechanics of implementation. This confusion has compromised health care in the United States and many other places—and it is no longer acceptable.” [8]

Boutwell has also said that “poverty is not a reason to expect and accept worse outcomes.”[9] Her social justice orientation and compassion stem from her formative experiences working in homeless shelters, street clinics, HIV outreach, prisons, and the slums of India and El Salvador and East LA, which have provided key insights into the human condition.

Read “Interview with Amy Boutwell, MD, MPP” in the September 2018 issue of Healthcare: The Journal of Delivery Science and Innovation for an in-depth look at Boutwell’s views and her career. [9]

Abhishek (Abhi) Dalal is an alumnus of the University of California at Berkeley.

Uyen (Annie) Phan is an undergraduate student at the University of California at Riverside. 

References

1Roe E, Schulman PR. High reliability management: Operating on the edge. Stanford, CA: Stanford Business Books, 2008.

2Harvey G, Wensing M. Methods for evaluation of small scale quality improvement projects. Qual Saf Health Care. 2003;2(3): 210-215. doi:10.1136/qhc.12.3.210.

3Fisher E, Shortell S, Savitz L. Implementation Science: A Potential Catalyst for Delivery System Reform. American Medical Association. 2016;315(4): 339-340. doi:10.1001/jama.2015.17949.

4Portela MC, Provonost PJ, Woodcock T, Carter P, Dixon-Woods M. How to study improvement interventions: a brief overview of possible study types. BMJ Quality & Safety. 2015;24(5): 325-336. doi:10.1136/bmjqs-2014-003620.

5New York State Department of Health Announces Results of Medicaid Redesign Efforts to Improve Patient Care Statewide, Yielding Measurable Reductions in Avoidable Hospital Use [news release]. Albany, NY: New York State Department of Health; June 19, 2018. https://www.health.ny.gov/press/releases/2018/2018-06-19_mrt.htm. Accessed August 28, 2018.

6The CHART Method [news release]. Boston, MA: Massachusetts Health Policy Commission; 2017. https://www.mass.gov/files/documents/2017/12/11/2017-chart-convening-morning-panel-slides-.pdf. Accessed August 28, 2018.

7Navathe A, Jain S, Jha A, Milstein A, Shannon R. Introducing you to Healthcare: The Journal of Delivery Science and Innovation. Healthcare: The Journal of Delivery Science and Innovation. 2013;1(1-2):1. doi:10.1016/j.hjdsi.2013.05.004.

8Kim JY. Introduction to Healthcare: The Journal of Delivery Science and Innovation. Healthcare: The Journal of Delivery Science and Innovation. 2013;1(1-2):3. doi:10.1016/j.hjdsi.2013.04.011.

9Dalal A. Interview with Amy Boutwell, MD, MPP. Healthcare: The Journal of Delivery Science and Innovation. 2018;6(3);218-219. doi:10.1016/j.hjdsi.2018.06.001.

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