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The What and the How

Posted By Jeff Cohn, Wednesday, May 15, 2013
Updated: Friday, September 19, 2014

The Washington Post from April 28, 2013 carried an article by Ezra Klein, "If this was a pill, you’d do anything to get it.” The author describes the recent work of Health Quality Partners (HQP), based in Doylestown, PA, focusing on improving healthcare outcomes and reducing expenses for Medicare patients with at least one chronic illness and one hospitalization in the past year. HQP has been part of a series of demonstration projects that emerged from the 1997 Balanced Budget Act that evaluate methods that aim to "improve the quality of items and services provided to target individuals and reduce expenditures.” Of the 15 funded programs, four improved outcomes but not costs. The HQP program was the only one to improve both. The initiative’s primary intervention has been the use of a nurse to visit enrolled Medicare beneficiaries weekly or monthly, whether they are sick or well. The HQP initiative reduced hospitalizations by 33% and Medicare costs by 22%. And now CMS is planning to eliminate the funding for the program.

Mr. Klein decries this policy decision, which is based on the unwillingness (or inability) of CMS to make the program permanent or to expand it to other populations. CMS plans to "integrate lessons from this experience” into designs for new scalable projects. The article describes how CMS pays for some very expensive, technology-based interventions without much scrutiny on their supporting evidence, while overlooking the successes already achieved through low-cost, non-technical interventions in small initiatives like HQP. He wonders what additional benefits CMS might accrue if they "took the lessons of HQP and used them to seed 15 more programs.” The HQP program has not had much of a budget. What if there were real resources? Couldn’t we get even better clinical and financial benefits?

As I read this I thought about a phrase we’ve used often to describe the effectiveness of the PD approach in improving outcomes: "It’s not the what, it’s the how.” What really are the "lessons of HQP?” Some might look exclusively at the end product and say, "do more of that- send more nurses to elderly, chronically ill patients’ homes in my community at least once a month” and assume that will achieve the same benefits. Others (like me) might look at the path that led to the HQP end product for the lessons. Maybe there are simple rules that are scalable, things like:

· Lead with confidence, curiosity, and humility (HQP’s founder, Ken Coburn, is reportedly this type of adaptive leader)

· Forge strong relationships with the community, and have them as thought partners

· Employ trusted members of the community to build healing relationships with the people being followed

· Ask the people what they need and help them develop skills to play a role in meeting that need

We all seem to be looking for the "solution,” the "magic bullet” that will cure what ails us. But what if it’s the "how” that is really the solution- what if it’s doing important work together, learning and evolving, that really matters?

Tags:  adaptive  catching butterflies  cohn  community  relationships 

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