Speaker 1: Hello, my name is Shannon Studden and I'm a Senior Program Specialist with the National Rural Health Resource Center. I'd like to welcome you to Visionary Board Leadership and the Transition to Value. This program was developed in coordination with the Federal Office of Rural Health Policy by the Technical Assistance and Services Center, a program of the National Rural Health Resource Center, or the Center for short. The Center is a national nonprofit organization dedicated to improving and sustaining the health of rural communities. The Center provides technical assistance, information, tools and resources, and strives to build state and local capacity. We work exclusively with rural communities. We've been around for nearly 30 years and have worked with over 250 rural communities across 46 states, specializing in the transition to value and population health, collaboration and partnership, performance improvement, health information technology, and workforce. One of the key elements of implementing changes to improve health is strong knowledgeable leadership. I've spent my career in the field of leadership development and know how critical effective leadership is to the long-term success of an organization. I also know how hard it is to be a leader. Even in the best of times, leaders are responsible for making very difficult decisions and working to meet the needs and expectations of a wide variety of people and groups, while at the same time keeping an eye on what's going on outside the organization and making sure that the organization is well positioned to respond to a changing environment. And that environment is certainly in a significant time of change. While health care has always been incredibly complex and ever-changing, we are in a time of unprecedented change and uncertainty in the health care industry. As a rural hospital board member, you're on the front lines of this transition. This program has been developed to provide you with some foundational knowledge and strategies that can help you lead your organization through the uncertainty and complexity associated with the shift to value-based payment and value-based care. The program is made up of six video modules, each lasting about 15 minutes. This first module is a few minutes longer since we're including some time to give you an overview of the program. The modules include both educational content and interviews with hospital board members and administrators from multiple locations around the country. Each video module is accompanied by discussion questions that you can use as a group to talk about ways that the module's topic might be relevant in your facility and your community, and one or two things for you to pay attention to or discuss with others before the next module. The format of this program was designed with busy board member schedules in mind. While your board should of course feel free to complete the series in any time frame and format that works for you, our intention is for videos to be shown during regularly scheduled board meetings and followed by a few minutes of discussion. If you allocate about 20 minutes during board meetings every other month to watch a video and have a brief discussion together, you should be able to complete the program within a year. Topics for the six modules are shown here on the screen. You'll see that only the first one is dedicated in detail to the transition to value. The rest of the modules are intended to provide perspectives and strategies that can support you and your organization through this transition. Before we get started, I want to say one more thing about the program. All of the information presented here is based on sound research done by nationally recognized experts. But because we want to make this a conversation, we won't be making extensive references to the literature or published research throughout the videos. We will, however, list references at the end of each module so that you can dig a bit deeper into anything you're interested in learning more about. We at the Center are also always available to provide additional supporting information or connect you to a resource or tool based on your need. And our contact information is provided at the end of each module as well. I'll end the overview of the program by introducing you to the interviewees you'll hear from throughout this program. Each of these people found the topic of visionary board leadership important enough to take time out of their busy schedules to share their perspectives with all of us. These leaders were chosen because of the strides they and their facilities have made on the journey to value and population health. But you'll also see that they've come up against their share of challenges, some of which they're still wrestling with today. We sincerely thank all of our interviewees for their support of this program and for their willingness to share their stories with us. So with that, let's get started on our first module. In this module, we'll explore the transition to value and population health. We'll take a brief look at the current and future state of health care and what it means to transition from volume to value and population health. Then we'll talk about the role of a rural hospital board in this transition and what it means to redefine the way we think about the health care system in a community and how to navigate this transition in the midst of uncertainty when the future is unclear and the environment is continually changing. So let's dive in. We're sure it's not news to you that the health care system in our country is in a severe state of stress. Rural health in particular has been stretched very thin for some time and the COVID-19 pandemic has emphasized just how fragile our rural health care system really is. Ever-rising costs in our aging population combined with the razor-thin margins that our rural hospitals operate under make our traditional system of health care delivery and payment unsustainable over the long term. To address this, the Center for Medicare and Medicaid Services, or CMS, has championed a value-based care approach to health care. The intent of a value-based approach is not only to lower health care costs but also to build a healthier population of people with greater physical, mental, and

Speaker 2: social well-being. The American health care system is moving into an entirely different method of paying our health care providers and our hospitals. We're moving from what was previously a payment for procedure to a new payment system that is largely based in value and is actually going to be built upon a system more focused on prevention and on wellness. So we started out with Medicare and in something called accountable care organizations and the Medicare payment has now shifted dramatically towards this new payment system. Instead of getting paid for every procedure that we do, we now get paid to take care of a group of patients or Medicare recipients in this particular case. And we are now looking at a much more holistic approach and the payment system is so utterly dramatic that we really need to make some massive shifts in our processes, changes in the way we basically care for patients, and very importantly we need to reach out to partners to help us keep our communities healthy and really look out for the well-being of our citizens. While health

