AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
PETER SIMON: Thank you again for inviting me to be here. I'm really not going to be able to control myself once I get going. So you're going to have to tell me when to stop, okay? I'm acknowledging some of my weaknesses. And before I actually get into the presentation, I just also want to share with you a little bit about who I am and what I need, because I think those are the two very, very important questions that if you want to build relationships, you have to be able to understand.
The part of my life that I think has helped me be adaptive and be able to work in a place like Rhode Island with a person like Bill Hollinshead, my boss, a lot of that came from my family and from my parents and from being a parent and raising kids. So I want to give lots of acknowledgment to that process of adult development that isn't quite finished yet. People ask me have you lived in Rhode Island all your life. And I usually say so far.
Information is a product and not a possession. It is up there because that was ultimately the cultural challenge that Bill and I faced in terms of making family health a reality in Rhode Island, because we live in ‑‑ we actually live in state government, like most of you.
And information isn't always seen as a product in state government. The other person who informed this thinking on our part I think was the person who said: What gets measured gets done.
I don't remember who said that.
UNIDENTIFIED SPEAKER: (Inaudible).
PETER SIMON: Thank you. Say that louder.
UNIDENTIFIED SPEAKER: (Inaudible).
PETER SIMON: Mason Pierre. Rhode Island is, as you know, not like where you come from. This first disclaimer is wherever I go, we're small. Don't ever underestimate the amount of small thinking that can go on any place. It's not necessarily easy when you're small. It's different, though. We have a million people, our birth cohort is now on the way up. It's about 14,000 live resident births a year. A very wise group of leaders in the '60s essentially forecast the Institute of Medicine report on the future of public health and essentially created a single state agency, eliminated all vestiges of local public health infrastructure. We have no county government, so to speak. We have, I think, a sheriff, and a court system that still relates to counties. Other than that there's no county government. So we're it. So when I need to talk to the local health officer, I just move around to different seats at the same table and talk to myself.
As you can see, we're doing well in some ways in performance measures around this medical home system that we're all working on, in terms of at least financing. We've had some success. And Medicaid managed care under the 1115 waiver in Rhode Island is called Right Care. You'll hear me talk about Right Care. Now, this is what I'm going to try and do and Ed reassured me it didn't all have to happen today. We'll maybe have another opportunity at some point in our futures to get back together and talk about things that Rhode Island can help offer you in terms of strategies and tactics to improve family health, where you come from.
We're going to talk about a few of the successes that I know pretty well. Some of the ingredients, some of the directions, you know, if you ever read a cook book, especially cook books that come with an ethnic direction, you have to be careful, because they don't always tell you everything about the way you put the ingredients together. They usually don't leave anything out, although some Jewish cook books that I've read actually do leave things out, because they never really want you to have something as good as theirs.
And then at the end some tips that might be worth thinking about on your way home. Ed talked about relationships. And we have a very significant problem with childhood lead poisoning in Rhode Island . We're part of the old lead belt that you hear and read about. Right now our incidence is about 37 per thousand, between the ages of nine months and three years. So every, this year we're going to have another, you multiply it out ‑‑ I won't bother. But these are just acronyms we won't even go into detail with. But there are a lot of relationships that need to be built and sustained. And it can't be done by one person.
So my other role in Rhode Island has been as a baseball manager and coach. And I've been an observer of good managers and good coaches for about 25 years. And I've always sort of been fascinated by what makes the difference between a championship team and a team of champions. So I can tell you right now that the biggest ingredient that goes into relationships is leadership. I'll define that later.
This is just basically to show you what we get when we put people together in one place and allow them to share with each other who they are and what they need and if I go out a common vision. That's the common vision right there for how we're going to eliminate childhood lead poisoning in Rhode Island .
This is, again, another product of a process of bringing people together, Public Health 101, again, letting people share who they are and what they need and coming up with a common vision that they all own. This is how we're going to reduce problems with abatement and reducing of lead hazards in property in the state of Rhode Island , which ultimately is the source of lead poisoning.
Another sort of product, an outcome, that I get calls all the time from all over the world about how does a place like Rhode Island achieve such high rates of lead screening in a population? Well, it's not hard. You just have to bring people together and make sure that they have a chance to let you know who they are and what they need. And then you can get there.
