What top five i nterventions would you support to achieve the triple aim of better care, better health, lower cost?

1. What top five interventions would you support to achieve the triple aim of better care, better health, lower cost?

2. Leveraging the Community Benefit Requirements of the Affordable Care Act for Collective Impact: The Atlanta Regional Collaborative for Health Improvement (ARCHI) Presented to: Grantmakers in Health March 7, 2014 A R C H I

3. Changes in Public Coverage Changes in Private Coverage Improving Health Care Quality Improving Health

4. The CHNA Opportunity in the ACA • Community health needs assessments (CHNA) are now required every three years of not-for-profit health entities in order to maintain their tax-free status • CHNA and implementation strategy required for each facility

5. The CHNA Opportunity in the ACA • CHNA: • A description of “community” and how it was determined • A description of process and methods, including data used and information gaps • A description of how input was gathered from those with a broad interest in the community • A prioritized list of community health needs, including how the list was prioritized

6. The CHNA Opportunity in the ACA • Implementation plan: • Must describe how each health need identified in the CHNA will be met, or • Describe identified needs that will not be met by that hospital and why • Must be approved by a governing body • Collaboration is encouraged

7. Solution Led by United Way, ARC, and Georgia Health Policy Center Funders (CDC, Kaiser, St. Joseph’s Healthcare, Grady, and the Lead Organizations) Public Health, Hospitals, FQHCs, Physicians, Behavioral and Other Providers Funders (CDC, Kaiser, etc.) Business, Education, County Commissioners, Faith Leaders, Insurers, Philanthropy County Commissioners

8. ARCHI Video

9. Seeding Innovations in Health A R C H I

10. Rippel, ReThink Health, & the RTH Dynamics Model

11. How can we work together to solve complex problems in a complex world using technology that helps us see, understand & talk about the real problems and develop sustainable solutions…

12. THE RIPPEL FOUNDATION Seeding Innovations in Health

13. THE FANNIE E. RIPPEL FOUNDATION • Founded in 1953 as a charitable foundation • 6 person Board of Directors • Home office Morristown, NJ; satellite location in Cambridge, MA • $85 million in assets; $6.4 million 2014 budget • 30 full and part time staff and long term contractors… and growing • Legal Mandate: Women, Elderly, Cancer, Heart Disease, Hospitals • 2007 Mission: “Seed Innovations in Health” • Primary program and investment: ReThink Health • 75% of total Rippel budget; 95% of program budget • Generated $2.5 million in grants and earned income to date • After 53 years of primarily making grants… • Almost no grants, not operating foundation; work through DCA • Commitment to collaboration with like-minded partners

14. JULIUS A. RIPPEL, PRESIDENT, 1953 - 1983 1959 – We have long known that health care facilities should be adapted to the patients rather than the opposite. 1967 - To avoid becoming sick may be the greatest health and medical challenge to contemporary society. 1968 - Sooner or later some group will find out how to build, organize and operate a hospital which will be better and more flexible than at present, and at a lower cost. 1968 - The greatest opportunity people have to achieve and maintain good health and well-being, at the lowest possible cost, is by their own intelligent methods of daily living habits. 1969 - We need to develop a health care system which will be recognized as distinct from medical care. This is a real key to solving our “medical problem.” 1969 - We must have substantially new manners of thinking to enable mankind to bridge the gap between the things that have been and the things which will be.

15. 45 YEARS LATER, WE BEGAN TO REALIZE….

16. RETHINK HEALTH A Collaborative Initiative of the Rippel Foundation

17. ORIGINS OF RETHINK HEALTH 1 6 1 • Don Berwick | CMS, IHI • Elliott Fisher | The Dartmouth Institute • Marshall Ganz | Leading Change, Harvard • Celinda Lake | Lake Research • Laura Landy | Rippel Foundation • Amory Lovins| Rocky Mountain Institute • Jay Ogilvy | Global Business Network • Elinor Ostrom | Nobel Laureate in Economics • Peter Senge | MIT, Society for Org. Learning • John Sterman | MIT System Dynamics Group 4 9 2 7 10 8 5 3

18. CHALLENGE & PRINCIPLES Action Results ReActing Thinking … work with leaders to demonstrate that sustainable redesign of regional health systems is possible and can improve health, care, costs, equity, ownership, productivity, regional economies, and communities vitality. Better health, better care, lower costs and access for all Collaboration by leaders across boundaries (in and out of health) Whole system thinking Redesign to meet health and care needs National purpose, local action RETHINKING 18

19. INTEGRATED APPROACH

20.  WORK WITH LEADERS & COALITIONS TO… Bring system stakeholders together in a way that builds trust, shared vision, and collaborative action.  Build purposeful and effective stewardship teams that can sustain efforts and achieve measurable results over time.  Assure that health resources are being spent to achieve the greatest impact.  Align community priorities with health system priorities. Finance and sustain efforts long enough to see real results and avoid rebound experiences.  Support innovation, implementation, and system redesign in ways that achieve high impact goals and build critical interdependencies.  Educate leaders to have a whole system and collaborative perspective. Engage in action-research Develop and share lessons, tools, approaches