Speaker 1: care revenue has traditionally been tied to high volumes where more procedures means more money, a value-based care approach rewards health care providers for quality and efficiency rather than quantity. Payments are now dependent upon a hospital's ability to demonstrate high quality measured by objective experiences of care and patient experience measured by subjective experiences of care at lower costs. This is often referred to as the triple aim. Many organizations working toward the triple aim focus at the same time on improving the work life of providers and staff as each element of the triple aim is only possible with a physically, mentally, and spiritually healthy team of providers and staff. This means that hospitals benefit when they can address patient health needs early before a visit to the emergency department or a readmission to the hospital is necessary. And because hospital staff have limited opportunities to connect with patients when they're not in the facility, many facilities are choosing to develop partnerships with entities across the community to share information and coordinate services in ways that maximize health outcomes and minimize cost. The reason that these partnerships are so critical is that medical care is only one of many factors that affect health outcomes. Our social environment, made up of things like income, education, employment, and social support. Physical environment, things like outdoor spaces, clean air, and clean water. Genetics, biology, and our own behavior play a major role. In fact, altogether, these other factors have been shown to predict about 80% of our health outcomes, while medical care only contributes about 20%. This means that health care providers cannot change health outcomes alone. It also means that we might need to broaden our view of the organizations that make up the health care system to include those entities whose focus is on the other 80% of factors that impact health outcomes.

Speaker 3: The health care system, you know, in our community is made up of any number of different organizations and obviously I think we like to think of ourselves as the lead organization in that and kind of a trusted resource. But obviously it extends to city government, you know, maybe a city recreation thing that promotes wellness, the YMCA that we have in town that's kind of a cooperative venture. And then also, obviously, some large employers that we have. We have a meatpacking plant in town, so that's a focus of a lot of our attention at times because it's a our largest employer. And then also the farming community, which is, you know, an established community that that's traditionally what we've been involved with, but obviously that that continues to evolve. And we've got a lot of players in that and also, of course, the assisted living and skilled nursing facilities that we have. Let's take a few

Speaker 1: minutes to go over some important concepts commonly associated with value-based care. You'll hear these terms used throughout this video series. The term population health is often used in conjunction with value-based care. In fact, in this series, we often refer to the transition to value and population health. This term can mean two slightly different things. One meaning is the health of a target population, improving health and reducing costs for specific groups of patients, often grouped by insurance type and focused on chronic disease. For example, a population health initiative might be focused on improving outcomes for Medicare patients with diabetes. These targeted populations can be identified through a variety of methods like community health needs assessments, conversations with focus groups, public health data, and secondary sources like the National Rural Health Resource Center's population health toolkit. The term population health can also refer to total community health, health outcomes of an entire group of individuals, often geographically defined, including the distribution and disparities of outcomes within the group. Population health is closely connected to a value-based approach because better health outcomes for the population result in increased revenue for hospitals. While many value-based payment systems focus on a target population, some states, Pennsylvania and Maryland, as of the publication of this program, have broadened their scope to reward improved outcomes across the population as a whole. We often hear the terms value-based payment and value-based care used interchangeably. There is a distinction between the two that we'd like to point out, however. Value-based payment centers on financial aspects, payment based on improved quality and patient experience, accompanied by lower cost. Value-based care refers to the practices of care that are put into place to support a value-based payment model and might include things like chronic disease management, care transitions, and new patient flow processes. The word transition in the phrase transition to value is one we should look at in a little more detail. The process of transitioning from a system where hospitals and medical providers increase revenue by increasing quantity to one where revenue comes from improved outcomes at lower cost requires dramatic changes. Policies and processes, and even the culture of the organization, must change to be aligned with this new way of doing business. While a degree of uncertainty can always be expected during a large-scale change, the transition to value comes with an added layer of complexity. That's because to some degree it requires a leap of faith. In fact, some compare the transition to value to walking across a shaky bridge. If we're too aggressive and move too quickly we might fall off, but if we move too slowly we risk being left behind. In the early stages, adjusting to a value- based model requires significant upfront investment of time and resources to support the new system. Hospitals may need to invest in things like new information management and analysis systems, changes to the quality system, and educating staff and providers. To accommodate these investments, it's common for costs to exceed revenue in the short term. Once organizations have successfully navigated the transition, however, revenue will likely increase enough to cover the initial investment over the long term.

Speaker 4: The hardest thing about this transition to value is that it does impact the bottom line, and of course we all know that we get paid based on when a patient comes in and is sick, and we need to deliver care to them. And so as we work toward keeping patients out of our clinics and out of our emergency room and out of our hospital, it becomes uncomfortable with how are we going to remain sustainable. So we call it sometimes the shaky bridge, but that feeling between being paid on volume and being paid on complete value, we're not there yet as a healthcare industry. So it is very uncomfortable to our physicians who in the past have been used to the more patients I see, the more productive I am, the more productive I am, the more I'm earning and the more value I create for my organization. So we've had to get them comfortable with not seeing a patient is valuable if we can maintain that patient's health in their home where it's more cost effective and appropriate for that patient. So it is difficult to switch to that way of thinking.

