DQ#5 theoretical

Description

Newman is also a unitarian theorist. It is important that the nurse comprehend the patient’s life experiences. You are being asked to listen to ” WIHI: Moving Upstream to Address the Quadruple Aim @ http://www.ihi.org/resources/Pages/AudioandVideo/WIHI-Moving-Upstream-to-Address-the-Quadruple-Aim.aspx” or review the power points this week to prepare your response for this week’s DQ. The presenter in the IHI audio addresses elements of the Triple Aim and speaks of the importance of the Quadruple Aim, moving upstream and the role vulnerabilities play in improving health factors. Based on your understanding of this Unitary Theorist work, clearly discuss the similarities (as it relates to the patients and their environment) noted in the the Triple and Quadruple Aim in the works of Newman and the importance of seeing the patient as a whole and the role patients living in disadvantaged environments play in preventing them from improving optimal health. [Practicing APRNs should comprehend issues families face, financial and other vulnerabilities they encounter while caring for vulnerable populationshttps://staff.ihi.org/resources/Pages/AudioandVideo/WIHI-Moving-Upstream-to-Address-the-Quadruple-Aim.aspxprofessor’s reply to my previous DQ In the furture you need to discuss the theory in depth and include the metaparadigm during the discussion.

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Chapter 15
Rosemarie Rizzo Parse’s
Humanbecoming School of
Thought
Developed by Bonnie Pope (2010)
Updated by D. Gullett (2014; 2020)
Copyright ©2020 F.A. Davis Company
On completion of this chapter, students
will be able to:
▪ Define the discipline and profession of nursing
as implicated by Rosemarie Parse.
▪ Discuss the three major themes of Parse’s
humanbecoming Theory.
▪ Describe the two research methods
developed by Parse.
▪ Discuss the components of humanbecoming:
The Art.
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On completion of this chapter, students
will be able to: (continued)
▪ Identify and discuss the postulates and
principles described by Parse and their role in
explicating Parse’s humanbecoming paradigm.
▪ Compare and contrast a simultaneity
paradigm, a totality paradigm and Parse’s
Humanbecoming paradigm.
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Academic Positions
▪ Faculty member, University of Pittsburgh
▪ Dean School of Nursing, Duquesne University
▪ Professor and Coordinator of the Center for
Nursing Research at Hunter College, New York
(1983 to 1993)
▪ Professor and Niehoff Chair in Nursing Research at
Loyola University, Chicago (1993 to 2006)
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Overview
▪ Metaperspective
▪ Original work was named Man-Living-Health: A
Theory of Nursing (1981).
• When the term mankind was replaced with male gender
in the dictionary definition of man, the name of the
theory was changed to human becoming (Parse, 1992).
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Discipline of Nursing
▪ Encompasses 3 paradigmatic perspectives
1. Totality paradigm
2. Simultaneity paradigm
3. Humanbecoming paradigm
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Totality Paradigm
▪ The totality paradigm frameworks and
theories are more closely aligned with the
medical model tradition.
▪ Nurses practicing according to this paradigm
are concerned with participation of persons
in health-care decisions but have specific
regimens and goals to bring about change
for the people they serve (Parse, 1999b).
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Simultaneity Paradigm
▪ In contrast, the simultaneity paradigm views the
human as unitary—indivisible, unpredictable, and
ever-changing (Parse, 1987, 1998a, 2007b),
wherein health is considered a value and a process.
▪ The ontology leads research and practice scholars
to focus on, for example, energy and
environmental field patterns (Rogers, 1992).
▪ Nurses focus on power in knowing participation
(Barrett, 2010; Rogers, 1992).
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Humanbecoming Paradigm
▪ With the humanbecoming paradigm in the ontology,
humanuniverse is an indivisible, unpredictable
everchanging cocreation, and living quality is the becoming
visible-invisible becoming of the emerging now.
▪ Nurses living the humanbecoming paradigm hold that their
primary concern is people’s perspectives of living quality
with human dignity.
