CASE STUDY SEPTEMBER 2017 Health Care Improvement in Pueblo, Colorado: Building on Common Ground Martha Hostetter Sarah Klein Douglas McCarthy Consulting Writer and Editor Consulting Writer and Editor Senior Research Director PUEBLO The Commonwealth Fund The Commonwealth Fund The Commonwealth Fund PROFILE The high-desert region encompassing Pueblo in southeastern HEALTH SYSTEM PERFORMANCE Colorado was one of only 14 out of 306 regions nationally to Improved on improve on a majority of performance measures tracked by OF17 32 indicators tracked over time — the Commonwealth Fund’s Scorecard on Local Health System second-most among all regions Performance, 2016 Edition. Socioeconomic challenges and HEALTH SYSTEM RANK geographic isolation have fostered a sense of interdependence 128 181 among local health care providers, who have leveraged the state’s OF vs. OF Medicaid expansion to enhance access to care while improving 306 306 regions in 2016 regions in 2012 coordination. Providers have also joined with public health and DEMOGRAPHICS (2014) social service agencies, businesses, educators, and nonprofits in creating the Pueblo Triple Aim Corporation, an improvement 170,798 residents (including 161,875 in Pueblo County) collaborative that uses data to define problems and create shared accountability for solving them. The group engaged the 55% white (vs. 62% nationally) $44,623 median community in youth development programs as part of an effort 41% Hispanic household income (vs. $58,489 nationally) (vs. 17% nationally) that reduced the teen pregnancy rate by more than half. This and other collaborative efforts tap state policy to accomplish local 3% other non-Hispanic 46% (vs. 8% nationally) living on incomes priorities while seeking to build community pride. below 200% of the 2% Black federal poverty level (vs. 12% nationally) (vs. 34% nationally) KEY TAKEAWAYS Note: Race/ethnicity data may not sum to 100% because of rounding. Data: D. C. Radley, D. McCarthy, and S. L. Hayes, Rising to the Challenge: A Scorecard on Local Health System Performance, 2016 Edition (The P ueblo’s providers have leveraged Local improvement collaboratives Commonwealth Fund, July 2016); and American Community Survey, Colorado’s Medicaid expansion use data to define problems and 2014 1-year estimates, www.factfinder.census.gov. Unless otherwise noted, data on the Pueblo hospital referral region are derived from to enhance access to care while promote shared accountability the Scorecard. improving coordination. for solving them. Pueblo, Colorado: Building on Common Ground 2 BACKGROUND (13.6% vs. 6.8%).1 Many residents suffer from disabilities, The high-desert city of Pueblo, home to over 108,000 whether from the complications of disease, injuries residents in southeastern Colorado, is a world apart from from steel jobs, or self-harm due to substance abuse.2 the buzzing economy that lines the Denver-to-Boulder Community leaders say that while Colorado’s legalization corridor just a few hours north. Once known as the of marijuana has added jobs, it has also strained social “Pittsburgh of the West,” the region evolved around the services by attracting homeless and drug-seeking steel industry, with the largest mill owned by John D. populations to the region, where the cost of living is lower Rockefeller. It suffered through many boom-and-bust than in other parts of the state. cycles in the 19th and 20th centuries, but the collapse of This case study is part of a series exploring the factors the steel market in 1982 and the recent recession were that may contribute to improved regional health system the worst blows, shuttering all but one of the mills and performance. It describes how Pueblo’s health care draining away thousands of jobs. For the past several provider organizations have joined forces with government decades, many of the region’s residents have lived in agencies including the public health and fire departments, generational poverty; nearly half (46%) subsist on incomes as well as business leaders, social service agencies, that are less than twice the federal poverty level. philanthropists, and educators to address the community’s Hispanics make up a large portion of the population health and social problems. Deliberate efforts to use data to (41%). One of four adults smoke and nearly a third are define the problems and secure engagement from diverse obese, both risk factors for diabetes, which is twice as leaders seem to have helped cut the teen pregnancy rate by prevalent among adults in Pueblo County as in Colorado half and curbed unnecessary hospital use, for example. The creation of the Historic Arkansas Riverwalk of Pueblo — a 32-acre waterfront promenade — has been part of the city’s downtown revitalization. commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 3 The new Comanche solar farm, one of the largest in the United States east of the Rockies, is part of the region’s effort to diversify its economy. “There is a nucleus of people here who are exceptionally for achieving significant improvements on a majority (17 devoted to collaboration,” says Rev. Linda Stetter, director of 32) of measures for which trend data exist. It was one of mission and spiritual care for St. Mary–Corwin Medical of only 14 regions among 306 studied by the Scorecard to Center, one of two hospitals in Pueblo. “I don’t think I’ve achieve this distinction — a finding even more notable lived in another community where the collaboration is this given the region’s high poverty rate, since higher income intentional.” Such collaborative efforts build on providers’ usually correlates with better health and health care. The commitment to health care quality improvement, first Scorecard found wide