21. SINCE 2007… • Grant funding from the California HealthCare Foundation and the Robert Wood Johnson Foundation plus increasing earned income • Experience in more than 30 regions across the country • Created and used the Dynamics Model in 50 settings, 9 academic institutions, and thousands of users • Successful distance learning course with 180 participants • Building a learning network and community • Extensive partnerships with motivated leaders, regions and organizations • Strong enterprise wide evaluation process • Impact on regional and national levels

22. RETHINK HEALTH DYNAMICS MODEL

23. Historical Data Stewardship Teams Exploring Simulated Scenarios in Strategy Labs REDIRECTING HEALTH FUTURES U.S. National Health Expenditures (1998-2020) Where? What? $ in Billions How? Why? Who? Keehan SP, Cuckler GA, Sisko AM, et al. National Health Expenditure Projections: Modest Annual Growth Until Coverage Expands And Economic Growth Accelerates. Health Affairs 2012. Heffler S, Smith S, Keehan S, Borger C, Clemens MK, Truffer C. U.S. health spending projections for 2004-2014. Health Affairs 2005:hlthaff.w5.74.

24. COMMON PITFALLS • Unsustainable program financing • Spreading resources over too many initiatives • Lopsided investments downstream or upstream • Triggering “supply push” responses to declining utilization • Exacerbating capacity bottlenecks • Perpetuating inequity • Neglecting or focusing only on disadvantaged, children, or seniors • Pursuing narrow goals and short-term impacts • Concentrating only on small sub-systems

25. WHY WE GET CAUGHT…. Hard to see the bigger system and where things/we fit Stakeholders see different problems and solutions Stakeholders speak different languages Don’t recognize that not all solutions are equal – good / bad Real conversations about money, priorities, strategy, etc. are difficult Alignment from the community to policy levels is challenging Pressure for short term results with limited evidence for better planning System is complex and hard to predict

26. UNSTICKING… Consider Many Pathways Engage in Deeper Dialogue Anticipate Consequences and Plausible Futures

27. RETHINK HEALTH DYNAMICS MODEL • Realistic yet simplified portrait of a local health system (N=8 to date) • Anchored to evidence from dozens of datasets • A common, testable framework and tool for open, experiential learning • Designed with and for diverse stakeholders • Not a prediction, but a way to see and feel how local health system can change ReThink Health. Summary of the ReThink Health Dynamics model. Available at http://rippelfoundation.org/docs/RTH-Dynamics-Model-Summary.pdf

28. OVERVIEW Selected Geographic Focus Productivity & Equity Risk Health Care Cost Aging Capacity • Other Trends • Insurance eligibility • Economic conditions • Health care inflation • Primary care slots Initiatives Payment Captured Scheme Savings Innovation Funds Population tracked separately in 10 segments by age, insurance, and income

29. SYSTEM CONNECTIONS

30. INITIATIVE OPTIONS

31. EXPLORE THE LIKELY CONSEQUENCES…

32. SEE DIRECTION, TIMING, MAGNITUDE 32

33. EXPLORE LIKELY CONSEQUENCES OF DECISIONS… Savings O What happened? Why? What can we do? Initial R Innovation Fund Capture &Reinvest Health Care Savings Costs O Funds Available Program for Investment B Investments O Fund Depletion Spending on Programs

34. HELPS LEADERS AND COALITIONS ANSWER… Are we doing the right things now? What should commit to do? Do we have the right partners engaged? How do we pay for it? How proud would we be to succeed? What is our plan going forward? 34

36. www.ReThinkHealth.org

37. Philanthropy can invest in aligning a community around strategies to improve health A R C H I

38. Philanthropy • Convener • Neutral voice • Demonstrate patience and perseverance • Exhibit and encourage collaboration for collective impact • Invest • Work behind scenes

39. Kaiser Permanente • Funded research that identified need/opportunity • Key influencer behind the scenes • Shared value of collective impact • Continuous engagement • Patient capital investment • Aligned CHNA requirement/grant making to support ARCHI

40. Philanthropic Collaborative Healthy Georgia • 20 foundations sought to improve primary care through collaboration, data sharing and joint planning • Grady Health System & Four Federally Qualified Health Centers (FQHCs) • Collaborations on Patient Navigator Program, Accountable Care Organization application & Mobile Phone App • Aligned with ARCHI – Care Coordination • Grady allows staff privileges for FQHC physicians

41. United Way of Metro Atlanta • Aligned major $3.5 M Grant “Forget the Box” • Grantees must • Demonstrate at least two ARCHI priorities • Collaborate • Participate in Rethink Health learning agenda • Selected grantee may become ARCHI pilot

42. Discussion:Share opportunities for investment in your community

43. Thank You! www.archicollaborative.org A R C H I