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Humanbecoming Investigative
Tradition
Focus of study is on universal humanuniverse living
experiences
Two modes of inquiry
1. Parasciencing
2. Humanbecoming hermeneutic sciencing
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Fundamental Idea
▪ Humans are indivisible, unpredictable, ever-changing
• Precludes any use of terms such as physiological, biological,
psychological, or spiritual to describe the human
• Other words often used to describe people, such as,
noncompliant, dysfunctional, and manipulative are not
consistent with humanbecoming
▪ Humanbecoming and humanuniverse are presented
as one word (Parse, 2007b).
• Joining the words creates one concept and further confirms
the idea of indivisibility.
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The Humanbecoming Ontology
Contains nine philosophical assumptions about
▪ Humanuniverse—as indivisible, unpredictable,
everchanging, cocreating unique becoming
▪ Ethos of humanbecoming
▪ Living quality—is the chosen way of being in
the becoming visible-invisible becoming of the
emerging now
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Humanbecoming Theory
▪ The principles of humanbecoming describe
the central phenomenon of nursing
(humanuniverse).
▪ Arise from the three major themes of
meaning, rhythmicity, and transcendence.
▪ Each principle describes a theme with three
concepts.
▪ Each concept explicates a fundamental
paradox of humanbecoming.
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Humanbecoming Language
▪ Nine concepts written in verbal form with
-ing endings to make clear the importance of
the ongoing process of change as basic to
humanuniverse emergence.
▪ Each concept is explicated with paradoxes, not
opposites, but rhythms, further specifying the
uniqueness of the humanbecoming language.
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Major Themes
Meaning—people coparticipate in creating what
is real for them as shown in their expressions of
living their values in a chosen way.
Rhythmicity—living paradox encompasses
apparent opposite experiences that coexist in
rhythmical patterns.
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Major Themes (continued) (continued)
▪ Transcendence—moving with now moments
is living the becoming visible-invisible
becoming with the ambiguity of the
continuous change of the emerging now.
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Statements of Principles
▪ First Principle: Humans construct personal
realities with unique choosings arising with
illimitable humanuniverse options.
• Concepts: imaging, valuing, languaging
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Statements of Principles (continued)
Second Principle: Describes rhythmical
humanuniverse patterns of relating
▪ Concepts: Revealing–concealing, Enablinglimiting, Connecting–separating
Third Principle: Explicated the idea that
humanuniverse is ever-changing, that is, moving
on with the possibilities of their intended hopes
and dreams.
▪ Concepts: Powering, originating, transforming
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Postulates
1. Illimitability
2. Paradox
3. Freedom
4. Mystery
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Humanbecoming School of Thought
▪ The principles are referred to as the
Humanbecoming Theory.
▪ The concepts, with the paradoxes, describe
humanuniverse.
▪ The beliefs described give rise to sciencing
and living the art of humanbecoming.
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Humanbecoming Investigative Tradition
(continued_1)
Sciencing humanbecoming:
▪ Is coming to know
▪ It is an ongoing inquiry to discover and
understand the meaning of living
experiences.
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Humanbecoming Investigative Tradition
(continued_2)
The humanbecoming investigative tradition has two
basic modes
▪ The Parse Method (Parse, 1987, 1990, 1992,
1995, 1997a, 1998a, 2001)
• Studying lived experiences from participants’
descriptions
▪ The Humanbecoming Hermeneutic Method
(Cody, 1995; Parse, 1995, 1998a, 2001, 2005).
• Studying lived experiences from written texts and art
forms
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Humanbecoming Nurses
▪ Believe persons know their way and live their
health situations according to their unique value
priorities.
▪ Ask what is most important for the moment.
• Explore meanings, wishes, intents, and desires related to
the situation from the perspective of the recipients
▪ Humanbecoming nurses are with persons in ways
that honor their wishes and desires.