variation among HRRs on indicators pursued in the 1980s at Parkview Medical Center, and of health care access, quality, avoidable hospital use, costs, subsequently taken up by other local institutions.3 and outcomes. It’s also notable that Pueblo’s economy has improved somewhat in recent years; its steelmaking equipment has DELIVERY SYSTEM: SPIRIT OF “CO-OPETITION” been repurposed to recycle scrap metal and build wind Because of Pueblo’s relatively small size and geographic turbines, and a large solar farm opened there in 2014. This isolation, health care services tend to be concentrated recovery may have played a role in the improvements within a few institutions, including two nonprofit tracked in the Scorecard. hospitals: the independent Parkview Medical Center and St. Mary–Corwin Medical Center, part of the Centura HEALTH SYSTEM PERFORMANCE IN PUEBLO network of faith-based hospitals. Together with Pueblo The Pueblo hospital referral region (HRR), a regional Community Health Center, a federally qualified health market for health care, includes the city and surrounding center (FQHC), and Health Solutions, a community mental Pueblo County as well as parts of adjacent counties. On 4 health center, they are Pueblo’s safety net. At Parkview, for the Commonwealth Fund’s Scorecard on Local Health example, about 80 percent of admitted patients are covered System Performance, 2016 Edition, the region stands out by Medicare or Medicaid or are uninsured. commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 4 Pueblo, Colorado, Hospital Referral Region Local Scorecard Performance Ranking Summary Change in Performancea (of 306 Local Areas) Quintile Rank Average of HRRs Pueblo in the U.S. 2012* 2016 2012* 2016 Count Percent Count Percent OVERALL 3 3 181 128 Indicators Access & with trends 32 33 4 4 193 191 Affordability Prevention & Area rate improved 17 53% 11 33% 5 2 270 115 Treatment Area rate Avoidable Hospital worsened 5 16% 3   9% 1 1 45 56 Use  & Cost Little or no change Healthy Lives 3 3 182 177 in area rate 10 31% 19 58% * Rankings from the 2012 edition of the Scorecard have been revised to match methodology and measure definitions used in the 2016 edition. a I mproved or worsened denotes a change of at least one-half (0.5) of a standard deviation (a statistical measure of variation) larger than the indicator’s distribution among all HRRs over the two time points. Little or no change denotes no change in rate or a change of less than one-half of a standard deviation. For complete results, visit the Health System Data Center. Data: D. C. Radley, D. McCarthy, and S. L. Hayes, Rising to the Challenge: A Scorecard on Local Health System Performance, 2016 Edition (The Commonwealth Fund, July 2016). High demand for services, coupled with lean a hospital provider fee that draws additional federal reimbursement and workforce shortages, foster matching funds to expand coverage to more low-income interdependence among Pueblo’s health care children and adults and enhance reimbursement to organizations. A spirit of “co-opetition” — a willingness providers, thereby reducing uncompensated care.5 This has to work together to pursue common interests, while helped Pueblo’s safety-net hospitals expand access to care, competing for patient loyalty — is evident in the two while also rewarding them for improving quality. In 2014, hospitals’ practice of sharing medical specialists, who Colorado further expanded Medicaid to more low-income are scarce resources in this region. Both have made a adults through the Affordable Care Act. commitment not to divert patients from their emergency departments, since there is nowhere else for patients to go. Such efforts are enabled by routine meetings of the CEOs and an open-door policy among leaders at both institutions to discuss community concerns. “Both hospitals have a significant role to play to address the large community health burden in Pueblo,” says Matt Guy, former executive director of the Pueblo Triple Aim Corporation, a health care improvement collaborative, and now president of the consulting firm Accelerated Matt Guy, former executive Transformation Associates. director of the Pueblo Triple Aim Corporation, a health care improvement collaborative, says Expanding Access to Care that local health care providers have come together to work on Local providers have worked to enroll people in health shared goals such as reducing coverage, building on Colorado’s efforts to expand emergency department use. Medicaid. These began in 2010 with the institution of commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 5 While the Scorecard did not detect a substantial drop in the region’s uninsured working-age adult population from Rebecca Hearst, R.N., serves as a patient advocate and navigator 2012 to 2014, the rate fell to 10 percent in 2015 — better at Pueblo’s community mental than state (12%) and national (13%) rates.6 The Scorecard health center, Health Solutions, which has used Medicaid funds found improvements from 2011–12 to 2013–14 on two to provide these services. related indicators: an increase in the share of adults with a usual source of care (from 77% to 81%), as well as a steep decline in the share of at-risk adults who went without a physician visit in the past two years (from 21% to 13%) — in both cases besting state and national rates. Parkview may have contributed to this improvement by providing Pueblo County’s urgent care and emergency facilities with lists of local primary care physicians, information on school- based clinics, and health department resources to share with patients. Health care providers have also expanded primary care capacity. In 2012, Parkview established an internal medicine residency