Published in Health Affairs Blog
By Jan Nicholson
Foundations seeking to drive systems change in health care have a powerful method they can use to educate health system leaders. The Nicholson Foundation has found that sponsoring out-of-state, or even out-of-country, learning trips is an especially effective way to spread knowledge and inspire new ways of thinking.
The Nicholson Foundation is dedicated to addressing the complex needs of vulnerable populations in New Jersey’s urban and other underserved communities. Over the years, we have sponsored many trips that have sent hundreds of New Jersey health leaders beyond the Garden State to study approaches used and innovations practiced elsewhere. The knowledge these leaders have brought back has helped transform how care is delivered at home.
Here are some of the beneficial outcomes we have seen from these learning trips:
- Helping participants gain perspective on how health care is financed and delivered elsewhere
Health care stakeholders often think that the way things are done in their state is the only way they can be done. This is understandable because the unique institutional and bureaucratic norms and expectations that have developed are frequently the only ones to which they have been exposed. In many instances, however, approaches outside of “business as usual” are worth learning about and considering.
For the past five years, The Nicholson Foundation has sponsored an annual out-of-state learning trip for members of the QI Collaborative, which consists of leaders of New Jersey’s Medicaid Accountable Care Organizations (ACOs). ACOs are groups of doctors, hospitals, and other health care providers who come together voluntarily to coordinate care for their Medicaid patients and share in any savings that may result. Several states have implemented Medicaid ACOs, but each state has unique legal structures governing them and financial means for supporting them.
The QI Collaborative’s most recent learning trip was to Minnesota, a state whose experience with the Medicaid ACO model is more extensive than New Jersey’s is. We wanted to expose New Jersey’s ACO leaders to the challenges and successes their Minnesota counterparts are having. According to trip participant Greg Paulson, executive director of the Trenton Health Team, “While each state has its own model, we’re all trying to achieve the same results. Sharing the creative approaches implemented in other states is incredibly valuable.”
The New Jersey participants saw the critical role that state financial support in Minnesota has played in enhancing the chances that the Minnesota model would be successful. As a result, the participants increased their advocacy to urge New Jersey state government to do the same. This has already yielded a positive outcome—Gov. Chris Christie (R) just announced in his “State of the State” address on January 12 his commitment to provide state funds to support the Medicaid ACOs.
- Helping participants learn best practices they can incorporate in clinics back in New Jersey
Federally qualified health centers (FQHCs) serve the most vulnerable populations, and they are always seeking ways to improve care and reduce costs. We are funding a series of trips for the New Jersey Primary Care Association and its FQHC members to visit highly regarded FQHCs in other states, so they can learn about and implement clinical and business practices successfully being used in other areas of the country.
In October and December 2015, representatives from the majority of New Jersey’s FQHCs traveled toCommunity Health Center in Middletown, Connecticut, and the Whitman-Walker Health in Washington, DC. According to trip participant Jillian Hudspeth, CEO of the New Jersey Primary Care Association, “Some of the New Jersey FQHC leaders were so impressed by what they saw on these site visits that they have begun to make policy and program changes.” Hudspeth, too, is incorporating many of the lessons learned from the trips into the association’s plans for the future.
- Introducing key decision makers to new models of care delivery
High-level health care decision makers who have the authority to implement broad systems change are busy people. They generally do not have time to scope out the field for promising up-and-coming programs. This presents a window of opportunity for foundations to play the role of “advance scouts” by learning about promising new approaches and bringing them to the attention of these decision makers.
An example of how foundations can play this advance-scout role is The Nicholson Foundation’s sponsorship of trips to Project ECHO. ECHO is an innovative model of care that was pioneered by Sanjeev Arora at the University of New Mexico. ECHO helps primary care providers learn how to better treat patients with certain chronic complex conditions by using telecommunications technology and case-based learning to foster mentoring partnerships between specialists and primary care providers. We’re currently working with partners to create a New Jersey Academic Medical Center ECHO Hub, which will expand the application of this model in the Garden State.
To bring the ECHO model to the attention of high-level decision makers at health plans, hospitals, and state agencies, we’ve sponsored five group trips to Project ECHO’s New Mexico headquarters. Through these trips, we’ve been able to build consensus around the usefulness of the model and achieve a commitment to work together to help develop and sustain ECHO in New Jersey.
- Inspiring participants to embrace radical new thinking
Perhaps the most far-flung and adventurous learning trip that The Nicholson Foundation has sponsored was a trip to India for a dozen members of Cooper University Hospital’s Advanced Care Center (a primary/specialty care clinic dedicated to serving safety-net patients in Camden, New Jersey). The group visited the pioneering Aravind Eye Care System. Aravind has developed a range of techniques to inexpensively treat cataracts and prevent blindness, including a method known as the “focused factory model.” Our goal was to have the trip participants, who work in one of New Jersey’s most challenging and underserved environments, look at how others are reengineering health care and to imagine their own radical solutions for the clinic in Camden.
As a result of the visit, the Cooper Advanced Care Center instituted group visits to treat several medical conditions using the focused factory model. To increase the efficiency and effectiveness of individual patient care visits, they also adapted another Aravind technique and are shifting some responsibilities for routine medical tasks from physicians to nurses and medical assistants.
- Spurring networking, friendships, and long-lasting collaborations among participants
Finally, one of the best reasons to sponsor learning trips is that they catalyze genuine friendships and long-lasting collaborations among participants in ways that typical conferences and meetings may not. In our work lives, we are often siloed into competing institutions, or defined solely by our affiliation with government, the private sector, philanthropy, or a nonprofit. Yet, we all face the same challenges when trying to improve the health care system. By building a collaborative spirit in a new context, learning trips can break down those barriers and help us approach these challenges together.
Linda Schwimmer, who as president and CEO of the New Jersey Health Care Quality Institute works to support the development of the state’s Medicaid ACOs, says that she has witnessed firsthand how the learning trips have built a sense of community among ACO leaders. “There’s something about stepping out of work responsibilities that allows people to build stronger personal connections and builds a sense of being members of a common group…they feel more bonded,” said Schwimmer. “Once participants are back from the trips, they’re more willing to pick up the phone and talk with each other….These trips build the deeper relationships necessary to drive change.”
David Barash, “Project ECHO: Force Multiplier For Community Health Centers,” GrantWatch section,Health Affairs Blog, July 20, 2015.
Joan Randell, “New Jersey’s Approach To Medicaid ACOs Is An Experiment Worth Watching,” Health Affairs Blog, August 25, 2015.
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