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Research & Practice
▪ The humanbecoming school of thought is a guide
for research, practice, education, and
administration in settings throughout the world.
▪ Scholars from five continents have embraced the
belief system and live humanbecoming in a variety
of venues, including health-care centers and
university nursing programs.
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Humanbecoming: Living the Art
▪ The Goal of the Nurse
• Living the humanbecoming beliefs is true presence in
bearing witness and being with others in their changing
health patterns of living quality.
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True Presence
▪ “True presence is an intentional reflective love, an
interpersonal art grounded in a strong knowledge
base” (Parse, 1998a, p. 71).
• Distinct from authentic presence, transforming presence,
presencing, and other terms in the literature
▪ True presence is a powerful humanuniverse
connection.
▪ True presence is lived in face-to-face discussions,
silent immersions, and lingering presence.
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Website
▪ http://www.humanbecoming.org/
Website contains further information for
those who are interested in living the art of
humanbecoming.
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References
Barrett, E. A. M. (2010). Power as knowing
participation in change: What’s new and
what’s next. Nursing Science Quarterly, 23,
47–55. Parse, R. R. (1981). Man-living-health:
A theory of nursing. New York: John Wiley &
Sons. Parse, R. R. (1987). Nursing science:
Major paradigms, theories, and critiques.
Philadelphia: W. B. Saunders.
Copyright ©2020 F.A. Davis Company
References (continued_1)
Parse, R. R. (1990). Parse’s research methodology
with an illustration of the lived experience of
hope. Nursing Science Quarterly, 3, 9–17.
Parse, R. R. (1992). Human becoming: Parse’s
theory of nursing. Nursing Science Quarterly,
5, 35–42.
Parse, R. R. (Ed.). (1995). Illuminations: The
human becoming theory in practice and
research. New York: National League for
Nursing Press.
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References (continued_2) (continued)
Parse, R. R. (1997a). The human becoming
theory: The was, is, and will be. Nursing
Science Quarterly, 10, 32–38.
Parse, R. R. (1998a). The human becoming school
of thought. Thousand Oaks, CA: Sage.
Parse, R. R. (1999b). Nursing: The discipline and
the profession. Nursing Science Quarterly, 12,
275.
Parse, R. R. (2001). Qualitative inquiry: The path
of sciencing. Sudbury, MA: Jones and Bartlett.
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References (continued_3)
Parse, R. R. (2005). The human becoming
modes of inquiry: Emerging sciencing.
Nursing Science Quarterly, 18, 297–300.
Parse, R. R. (2007b). The humanbecoming
school of thought in 2050. Nursing Science
Quarterly, 20, 308.
Parse, R. R. (2012a). New humanbecoming
conceptualizations and the humanbecoming
community model: Expansions with sciencing
and living the art. Nursing Science Quarterly,
25, 44–52.
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References (continued_4) (continued)
Parse, R. R. (2012b). “The things we make, make
us” Nursing Science Quarterly, 25, 125.
Parse, R. R. (2013a). Living quality: A
humanbecoming phenomenon. Nursing
Science Quarterly 26 (2)
Rogers, M. E. (1992). Nursing science and the
space age. Nursing Science Quarterly, 5, 27–34.
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References (continued_5)
Santopinto, M. D. A., & Smith, M. C. (1995).
Evaluation of the human becoming theory in
practice with adults and children. In: R. R.
Parse (Ed.), Illuminations: The human
becoming theory in practice and research
(pp. 309–346). New York: National League
for Nursing Press.
Smith, M. K. (2002). Human becoming and
women living with violence. Nursing Science
Quarterly, 15, 302–307.
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Chapter 16
Margaret Newman’s Theory
of Health as Expanding
Consciousness
Developed by Dorothy Dunn (2010)
Updated by D. Gullett (2014; 2020)
Copyright ©2020 F.A. Davis Company
On completion of this chapter, students
will be able to:
1. Articulate Newman’s definition of expanding
consciousness.
