Community Partnerships Create Foundation for Healthcare Transformation

By Luci DeHaan

Five years ago, SBH embarked on an ambitious state-funded initiativeto transform the way health care is delivered to patients in our communities.

SBH convened and led a network of 250 health and social service providers to rethink how we look at “health” and “health care” and develop an integrated system of care that focuses on wellness and community partnerships as a foundation for the delivery of comprehensive care.

The program, called DSRIP, concluded this year.

SBH Medicine recently spoke with Irene Kaufmann, Senior Vice President of Ambulatory Care and Population Health, to look back at the work of DSRIP and where we are now.

SBH: It’s been five years, how do you feel?

Relieved, proud, hopeful. This was an incredibly ambitious and innovative
program that had many facets but was rooted in the value of community-level collaborations, which we achieved.

SBH: To refresh our minds, can you tell us what was “DSRIP?”

Sure. DSRIP is an acronym for what sounds like a complicated name but the name actually tells you what the program is. It stands for Delivery System Reform Incentive Payment. It’s a reform of both the healthcare delivery system and of the provider payment system now redesigned to reward doctors based on patient outcomes. It was the most transformative program since Medicaid was established in the 1960s. The state has always worked on individual Medicaid reforms in terms of cost containment for what doctors do such as evaluation, treatment, diagnostic testing, and how they do it such as patient-centered primary care and ratio of providers to support staff … things like that. But this was the first time that we thought of reform in a way that marries and integrates how we deliver care with how we pay for it. These two domains are really managed by different agencies so that was one big innovation right there.

DSRIP brought together various government agencies, healthcare providers and community organizations – all of which had been thinking about very different aspects of care – and asked them to step out of their silos and collaborate to deliver care through a coordinated framework.

SBH: One stated goal of DSRIP was to reduce unnecessary emergency room visits, but you are saying it was much more than that?

Yes. There were many measurable goals to DSRIP, but the overriding theme was to take the healthcare delivery system from one that is very much based on “sick care” and transition to one that features “prevention and wellness.” So yes, we take care of you as a person, but in order to understand how well we’re delivering care, we’re now also looking at our impact on the total population assigned to us. Our system was built to account for every episode of care. We’re now moving to a system that is capitated where we’re thinking about how to improve the health of an individual or a population in measurable ways within a given timeframe.

We are now incentivized to think very creatively about how and when to bring people in for office visits, what we could do outside of that visit to promote wellness, and how we can prevent illness or existing conditions from being exacerbated because of social factors. So this is really a major principle – to move our system from a fee-for-service system to one that is value based.

SBH: So where do community partnerships come into the picture?

Well first we need to look more broadly at all of those factors that really impact a person’s health and well-being. So now it’s not just medical care. It’s about mental health. It’s about access to education, to meaningful work, and to decent housing. It’s access to a more just penal system.

A hospital can address big sickness issues, but it can’t address these other factors. So through DSRIP, we began integrating medical care with the resources that exist outside of the hospital and designing a system where they can be coordinated to work more effectively with each other.

Many services are provided by small community-based organizations that address social determinants of health like food insecurity, housing, employment, and behavioral health that are essential to people’s well-being. CBOs are effective because people can more easily engage with services and resources from providers and agencies that are local to their neighborhood, that share the same language and references and understand their concerns.

SBH: You said organizations are all thinking about different things. How do you get everyone on the same page to work together?

Our DSRIP network includes 250 organizations that run the spectrum of health and social services. First, we gave people a seat at the table. We created a structure that allowed people from all of these organizations to have a seat on our governing committees. We had about 75 seats available and we constantly rotated to give as many organizations and their representatives an opportunity to participate.

We engaged them in joint initiatives with us and each other to address care gaps. We integrated services and reconfigured our combined workforce into extended care teams. We essentially restructured the idea of care teams and redefined the focus of their activity around care coordination and prevention.

Our projects were carefully selected to meet community needs that were defined through surveys, input from our partners, and community data that told us where there were glaring gaps in care. Our partners saw the results and they bought in. We also allowed people not only to have a voice but also to lead. It was a process and by year three people wanted to participate because they realized they had a voice and they could direct how to provide services.

In time, the initial competitiveness that provider organizations had was gone. We didn’t talk about “my patients” or “my clients.” We talked about how we have this community that has these overwhelming needs, what could we each offer, and how could we work together as providers to take care of this population. That’s how the shift played out.

SBH: Were there any notable outcomes that come to mind?

These enduring collaborations are a critical outcome. I think about where we were five years ago – each with our separate agendas, interests, and territories. Now, we have achieved a continued trust and ability to come together to solve a care need or launch a community initiative as needed.

Here is an example. Because we are a known coalition, the City of New York contacted us six months after DSRIP ended for our input on how to increase COVID-19 testing in the Bronx. We reached out to our members and in no time we had these providers come together, ready to give ideas and join together to get their community tested.

Another example – and there are many – is our work with transitions of care, which has been incredibly successful and has become a model program for the state and many of the health plans that we worked with. Moving patients from one provider environment like a hospital to a setting like the community or a nursing home can be one of the most dangerous times for a patient. Critical Time Intervention is an intensive case management program for newly discharged people with serious mental health conditions and who are homeless or precariously housed. The first three month period after discharge is when they’re at very high risk. You provide that intensive care management like you’re tied at the hip with your client during that critical period of time and then you start pulling back over the next three months as they integrate more and more within the community. We launched CTI with three partner agencies and reduced readmissions among this population by 47 percent. It surpassed our expectations.

SBH: So from a hospital standpoint, did SBH reduce emergency room admissions?

Yes, our readmission rate has been reduced. We’re down to 12 percent from 25 percent. Through our work with our community partners on our many initiatives, we’ve achieved millions of dollars in savings. These reductions are ultimately a benefit to the system in a capitated world. That’s the direction you want to go. Keep your population healthy with access to communitybased care and reduce reliance on acute, episodic care. This can only be achieved by working with all providers in the care continuum.

SBH: DSRIP ended in March 2020 just when the COVID-19 pandemic was surging in the Bronx. I imagine these collaborations are important now.

Absolutely. This pandemic has exacerbated all of the issues that affect our underserved patient population – housing, employment, food insecurity, substance abuse, and mental health. We can give the best medical care but if we don’t work with these other sectors of our community, it will be devastating. When patients come in, we screen them for food insecurity and make sure they have channels of referrals for families.

During the height of the pandemic, we joined a larger coalition that was connected with food distribution centers. They had the food, but they needed to figure out who to distribute it to. They reached out to us because they knew that we already learned how to work with our community organizations and identify the people who are at most risk. We were able through this coalition to deliver over a thousand meals to the highest risk patients in the community every day.

SBH: Where do we go from here?

I think that we continue with what we built and stay connected with our partners. We continue pressing our whole system to focus on wellness instead of sick care. It’s a very hard change for us because we’re wired to address sick care within big hospital institutions. But we’ve proven that a community-based wellness model is less costly and really works to address the many different factors that affect health and well-being.

Our Health and Wellness Center across the street is a physical representation of what DSRIP is all about. It is a space where patients are immersed in a wellness eco-system of medical, nutrition, fitness, and mind body care. Our DSRIP objective was to begin to create a foundation for change – a foundation on which we could build the possibility for this integration to occur – and I think we accomplished that.