Speaker 5: The problem is a lot of it boils down to compensation. I mean, there are things that maybe we would like to do, but they aren't going to pay us for it. And we're already at a negative bottom line. So like I said, we're in a survival mode almost here. The hope is that by providing a continuum of care that deals with the problems before they develop, that we can be more efficient and save money.

Speaker 6: So as we look at moving from a traditional disease model to population health and value, one of the things that we're considering is we want our whole community to feel physically, mentally healthy, socially engaged. We want them to be able to experience at the base level all of the needs that they have. That might mean housing. It might mean food. It might mean any number of things might come into play. And we know that using a traditional model of we expect you to be here at a specific time and you have to see a provider where you may or may not feel comfortable talking, we know we need to meet you where you need to be met. And so we've really had some great successes doing a lot of different things.

Speaker 5: With the change to value, I think we've become much more aware of the social determinants of health and how that affects health care. I think we need to try to educate our legislators, our representatives to government, how important their role is in providing a stable community and education and spending money in the proper places to provide a continuum of health care.

Speaker 2: Leadership is ultimately important, I think partially because the leaders basically set the tone and the culture of the organization. So if leadership has set a culture that is change ready and is basically able to respond to crises, for example, that leadership sets the tone. And what we see is that our health care workers look to the leaders, look to the CEO and the other C-team. It looks to the board of directors to assess, first of all, whether the change is really serious. And secondly, to check for signs of resilience. Are leaders panicking? Are they calm? Just basically, we're going to look there first. And that's why it's really so important that leaders have a plan. The culture is ultimately important. With a culture that has been set by the board and the top leadership that basically responds to that change, we're able to make the change more rapidly. We're able to make it more thoroughly and we avoid a whole lot of mistakes and frankly, some of the panic that we often see in hospitals with less than stellar leadership. I think we're very concerned about hospitals and clinics that might have had frequent turnover of leadership, where boards might be changing pretty dramatically, where leadership may not be engaged, etc. And where the leadership has been consistent, where it has been good, we find that the culture itself helps to facilitate that change. The leaders don't have to be constantly looking around to make sure that the staff is doing what it's supposed to, that in essence, culture very often kind of sustains itself. The role of hospital board

Speaker 1: members in all this is to provide guidance and strategic direction and promote a culture that embraces this change. In order to do this well, we encourage you to learn all you can about value based care and do what you can to keep your knowledge up to date as rules and regulations continue to evolve. As a board member, when you have a good understanding of the concepts associated with value and population health, you're able to set policies and direction that will help your facility and your community make the changes needed to succeed in this new environment. The transition to value also presents a real opportunity for you as board members to leverage what you already know about your community. Because a population health approach requires engaging partners and community members in the process, board members can convene meetings and initiate partnerships, serving as the link between the hospital and the community. Once the stage has been set by board members, hospital and community partners can then work together to develop

Speaker 7: strategies for addressing key health challenges. Our board has been very supportive of the transition to value. They know that it's difficult at this time. A lot of our work is still fee-for-service that we're reimbursed on, so we know that it's difficult, but we realize the importance of transitioning. We've done a lot of efforts that the board has supported as far as population health within our community, working, partnering with other organizations too to reduce the stigma of mental health or age-to-age initiatives, bringing seniors that may be experiencing isolation or loneliness together with younger adults or children, looking at initiatives that address the social determinants of health. All the things that we know that we can't control solely as an organization, but working together with other entities to make

Speaker 5: sure that we can make some change in our community. A board is different from the role of the CEO. We're supposed to be visionary, and we have one employee, our CEO, and we aren't restricted from talking or acting on the medical staff, and the CEO really helps us and guides us in what needs to be addressed in the board meetings, but we also have a vision of what we're supposed to be doing, and that's provide a continuum of quality care for our community, and that's our guide. Between now and the next module,

Speaker 1: we encourage you to consider these questions and discuss them with your fellow board members. Do you have all the knowledge you'd like to have about the transition to value and population health? If not, how can you learn more? Where does your organization currently stand in the process of transitioning to value? What changes have already been made? What would you still like to see happen? What are the biggest challenges for your facility in the transition to value? How are you addressing these challenges? And here's something you might want to consider doing before the next module. A resource guide specifically for this series has been published to the center's website. This resource guide contains a number of additional resources to help you learn more about navigating the transition to value, including some webinars that may be of interest to you. Check out this resource guide by searching for visionary board leadership on our website, and of course, please feel free to contact us at the center anytime for additional support. In our next module, we'll dig a little bit deeper into how you can use your understanding of the transition to value and population health to develop and share a long-term vision. We'll help you think about the impact that a successful conversion to value-based care could have on your facility and your community, and what this future vision means to you personally. Thanks for joining us, and we'll see you next time.