2. Discuss the distinct paradigmatic views of
caring in the human health experience.
3. Describe mutual transformation in the nurse–
client partnership.
4. Understand the Health as Expanding
Consciousness (HEC) research process.
5. Identify and discuss the central concepts
important to nursing practice grounded in the
theory of HEC.
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Background
While caring for her mother, who had
amyotrophic lateral sclerosis, Newman realized:
▪ having a disease does not make a person
unhealthy.
▪ time, movement, and space are in some way
interrelated with health, which can be
manifested by increased connectedness and
quality of relationships.
These realizations led to her doctoral studies
with Martha Rogers at NYU.
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Early Influences on Health as Expanding
Consciousness (HEC) Theory
▪ Martha Rogers
• health and illness not as two separate realities, but
rather as a unitary process
• argued that all of reality is a unitary whole and that
each human being exhibits a unique pattern
• saw the life process as showing increasing
complexity
▪ Itzhak Bethov
• viewed life as a process of expanding consciousness
▪ Personal experience
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First Enunciation of HEC Theory
▪ Health includes both disease and wellness.
▪ Disease is a manifestation of the underlying
pattern of the person.
▪ The underlying pattern is present before the
disease appears.
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First Enunciation of HEC Theory
(continued)
▪ Health is an expansion of consciousness.
▪ “[t]he responsibility of the nurse is not to
make people well, or to prevent their getting
sick, but to assist people to recognize the
power that is within them to move to higher
levels of consciousness” (Newman, 1978).
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New Paradigm
Developed the Unitary-Transformative
Paradigm (Newman, Marilyn Sime, and Sheila
Corcoran-Perry, 1991)
▪ Newman saw human beings as unitary and
inseparable from the larger unitary field that
combines person, family, and community all
at once.
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Three Paradigms
Particulate-deterministic: Phenomena are
isolatable, deterministic, and measurable.
▪ Relationships between entities are orderly,
predictable, linear, and causal.
▪ Health has clearly defined characteristics:
healthy or unhealthy, change occurs in a
predictable, causal way.
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Three Paradigms (continued_1)
Interactive-integrative: Multiple antecedents
bring about a change in a phenomenon.
▪ Multiple causes contribute to an outcome.
▪ Diet, exercise, smoking, family history, and
lifestyle are interconnected in their effect on
heart attacks.
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Three Paradigms (continued_2)
Unitary–transformative:
▪ A nurse practicing within the unitary–
transformative paradigm does not think of
mind, body, spirit, and emotion as separate
entities but rather sees them as
manifestations of an undivided whole.
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Three Paradigms (continued_3)
Unitary-transformative paradigm generates
data that are essential to nursing (the
knowledge of the discipline).
Particulate-deterministic and Interactiveintegrative paradigms generate data that are
relevant to nursing.
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HEC Perspective
▪ HEC theoretical perspective possesses
multifaceted levels of awareness.
▪ Is able to sense how physical signs, emotional
conveyances, spiritual insights, physical
appearances, and mental insights are all
meaningful manifestations of a person’s
underlying pattern.
▪ These manifestations provide insight into the
nature of the person’s interactions with his or
her environment.
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Newman stated
Practicing within a unitary paradigm requires a
completely new way of seeing reality—it is like
moving from seeing the Sun as revolving
around Earth to realizing that it is actually Earth
that revolves around the Sun (Newman, 2008a).
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Nursing Practice in HEC Perspective
▪ Health is an evolving unitary pattern of the
whole, including patterns of disease.
▪ Consciousness is the informational capacity
of the whole and is revealed in the evolving
pattern.
▪ Pattern identifies the human-environmental
process and is characterized by meaning.
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Important Concepts Within HEC
▪ Expanding
consciousness
▪ Time
▪ Presence
▪ Resonating with the
whole
▪ Pattern
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▪ Meaning
▪ Insights as choice points
▪ Mutuality of the nursepatient relationship
Expanding Consciousness
Consciousness not limited to cognitive thought.