program, which retained over half its graduates in its first two years. (This program complements a longstanding family medicine residency at St. Mary–Corwin.) The hospital also opened Mike Baxter is president another primary care clinic and “leased” one of its staff and CEO of Parkview Medical Center, which endocrinologists to the FQHC for a few days each month, has earned national enabling easier access to this in-demand service. During recognition for its efforts to improve the period the Scorecard measured, many of the practices quality and promote affiliated with St. Mary–Corwin established themselves evidence-based care. as patient-centered medical homes, part of an initiative to make after-hours care more available and chronic disease management and preventive services more accessible.7 Medicaid expansion also helped the FQHC hire more nurse practitioners and physician assistants to work on care teams in an expanded facility, thereby eliminating a waiting list for accepting new patients. Today the community health center is able to provide same- or next-day appointments for urgent issues and schedule most routine visits in less than 21 days, though it still faces capacity challenges given its difficulty in hiring primary care providers.8 Since 2009, it has operated five school- based clinics in a partnership with Parkview Medical Center that provide primary care, vaccinations, birth control, sports fitness exams, prescriptions, and referrals for specialty care. commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 6 Improving the Quality of Care its board.10 Among other efforts, staff members began Pueblo’s most notable gains were on measures assessing checking on patients every hour and making bedside shift the delivery of preventive care and evidence-based changes to promote clear and continuous communication treatment. Improvements on 10 of 12 indicators vaulted the among providers and between patients and providers. region from the fifth to the second quintile of performance With incentives from public and private insurers to on this domain. This progress suggests that quality improve the quality of care, Pueblo Community Health improvement has become embedded in the local health Center has achieved its goal of performing above the care culture. This may be attributable, in part, to deliberate national median among FQHCs for nine of 15 indicators steps taken by Parkview Medical Center, which retains tracked by the federal government. Through Colorado the largest market share in the region, to reduce variation Medicaid’s Accountable Care Collaborative, created in and promote evidence-based care.9 Leaders say Parkview’s 2010 to improve care while expanding coverage, the FQHC commitment to quality improvement — and national receives per member per month funding (in addition to recognitions it received as a result — spurred others to fee-for-service reimbursement) to coordinate care for improve. “Several thousand people visited to see what the its 20,000 Medicaid patients. It uses a web-based system hospital was doing,” says Michael Pugh, who served as CEO and claims data to identify gaps in care — for example in the 1990s. missed postpartum appointments or well-child checks — During the years tracked by the Scorecard, Parkview set and to work with frequent emergency department or goals to reduce patient harm and improve clinical quality hospital users to offer chronic care management and and service, reporting progress monthly to all staff and other support.11 In 2011, the FQHC received recognition Parkview Medical Center Fiscal Year 2017 Quality and Service Goals Year-to-Date PILLAR GOAL BY June 30, 2017 Operating Measure Actual* REDUCE PATIENT HARM Central Line–Associated Bloodstream Infections Reduce total number of CLABSIs 20% or more Goal is (CLABSIs ) from 10 to fewer than 8 being met Reduce Catheter-Associated Urinary Tract Reduce total number of CAUTIs 14% or more Goal is QUALIT Y Infections (CAUTIs) from 20 to fewer than 17 being met IMPROVE CLINICAL OUTCOMES Reduce overall readmission rate 10% or more Goal is not Reduce Readmission Rate from 11.1 to 10.0 or less being met Goal is Reduce Sepsis Mortality Rate Reduce sepsis mortality rate from 11.1% to 10% being met Increase hand hygiene compliance based on Goal is not Achieve Hand Hygiene Compliance internal surveillance to 94% or higher being met Overall HCAHPS from 75.3 to 76.3 or higher Goal is Increase Overall Service Score SERVICE HCAHPS data (Note: 2-month lag) being met HCAHPS score from 75.45 to 79.45 or higher Goal is Improve Physician Communication Score HCAHPS data (note: 2-month lag) being met HCAHPS score from 79.7 to 80.7 or higher Goal is Improve Hospital Cleanliness Score HCAHPS data (note: 2-month lag) being met Notes: Goals not shown for people (employees), growth, and finance. HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems. * Actual as of Sept. 2016. Data: Parkview Medical Center. commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 7 as a medical home by the Accreditation Association of Ambulatory Health Care for its efforts to expand access Quality-of-Care Performance for Pueblo and improve the quality of care. Community Health Center and Ranking Compared with Federally Qualified Health Collaborative efforts to promote preventive care and to Centers Nationally improve care coordination across settings have also been launched. Pueblo’s public health department partners with Adjusted the residency programs at Parkview and St. Mary–Corwin Quartile 2013 2014 2015 Ranking to promote colorectal cancer screenings through a chart review and tracking system, which led to an increase in Quality of Care Measures 2014 2015 the number of adults screened.12 