▪ It is the information of the system: The
capacity of the system to interact with the
environment.
▪ Relationships that are more open, loving,
caring, connected, and peaceful are a
manifestation of expanding consciousness.
▪ People are best able to experience expanding
consciousness when they are not chained to
linear time.
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Time
▪ Newman’s latest work asserts that it is only
when nurses move away from a sense of
linear time to a more universal
synchronization with the here and now that
they can be truly present to patients in a
meaningful and whole manner (Newman,
2008a).
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Presence
Newman (2008b) asserted that it is only in
relationship that people can fully come to know
themselves.
▪ Nurses are truly present to patients they
concentrate more on intuitive knowing than
on the gathering of facts and health-related
data.
▪ Understanding the concept of resonance
enables a transforming presence.
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Resonating With the Whole
▪ Learning to resonate with patients involves
relational engagement and reflection.
▪ Resonance is a way to sense into the whole
through attention to one aspect or part of it,
always with an eye on comprehending the
whole.
▪ Resonance enables nurses to tap into the
pattern of the whole.
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Pattern Recognition
Nurses grounded in the theory of HEC are able
to be in relationships with patients, families,
and communities in such a way that insights
arising in their pattern recognition dialogue
shed light on an expanded horizon of potential
actions (Litchfield, 1999; Newman, 1997a).
Pattern is characterized by meaning and is a
manifestation of consciousness.
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Insights as Choice Points
The disruption of disease and other traumatic
life events may be critical points in the
expansion of consciousness.
▪ This disrupted state presents a choice point
for the person to either continue going on as
before, even though the old rules are not
working, or to shift into a new way of being.
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The Nurse–Patient Relationship
Nursing within the HEC perspective involves
being fully present to the patient without
judgments, goals, or intervention strategies.
▪ It involves being with rather than doing for
▪ Mutually transforming effect of the nurse–
patient interaction.
▪ This mutual transformation extends to the
surrounding environment and relationships
of the nurse and patient.
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The Nurse–Patient Relationship
(continued)
▪ Sensing one’s own pattern is an essential
starting point for the nurse.
▪ The nurse must have a tolerance for
disequilibrium, disorganization, and
dissonance, even if they are uncomfortable
states.
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Insights
▪ Patients faced with life-threatening events
often reflect on how they used their energy
and transform their life pattern.
▪ Patients with terminal illnesses often reevaluate their priorities.
▪ This “expansion of consciousness” is an
innate tendency in humans.
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HEC as Research Praxis
▪ Margaret Newman’s early research (1966,
1971, 1972, 1976, 1982, 1987, 1986) added
to an understanding of the interrelatedness
of time, movement, space, and
consciousness as manifestations of health.
▪ Newman’s Pattern Recognition Method
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Applying HEC
▪ The nurse should ask clarifying questions to
come to an understanding of the patient.
▪ The nurse should be open, caring, and
nonjudgmental in this clarification process.
▪ The nurse understands rather than predicts
cause and effect.
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Applying HEC (continued)
▪ Be fully present in unconditional acceptance.
▪ Caring relationship of pattern recognition
makes it possible to understand meaning.
▪ Be open to new perspectives/possibilities.
▪ Pattern is characterized by meaning and is a
manifestation of consciousness.
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Website
▪ https://sites.google.com/site/margaretnew
mantheory/
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References
Endo, E. (1998). Pattern recognition as a nursing
intervention with Japanese women with
ovarian cancer. Advances in Nursing Science,
20(4), 49–61.
Newman, M. A. (1966). Identifying and meeting
patients’ needs in short-span nurse-patient
relationships. Nursing Forum, 5(1), 76–86.
Newman, M. A. (1971). Time estimation in
relation to gait tempo. Perceptual and Motor
Skills, 34, 359–366.
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References (continued_1)
Newman, M. A. (1972). Nursing’s theoretical
evolution. Nursing Outlook, 20(7), 449–453.
Newman, M. A. (1976). Movement tempo and
the experience of time. Nursing Research, 25,
173–179.
Newman, M. A. (1978). Nursing theory.
(Audiotape of an address to the 2nd National
Nurse Educator Conference in New York.)
Chicago: Teach’em, Inc.
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References (continued_2)
Newman, M. A. (1982). Time as an index of
expanding consciousness with age. Nursing
Research, 31, 290–293.
Newman, M. A. (1986). Health as expanding
consciousness. St. Louis, MO: C. V. Mosby.
Newman, M. A. (1987). Aging as increasing
complexity. Journal of Gerontological Nursing,
12, 16–18.
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References (continued_3)
Newman, M. A. (1994a). Health as expanding
consciousness (2nd ed.). Boston: Jones and
Bartlett (NLN Press).
Newman, M. A. (1997a). Experiencing the whole.
Advances in Nursing Science, 20(1), 34–39.
Newman, M. A. (1997b). Evolution of the theory
of health as expanding consciousness.
Nursing Science Quarterly, 10(1), 22–25.
Newman, M. A. (2008a). It’s about time.
Nursing Science Quarterly, 21(3), 225–227.
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Moving upstream to achieve
the Quadruple Aim
Rishi Manchanda MD MPH
@RishiManchanda
Objectives
• Describe the importance of upstream social
determinants to the Quadruple Aim
• Describe how QI and practice redesign can
help operationalize changes needed to move
healthcare upstream
• Describe best practices for:
• Patient engagement approaches that can
improve how upstream information can be used
• Provider and staff training
• Sharing upstream data to bolster local
partnerships required to achieve whole person
care
• Improve readiness to move upstream
Outcomes
• Effective interventions
• Less preventable illness
• Decreased disparities
Patient
Experience
• Satisfaction
• Quality
• Trust
Costs
Quadruple
aim
Provider Experience
• Professionalism
• Joy at Work
• Recruitment & Retention
© 2015 Rishi Manchanda/ HealthBegins
• Lower per-capita costs
• Appropriate spending &
utilization
Equity
•
•
•
Societal opportunity
Decision making
Structural Fairness
• Coalesce around a common civic purpose –
transform traditional service providers and institutions
into catalysts of civil society.
• Increase performance management capabilities &
human capital development in the social sector as
an “upstream” force multiplier in education, housing,
food security, transportation, and other areas of
action
• As healthcare and social service spending is
rebalanced, we should not underestimate the
degree of waste, missed opportunity, and suffering
that results when these sectors remain siloed
© 2015 Rishi Manchanda/ HealthBegins
A Medical- Legal Partnership
for ‘High Utilizer’ Homeless Veterans
Upstream
Medicine
Health Systems
Improvement
• Performance
Management/Quality
Improvement
• Practice Transformation
• Payment Reform
Population
Medicine
• Preventive
Medicine
• Social Medicine
• CommunityOriented Primary
Care
© 2015 Rishi Manchanda/ HealthBegins
Social
Determinants
of Health
• Public Health
• Community
Development
• Social Services
Cross-sector work creates more
robust community social capital
Density of relationships among organizations contributing to population health activities.
Glen P. Mays et al. Health Aff 2016;35:2005-2013
©2016 by Project HOPE – The People-to-People Health Foundation, Inc.
More community social capital
associated with lower mortality
Differences in county mortality rates associated with comprehensive population health system
capital, 2014.
Glen P. Mays et al. Health Aff 2016;35:2005-2013
©2016 by Project HOPE – The People-to-People Health Foundation, Inc.
A Library as a Hub for Health
Free Library of
Philadelphia:
Of the 5.8 million inperson Free Library
visits in 2015, 500,000
included
attendance at
specialized
programs that
addressed multiple
health determinants,
such as housing and
literacy.
©2016 by Project HOPE – The People-to-People Health Foundation, Inc.