Case managers at the Perinatal Health FQHC coordinate care for high-risk obstetric patients by Access to Prenatal Care (First scheduling appointments for them at St. Mary–Corwin’s 75.6% 79.2% 81.1% 2 2 Prenatal Visit in 1st Trimester) high-risk obstetrics clinic, making sure they attend, and Low Birth Weight 9.5% 10.1% 9.0% 4 3 helping them adhere to recommended treatment. Preventive Health Screening & Services Since 2001, the FQHC has been the first point of contact Cervical Cancer Screening 48.4% 68.0% 64.1% 1 2 for hospitals when they discharge patients who do not Weight Assessment and Counseling for Nutrition have an identified source of primary care. In recent years, and Physical Activity of Children 6.0% 18.1% 63.6% 4 2 Parkview added a dedicated team to contact patients after and Adolescents Adult Weight Screening discharge to ensure they understand their treatment plan and Follow-Up 27.4% 84.6% 90.0% 1 1 and have a follow-up appointment scheduled. In 2015, the Adults Screened for Tobacco Use and Receiving Cessation — 73.9% 80.9% 3 3 Southeastern Colorado Transitions of Care Consortium Intervention (launched by the Pueblo Triple Aim Corporation) Colorectal Cancer Screening 24.1% 36.4% 42.1% 2 2 brought together Pueblo’s urban and regional hospitals, Childhood Immunization 85.8% 89.1% 80.2% 1 2 community mental health center, and the FQHC, physician Depression Screening — 5.9% 18.2% 4 4 groups, insurers, and the Medicaid Regional Care Collaborative Organization to align and improve their care Dental Sealants — — 30.0% — 3 coordination efforts. Chronic Disease Management Asthma Treatment (Appropriate Pueblo’s fire department has joined the consortium, Treatment Plan) 50.5% 100.0% 94.0% 1 2 prompted by a growing number of 911 calls, which Cholesterol Treatment (Lipid Therapy for Coronary Artery 52.6% 66.4% 92.4% 4 1 increased from 2,000 in 2008 to 21,000 in 2015. Some Disease) came from residents who would repeatedly fall in their Heart Attack/Stroke Treatment (Aspirin Therapy for Ischemic 20.6% 51.5% 80.0% 4 3 homes; others came from people who simply needed a Vascular Disease Patients) way to access the health system.13 This resulted in the Blood Pressure Control (Hypertensive Patients with 66.6% 65.2% 69.0% 2 2 2016 launch a pilot program called Directing Others to Blood Pressure < 140/90) Service, or DOTS, in which fire department staff and Uncontrolled Diabetes (Diabetic 38.4% 33.4% 32.0% — 3 providers connect frequent users of the emergency Patients with HbA1c > 9%) response system with medical homes or other sources of HIV Linkage to Care — 100.0% 100.0% — — help. Fire department staff also visit frequent 911 callers to Note: Quartile ranking is out of Health Resources and Services Administration (HRSA)-funded health centers nationwide; 1st or 2nd identify needs — such as a grab bar in their bathroom or an quartile of performance is above the national median. eyeglass prescription — that could be addressed to head off Data: HRSA Health Center Program, Pueblo Community Health Center 2015 Profile. future emergencies.14 commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 8 COLLABORATING REGIONALLY TO Donald Moore, CEO of Pueblo COORDINATE CARE FOR MEDICAID PATIENTS Community Health Center, says Colorado’s Medicaid Accountable Care Colorado in 2010 created a Medicaid Accountable Collaborative has enabled the health Care Collaborative (ACC) to promote care coordination center to invest in the infrastructure and efficiency while expanding coverage for Medicaid needed to coordinate patient care. beneficiaries.a The ACC comprises seven regional care collaborative organizations (RCCOs) selected by the state, which pays them a fee of up to $12 per member per month (PMPM) to oversee medical management, provider network development and support, and performance reporting. RCCOs contract with primary care providers, who receive $3 PMPM from the state (on top of fee-for-service reimbursement) for participating in care coordination and quality improvement activities. Both may also earn financial incentives for meeting performance targets. Integrated Community Health Partnership, LLC, is the RCCO serving Pueblo and 18 other counties in southeastern Colorado. Its members include a behavioral health organization and four community mental health centers as well as a consortium of three FQHCs.b The RCCO passes a portion of its fee to the FQHCs to coordinate care for their Medicaid patients and to the community mental health centers (Health Solutions in Pueblo) to coordinate care for other Medicaid beneficiaries. For example, Health Solutions hired 10 registered nurses to serve as patient advocates and navigators primarily on behalf of dually eligible Medicare and Medicaid clients. They spend time in providers’ practices and connect clients to resources to Addressing Social Determinants meet their medical and nonmedical needs. Pueblo’s health care providers have also moved to address To date, the most beneficial aspect of the RCCO has the social determinants of poor health, including poor been to bring the partners together to identify what nutrition. In response to evidence that 17 percent of Pueblo is and isn’t working in their communities, according to Chris Senz, CEO of Integrated Community Health residents lacked access to healthy food, St. Mary–Corwin Partnership. The program has enabled FQHCs such as in 2013 launched a farm stand in its own neighborhood, the Pueblo Community Health Center to create a care which is considered both a food desert because of its lack coordination infrastructure that was not possible under traditional fee-for-service reimbursement, according of healthy food options and a food swamp because of its to Donald Moore, its