Anna U. Morgan et al. Health Aff 2016;35:2030-2036
If a library can be a health hub, how
about a school, barbershop, or a home?
Taylor, L. Hyatt, A. Sandel. M (2016, Nov 17) Defining The Health Care System’s Role In Addressing Social Determinants And Population Health.
[HealthAffairs Blog]. Retrieved from http://healthaffairs.org/blog/2016/11/17/defining-the-health-care-systems-role-in-addressing-social-determinantsand-population-health/#one
Housing as a health intervention
Upstream
Intervention
Target
Population
Healthcare
Outcomes
Housing First
People
$29,388 per person per year in net savings, and
experiencing
$8,949 per person per year in net savings,
chronic
respectively Larimer, 2009; MHSA, 2014
homelessness—
Seattle and Boston
Special Homeless
Initiative
Adults with serious
mental illness—
Boston
93% reduction in hospital costs, resulting in $18
million reduction in health care costs annually
10th Decile Project
High-need
homeless—Los
Angeles
72% reduction in total health care costs;
positive ROI – Every $1 invested in housing and
support estimated to reduce public & hospital
costs by $2 the following year and $6 in
subsequent years Burns, 2013
My First Place
Foster care
recipients—
California
Better health outcomes; $44,000 per person per
year in net savings First Place for Youth, 2012
Levine, 2007
Adapted from: Taylor LA, Tan AX, Coyle CE, et al. Leveraging the Social Determinants of Health: What Works? Yi H, ed. PLoS ONE. 2016;11(8):e0160217.
doi:10.1371/journal.pone.0160217.
Food and nutrition as health interventions
Upstream
Intervention
Target
Population
Healthcare
Outcomes
Women, Infants,
and Children (WIC)
Low-income
women and
children—selected
cities and states
(U.S.)
Better health outcomes; $176 million per year
in net savings in U.S.
Older adults—
nationwide
A 1% increase in meals delivered to the homes of
older adults was estimated to be associated with
reduction of $109 million in Medicaid costs;
Home-delivered
meals
Foster, Jiang, & Gibson-Davis, 2010; Khanani et al., 2010; Hoynes, Page, & Stevens,
2009
A $25 annual increase in home-delivered meals
per older adult was estimated to be associated
with a 1% decline in nursing home admissions
Thomas & Mor, 2013a; Thomas & Mor, 2013b; Thomas & Dosa, 2015
Adapted from: Taylor LA, Tan AX, Coyle CE, et al. Leveraging the Social Determinants of Health: What Works? Yi H, ed. PLoS ONE. 2016;11(8):e0160217.
doi:10.1371/journal.pone.0160217.
The impact of linking social &
healthcare services (moving upstream)
Upstream
Intervention
Target
Population
Outcomes
“Effects of
Social Needs
Screening and
In-Person
Service
Navigation on
Child Health: A
Randomized
Clinical Trial”
1809
children,
enrolled in
primary care
and urgent
care settings
At 4 months after enrollment, the
number of social needs reported by the
intervention arm decreased more than
that reported by the control arm, with a
mean (SE) change of −0.39 (0.13) vs
0.22 (0.13) (P < .001). Pediatrics, 2016. Caregivers in the intervention arm reported significantly greater improvement in their child’s health, with a mean (SE) change of −0.36 (0.05) vs −0.12 (0.05) (P < .001). Gottlieb LM, Hessler D, Long D, Laves E, Burns AR, Amaya A, Sweeney P, Schudel C, Adler NE. Effects of Social Needs Screening and In-Person Service Navigation on Child HealthA Randomized Clinical Trial. JAMA Pediatr. 2016;170(11):e162521. doi:10.1001/jamapediatrics.2016.2521; Healthcare payers are considering upstream factors • Affordable Care Act → More coverage for millions of people with more social needs • Value-Based Payment reform and Alternative Payment Models (bundled payments, ACOs, MACRA) → Healthcare providers financially accountable for health and costs of care • Payers are considering upstream factors • CMMI Accountable Health Communities • California Accountable Communities for Health Initiative (CACHI) • Health Plans / Managed Care Organizations • Self-insured Employers Findings Medicaid MCO leaders describe investments in social determinants of health in terms that reflect components of the Triple Aim Findings Improved health care quality: “We can’t do the work we’ve been charged with and do it well unless we figure [social determinants of health] out.” Findings Improved patient care experience: “We [address social determinants because we] want to have high levels of consumer engagement [and] high levels of consumer satisfaction, which is the most important benchmark for me.” Findings Decreased costs: “We don’t go into this as if we were making grants. We go into this more as if we were making business investments.” Identifying upstream risks at the workplace Biometrics nationally ▪ Across the US, half of large employers either offer employees the opportunity or require them to complete biometric screening. Health Aff (Millwood). 2015 Oct;34(10):1779-88. doi: 10.1377/hlthaff.2015.0885. ▪ California Central Valley employees screened: 87% Biological risks ▪Diabetes 11%, ▪We added 4 SDOH questions to the biometrics: Social risk identified Acting on upstream issues as a self-insured employer ‒Financial, Food and Housing Insecurity ▪10% of employees identified with biological, psychological AND social health risks ▪Targeted care management through primary care onsite clinics with integrated psychosocial services ▪Community benefits & corporate philanthropy ▪Evaluation, risk models, and value contracting 22 Our healthcare workforce is asking for help “I'm a primary care pediatrician in [a rural county]. Highest teen preg rate, meth addiction, high school drop out rate... Many more issues. Understand upstream approach for years. Try my best but falls by the wayside as I don't have resources - No help, city/ county overwhelmed. Patients lost to follow up- I'm seeing over 30 a day. How to manage? Would like to discuss.” Lopsided US has a lopsided health: social services ratio Bradley , E.H and L.A. Taylor, 2013. The healthcare paradox: Why spending more is getting us less. New York: Public Affairs . Burnout & clinic capacity to address social determinants of health Survey of over 500 primary care clinicians “My clinic has the resources, such as dedicated staff, community programs, resources or tools to address patients’ social needs” After multivariate analysis, lower perceived capacity of clinics to address social needs was the strongest predictor of clinician burnout. Source: Olayiwola et al. from presentation. Arizona Alliance of Community Health Centers, Phoenix, AZ. Feb 2016. Social factors account for 60% of premature death & impact the Quadruple Aim Robert Wood Johnson Foundation “Health Care’s Blind Side” December 2011 But only 1 in 5 MDs have confidence to address them Schroeder S. N Engl J Med 2007;357:1221-1228 Poorer Outcomes • Less effective interventions • Preventable illness • Health disparities Poor Patient Experience • Frustration & Helplessness • Costs of Care • Distrust No social determinants integration = No Quadruple aim Poor Provider Experience • Eroding Professionalism • Poor recruitment & retention • Burnout © 2015 Rishi Manchanda/ HealthBegins Higher Costs • Wasteful spending • Opportunity costs • Avoidable utilization Less equity • • • Decreased opportunity Structural violence Inequity “I get it. So how do we this?” © 2015 Rishi Manchanda/ HealthBegins Objectives • Describe the importance of upstream social determinants to the Quadruple Aim • Describe how QI and practice redesign can help operationalize changes needed to move healthcare upstream • Describe best practices for: • Patient engagement approaches that can improve how upstream information can be used • Provider and staff training • Sharing upstream data to bolster local partnerships required to achieve whole person care • Improve your readiness to move upstream Let’s start with a Case Study • Mr. M is a 51 year old father of two, diagnosed with Type II diabetes at age 38. Last HbA1c = 8.2. BMI: 29 • Medications: – Metformin 1000mg po bid – Glipizide 10mg po bid – No known problems with medication adherence. • At the end of last month, he was extremely dizzy, nearly fainted and was hospitalized. Diagnosis: Hypoglycemia