CEO. The ACC program saved an abundance of cheap, low-nutrition options.15 The hospitals’ estimated $37 million statewide in fiscal 2014–15, physicians are able to write prescriptions for high-risk according to the state of Colorado.c patients, including those who are obese and/or diabetic, to a D . Rodin and S. Silow-Carroll, Medicaid Payment and Delivery receive free fruit and vegetables there.16 Parkview has also Reform in Colorado: ACOs at the Regional Level (The sought to promote better nutrition by sending nurses to Commonwealth Fund, March 2013). b The consortium is known as the Colorado Community Managed worksites and public venues to offer dietary advice and free Care Network. diabetes screenings. Such work is reinforced by the public c Colorado Department of Health Care Policy and Financing, Legislative Request for Information, Nov. 1, 2015; J. Lloyd, R. health department’s efforts to help local food retailers Houston, and T. McGinnis, Medicaid Accountable Care Organization Programs: State Profiles (Center for Health Care Strategies, Oct. purchase freezers or make other changes necessary to sell 2015); National Academy for State Health Policy, Colorado ACO. healthier products, and successful lobbying of Walmart to open a store in one of Pueblo’s poorest neighborhoods. commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 9 St. Mary–Corwin has also partnered with the city to enforce code violations against landlords for problems that ENGAGING FAITH COMMUNITIES, TRYING impact health, like mold and bug infestations. And Stetter COMPLEMENTARY APPROACHES has led an effort to educate Pueblo’s religious leaders about When Rev. Linda Stetter came to Pueblo to become the health issues and enlist them in supporting members of director of mission and spiritual care for St. Mary–Corwin Medical Center in 2013, she started church-hopping on their congregations. Sundays. Thus far she’s visited more than 90 of the city’s 125 churches. Having worked in communities with strong COLLECTIVE ACTION ACROSS SECTORS interfaith associations, Stetter knew that religious leaders could serve as community partners for hospitals such as Several leaders note that Pueblo has a history of hers — offering pastoral care to sick members of their collaborative efforts, most notably the One Community congregations or speaking to congregants about good Pueblo initiative, begun in 2008, involving health nutrition and other healthy behaviors. She began offering providers, educators, law enforcement officials, and judges quarterly symposia to clergy on such topics and now in supporting healthy child and youth development, in receives requests from them to be educated about issues part by promoting access to mental and physical health like autism that are of concern to their congregants. services. The effort involves collecting extensive data and Stetter hopes to try the Memphis Model in Pueblo, an reporting it on a public dashboard.17 approach developed at Methodist Le Bonheur Healthcare in Memphis, Tenn. Through the hospital’s Congregational Health Network, members of some 500 Memphis Rev. Linda Stetter, churches, many African American, have agreed to help director of mission and chronically ill congregants, in part by checking up on them spiritual care for St. after hospitalizations. “They are cared for like neighbors Mary–Corwin Medical Center, at the hospital’s used to care for neighbors,” says Stetter. Methodist Le farm stand. St. Mary– Bonheur has reported that over a three-year period Corwin physicians can write prescriptions for patients served through this network had shorter hospital patients to receive free stays, longer intervals between hospitalizations, and fruit and vegetables. significantly lower mortality rates.a Stetter also helps direct St. Mary–Corwin’s use of complementary therapies such as acupuncture and mindfulness in the intensive care unit, emergency department, and elsewhere to help those dealing with addiction, pain, and stress. Such approaches have been especially needed to help the hospital’s pain management clinic treat a population of opioid-dependent patients. In 2007 two local doctors were forced to close their practices over alleged overprescribing, and Pueblo has received negative publicity as the highest drug-prescribing city in Colorado.b The hospital’s commitment to complementary therapies — including the services of a harpist — is an effort “to help people cope with their chronic illnesses and their mental conditions beyond the hospital walls,” says Stetter. a A . Halperin, “It Really Does Take a Village: How Memphis Is Fixing Healthcare,” Salon, Sept. 3, 2013. b L . Sword, “Pain Specialist Plans Doctors’ Class,” The Pueblo Chieftain, Oct. 9, 2013. commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 10 In 2010, Pueblo’s two hospitals conducted their first the rate of preventable hospitalizations — may be community health needs assessments, a requirement influenced in part by initiatives such as the care transitions for nonprofit institutions under the Affordable Care consortium described above. Act, and the public health department created a new To guide their work, members worked with the ReThink community health improvement plan. These analyses cast Health initiative, a nonprofit promoting regional health into stark relief the breadth and depth of Pueblo’s health improvement, to model the long-term effects of various problems and prompted leaders to move beyond ad hoc health policies on Pueblo residents’ lives, health care costs, efforts to take collective action. After hearing about the quality of care, equity, and productivity.20 This exercise Institute for Healthcare Improvement’s Triple Aim — for helped convince employers facing rising health costs and improved care, improved population health, and reduced overburdened safety-net providers that making long-term per capita costs — leaders founded the Pueblo Triple and even modest investments in better health could yield Aim Corporation, a nonprofit with a dedicated staff and significant financial returns. “The big thing that became infrastructure.18 Leaders from the business community, evident through the modeling was that to have impact social services, philanthropy, economic development, and they would have to move upstream and look at those social education, as well as Latino and other community groups, determinants of health,” says Randy Evetts, senior program have joined. officer for the David and Lucile Packard Foundation, which The group uses a data dashboard to track key population financed the development of the dashboard and supports health indicators for Pueblo County residents, compare a number of causes in Pueblo, the birthplace of David Pueblo’s performance with other counties, and set goals Packard, Hewlett-Packard’s cofounder. The Pueblo Triple for improvement.19 At this stage, some targets — such ­ Aim Corporation has leveraged grants from a number of as a reduction in the premature death rate — appear to foundations to fund its work.21 be largely aspirational, while others — such as reducing Pueblo Triple Aim Corporation: Triple Aim Metrics Indicator Baseline rate* Recent rate** Target rate POPULATION HEALTH Years of Potential Life Lost (before age 75; rate per 100,000, age-adjusted) 8,435 8,552 7,940 Percent of Residents Reporting Fair to Poor Health 16% 18% 13% PATIENT EXPERIENCE Clinical Care: Access and Quality (composite rank among 60 Colorado counties) 13 12 10 Percent of Residents with No Insurance 14% 15% 13% COST OF CARE Population Health and Resource Use (illness burden score compared to 1.25 1.34 1 statewide average) Preventable Hospital Stays (rate per 1,000 Medicare enrollees) 68 35 33 * Baseline rate represents the 2010 reporting year. ** Recent rate represents the 2016 reporting year, except for Population Health and Resource Use (illness burden score compared to statewide average), which represents the 2012 reporting year. Data: Triple Aim Measures (Pueblo Triple Aim Corporation, n.d.). commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 11 The group’s initial effort, led by the public health County more than halved its rate during this time, department, sought to reduce teen pregnancy rates, representing a much larger decline in absolute terms (a which for years were among the highest in the state. Past reduction of 35.2 per 1,000 in Pueblo vs. 19.2 per 1,000 efforts to address the issue had splintered, in part over for the state). The local public health department helped disagreements about whether to promote contraception promote use of LARC, in part by talking to providers. “We or abstinence-only approaches (many in the community found that teens were very scared and reluctant to even identify as Catholic or evangelical Christian).22 Cognizant come in to a clinic and talk about their sexual health,” of this history, the Triple Aim group recast the issue as not says Sylvia Proud, director of Pueblo City-County Health just preventing pregnancies but promoting positive youth Department. “We have done a lot with how to talk to teens, development — including mentoring initiatives, efforts how to make clinics more teen-friendly environments.” to educate teens about their career options, and a sexual Members of the Pueblo Triple Aim Corporation are also health educational campaign.23 working to increase healthy behaviors and reduce obesity. The community’s effort to reduce teen pregnancy gained Pueblo was the first Colorado city to ban smoking in momentum from Colorado’s groundbreaking policy to public spaces; the group is now working with the housing make long-acting reversible contraception (LARC) free authority to make low-income housing units smoke free. to low-income teenagers and women through family The organization also participates in national learning planning centers, which led to a 50 percent drop in the collaboratives on health improvement.25 Exhibit 5. Teen Pregnancy Rate Per 1,000 Women Ages 15-19: Pueblo state’s teen pregnancy rate from 2009 to 2015.24 Pueblo County vs. Colorado State Teen Pregnancy Rate per 1,000 Ages 15–19: Pueblo County vs. Colorado State 62.7 59.2 42.2 41.1 37.3 30.6 37.5 34.4 27.5 33.1 28.0 Pueblo County 22.4 19.5 18.3 Colorado 2009 2010 2011 2012 2013 2014 2015 Data: Pueblo City-County Health Department, based on vital statistics data collected and reported by the Colorado Department of Public Health and Environment. commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 12 The public health department has played a leading role in reducing teen pregnancies. From left to right: Public Health Director Sylvia Proud, Program Manager Zak VanOoyen, Public Health Nurse Desiree Wolfe, and Nurse Practitioner Janet Pippenger. LESSONS Cross-sector coalitions can help communities Supportive state policies lay the groundwork build the will needed to take collective action. for local improvement. Pueblo has benefitted from The Pueblo region has worked to create a positive supportive state policy, most notably Colorado’s health identity in the face of long-standing social problems that care reforms that expanded Medicaid before and after can wear down the spirit of volunteerism over time. enactment of the Affordable Care Act, as well as the Improvement efforts have gained traction in recent years creation of the Medicaid Accountable Care Collaborative as community leaders have found common ground, and policies such as support for the use of long-acting helped to a great extent by coalitions such as the Pueblo reversible contraceptives. But the grassroots efforts led by Triple Aim Corporation.26 Cross-sector efforts have built Pueblo’s community leaders have ensured there is fertile on one another to develop leaders’ capacity for public– ground for localizing state policy to serve the priorities of private collaboration, nurtured by financial support from this independent region, which can be wary of receiving foundations, local charities, and an insurer. To make dictates from state government. “There is a very fierce progress in a collaborative way, community leaders need Pueblo culture of, ‘We are going to do it our way,’” says Guy. to cultivate a sense of “patient urgency,” says Guy, by “We will take your help, but this is our community, and we slowly building trusting relationships while immediately are going to do it our way.” taking incremental steps toward achieving agreed-upon goals for improvement. commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 13 NOTES Colorado Department of Public Health and the 1 half of Pueblo County as a medically underserved area Environment, Visual Information System for Identifying (https://www.colorado.gov/pacific/sites/default/files/ Opportunities and Needs, Data by County, Diabetes — PCO_HPSA-mua-mup-map.pdf). Adults, 2013–2015. 9 Use of concurrent review of medical records while J. Puzzanghera, “Low Pay? Disabilities? Video Games? 2 patients are still hospitalized enabled timely delivery Researchers Seek Answers,” The Pueblo Chieftain, Dec. of education and reminders to staff at the point of 3, 2016. care, leading to top performance on measures of care processes for pneumonia and heart in failure in 2007 B. J. Ivey, “Improving Quality at Parkview,” Journal for 3 and 2008. See A. Lashbrook, Parkview Medical Center: Healthcare Quality, Sept./Oct. 1992 14(5):56–62. Underscoring the Importance of Communication in Pneumonia Care (The Commonwealth Fund, Dec. 2009). The Pueblo hospital referral region also includes parts 4 of Crowley, Custer, El Paso, Fremont, Huerfano, Las 10 Parkview was recently noted as one of 49 hospitals Animas, and Otero counties. nationwide to achieve the lowest rates of hospitalwide readmissions from July 2014 through June 2015; see The Colorado hospital provider fee was enacted in 5 H. Punke, “49 Hospitals With the Lowest Readmission 2009 following recommendations of a bipartisan Rates,” Becker’s Infection Control and Clinical Quality, Blue Ribbon Commission on Health Care Reform. Dec. 28, 2016. Enabling legislation prohibits hospitals from shifting the fee to clients or insurers. Since enactment of the 11 Pueblo Community Health Center is also eligible for fee, reimbursement to hospitals for care provided to quality bonuses from Kaiser Permanente for meeting Medicaid patients has increased from 54% to 75% of targets for its Medicare Advantage patients, as well as costs statewide, while the amount of bad debt and from other private insurers. charity care decreased by 58% from 2013 to 2015, according to the state’s Hospital Provider Fee Oversight 12 The project resulted in the creation of a toolkit and Advisory Board; see Colorado Health Care for statewide use and paved the way for related Affordability Act Annual Report, Jan. 15, 2017. collaboration, such as an effort to increase the referral of tobacco users to cessation resources. Commonwealth Fund analysis of data from the U.S. 6 Census Bureau, 2015 1-Year American Community 13 K. Galer, “Pueblo Fire Launches New Program to Help Survey Public Use Micro Sample (ACS PUMS); also see Decrease Record Number of Calls for Service,” KKTV 11 S. L. Hayes, S. R. Collins, D. C. Radley, D. McCarthy, and News, Feb. 12, 2016. S. Beutel, A Long Way in a Short Time: States’ Progress on Health Care Coverage and Access, 2013–2015 (The 14 Pueblo County DOTS Program (n.d.). Commonwealth Fund, Dec. 2016). 15 See U.S. Department of Agriculture, Food Access Colorado Health Neighborhoods (Centura Health, n.d.). 7 Research Atlas and County Business Patterns 2012 (USDA, n.d.). The federal government has designated Pueblo 8 Community Health Center as a health professional 16 The food purchases are funded by local medical shortage facility (https://datawarehouse.hrsa.gov/ practices, accountable care organizations, and a grant tools/analyzers/HpsaFindResults.aspx), and about from the hospital’s foundation. The local food bank also will begin donating food this year. commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 14 17 See One Community Pueblo dashboard (n.d.). 22 In the 1990s the community lost a $1 million grant from the Colorado Trust because members of the 18 B. Milstein, “ReThinking Health in Pueblo, Colorado: collaboration formed to use the funds couldn’t agree A Stewardship Strategy to Advance the Triple Aim,” on the best way to address teen pregnancy. Improving Population Health Blog, Aug. 21, 2012; and K. Mitchell, Pueblo County Triple Aim: Tips for Population 23 See The Pueblo County Teen Pregnancy Research Project Health Success (Institute for Healthcare Improvement, Final Report (John Snow, Inc., n.d.). Jan. 13, 2016). Data provided by the Pueblo City-County Health 24 19 See Triple Aim Measures (Pueblo Triple Aim Department, based on vital statistics collected Corporation, n.d.). and reported by the Colorado Department of Public Health and Environment. The Long-Acting 20 ReThink Health is an initiative of the Fannie E. Rippel Reversible Contraception Program, originally Foundation. For background on the ReThink Health funded anonymously by the Susan Thompson Dynamics model, see: https://www.rethinkhealth.org/ Buffet Foundation, gained state funding in 2016; resources-list/dynamic-modeling-strategy/. see S. Tavernise, “Colorado’s Effort Against Teenage Pregnancies Is a Startling Success,” New York Times, July 21 Major grants have included $709,000 from the 5, 2015. Colorado Health Foundation and $565,000 from Kaiser Permanente, which opened medical offices in Pueblo 25 Pueblo is one of 24 communities participating in the in 2009 to serve its new Medicare Advantage and SCALE (Spreading Community Accelerators through commercially insured members. The grant from Kaiser Learning and Evaluation) initiative led by the Institute helps support efforts to reduce avoidable readmissions for Healthcare Improvement with funding from the and emergency department use and promote Robert Wood Johnson Foundation, and is one of community health. Pueblo Triple Aim Corporation 50 communities participating in the Invest Health also has a $25,000 contract with Colorado’s Medicaid initiative sponsored by the Robert Wood Johnson agency to further develop community data in Foundation and the Reinvestment Fund to promote conjunction with the Medicaid Regional Collaborative cross-sector collaboration at the neighborhood level. Care Organization. 26 J. Kania and M. Kramer, “Collective Impact,” Stanford Social Science Review, Winter 2011. commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 15 ABOUT THE AUTHORS ACKNOWLEDGMENTS The authors thank the following individuals who Martha Hostetter, M.F.A., is a writer, editor, and partner generously shared information and insights for the case in Pear Tree Communications. She was a member of the study: Andrea Aragon, president, Pueblo United Way; Commonwealth Fund’s communications department Catherine Bader, administrative manager for community from June 2002 to April 2005, serving as the associate health, Centura Health; Mike Baxter, president and editor and then creating the position of Web editor. She is CEO, Parkview Medical Center; Greg Bowman, M.D., currently a consulting writer and editor for the Fund. Ms. chief quality officer, Parkview Medical Center; Jason Hostetter has an M.F.A. from Yale University and a B.A. Chippeaux, deputy clinical director, Health Solutions; from the University of Pennsylvania. Randy Evetts, senior program officer, David and Lucile Sarah Klein is editor of Transforming Care, a quarterly Packard Foundation; Matt Guy, president, Accelerated publication of the Commonwealth Fund that focuses Transformation Associates (former executive director, on innovative efforts to transform health care delivery. Pueblo Triple Aim Corporation); Holly Kortum, She has written about health care for more than 15 years executive director, Southern Colorado Operations, Kaiser as a reporter for publications including Crain’s Chicago Permanente; Maureen McDonald, senior director, Kaiser Business and American Medical News. Ms. Klein received a Permanente Community Benefit; Donald Moore, CEO, B.A. from Washington University in St. Louis and attended Pueblo Community Health Center; Carl Patten, Jr., director the Graduate School of Journalism at the University of of medical legal partnerships, Centura Health; Sylvia California at Berkeley. Proud, director, Pueblo City-County Health Department; Michael Pugh, former CEO, Parkview Medical Center; Douglas McCarthy, M.B.A., is senior research director Jessica Sanchez, vice president for quality, Colorado for the Commonwealth Fund. He oversees the Fund’s Community Health Network; Chris Senz, CEO, Integrated scorecard project, conducts case-study research on Community Health Partners; Linda Stetter, director of delivery system reforms and innovations, and serves as mission and spiritual care, St. Mary–Corwin Medical a contributing editor to the Fund’s quarterly newsletter Center; and Matthew Wilkins, director of integrated Transforming Care. His 30-year career has spanned healthcare, Health Solutions. research, policy, operations, and consulting roles for government, corporate, academic, nonprofit, and philanthropic organizations. He has authored and Editorial support was provided by Ann B. Gordon. coauthored reports and peer-reviewed articles on a range Photos by Steve Bigley. of health care–related topics, including more than 50 case studies of high-performing organizations and initiatives. Mr. McCarthy received his bachelor’s degree with honors from Yale College and a master’s degree in health care management from the University of Connecticut. He was a public policy fellow at the Hubert H. Humphrey School of Public Affairs at the University of Minnesota during 1996–1997 and a leadership fellow of the Denver- based Regional Institute for Health and Environmental Leadership during 2013–2014. He serves on the board of Colorado’s Center for Improving Value in Health Care. commonwealthfund.org Case Study, September 2017 Pueblo, Colorado: Building on Common Ground 16 For more information about this brief, please contact: Martha Hostetter, M.F.A. Consulting Writer and Editor The Commonwealth Fund mhcmwf.org About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high performance health care system. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff. Vol. 31 Commonwealth Fund case studies examine health care organizations that have achieved high per- formance in a particular area, have undertaken promising innovations, or exemplify attributes that can foster high performance. It is hoped that other institutions will be able to draw lessons from these cases to inform their own efforts to become high performers. Please note that descriptions of prod- ucts and services are based on publicly available information or data provided by the featured case study institution(s) and should not be construed as endorsement by the Commonwealth Fund. commonwealthfund.org Case Study, September 2017