So we, in this belief that our information is a product, started sharing our information with managed care providers, after Right Care was implemented, there were three essential vendors that ensured 95% of childhood population in the state. And because I showed up at the right time in the right place, I was one of the performance indicators for their contract, lead screening rates by 18 months of age. So there was a big bucket of money that they could share if they hit that number in their contract. So they were all interested in performing and getting that money so that we got them essentially to come together to share information. We exchanged data from our surveillance system, what we call LESS now, L‑E‑S‑S, and that process of partnering on a continuous basis for improving the rates of lead screening with managed care organizations, the Academy of Pediatrics , parents, everybody came together. They let everybody know who they were and what they needed.
This is where they were when they started, about 44% according to the claims data they had. That's the reporting mechanism to get their incentive dollars.
Prior to the effort, we knew that there were about 80% of the kids in our population based on birth cohort were screened. So there's a huge gap that comes back to the quality of the information that people have to actually get better (phonetic). And this is where they ended up after the process. This is a quarterly process. They didn't want to stop doing it. Even though, Medicaid participant, from the agency, that funds them said: You know, 87%, shit, you outta quit this and go someplace else. They were learning so much, and I don't think it was about lead screening.
Kids Net ‑‑ I haven't talked about Kids Net yet. Kids Net, raise your hand if you don't know what Kids Net is. Thank you. Kids Net is an integrated child health trafficking system. Built on a platform where we have a data warehouse that links at the individual child level information from all these components of preventive child health services system on a population basis. And that allows us, in real time, to provide to Kids Net sites in the state reports on what really are the gaps for kids who are about to come into the office within the next month. So we built essentially a database that allows people to look at their own performance, at the practice level. Now, because we've also invested in geo coding, and we're also investing in friendships and alliances with insurers, we also can talk a little bit about performance that more than just that individual child and practice level. We can disaggregate or aggregate the data along geographic lines and communicate some information to policy makers who are at local government levels, and this has been very valuable in terms of some of our efforts to improve access to safe affordable housing for families.
Okay. Any questions about Kids Net? Okay. Every birth since January 1st, 1997 . This actually should say draft on it, but we've taken the values of the medical home statement that comes out of the American Academy of Pediatrics, and an internal process that has not yet been vetted by families and by our partners in the community, we've come up with measures that we think reflect the values of a medical home. And this is just the group of indicators that we're proposing in care coordination.
Oops. I don't know how I did that. Anyway, my apologies to the community pediatricians in the United States , but CATCH, has everybody heard of CATCH here? If you don't have your CATCH state facilitators closest to you, make a call when you go home. Catch has been for me one of the most empowering tools to bring bottom up inside out together with top‑down outside‑in. I think that's really the most important message I have for you today, that public health, to be successful in achieving our goals for family health, needs to marry top‑down inside‑in with bottom‑up inside‑out.
CATCH, as you know, funds small grants to individual pediatricians who want to make a difference, not just with the alligators but at the level of the swamp. So they're getting pediatricians out of their offices, thinking systematically about what kind of a community do we want to help raise healthy children? Now, everybody has, whether it's written down or not, what my French colleagues call a representation: How you think the world works? This is mine, this is one that I got from reading Gregory Bateson "Steps of Ecology of the Mind." It's a little dark, I am an optimist. But I do think that this is the way the world is really working. So that's a little bit more about who I am.
And this is Bill Hollinshead. He's the one, again, who has to show the five components of leadership, because they've given him the top job, although, as I said to you before, we expect leadership at every level, anybody who comes to our table, we look to for leadership. Remember, the geese and the wedge. You know we've got to relieve that goose flying at the cutting edge, because it gets tiring. Those guys get tired. So they rotate. They back each other up. This is essentially on one piece of paper is one of our attempts to actually share a vision about how we think we can improve child health.
I mention this Institute of Medical Reports are important, although they're not all right. And they're not all the story. Because medicine is only part of what it takes to create a healthy community. Anyway, this is important because I think for the first time ‑‑ well not necessarily the first time. But most recent time that really important information has been aggregated in one place for people like us to be able to say, okay, these are important influences in child health. Okay? Sort of the arrows that push down on the trajectories for our children, and also the ones that keep them from falling, so to speak.
I was supposed to be bringing you order forms. I'll make sure there's a link associated with this up on the website, eventually. But you really all need this book. It's not everything. But it is 95% ‑‑ (inaudible) because we all don't see it the same way. Again, what do I need? We need to have, if we're going to have a shared vision of child health, find that on the academy website. It isn't there. Our Academy of Pediatrics does not have an explicit definition of child health. This was the, the part of this report that I think I struggled with the most which is how to depict trajectories for developmental health trajectories, because children, as you know, are not just small adults. Things change all the time, and they change in lots of different ways. It's like a kaleidoscope. So we have that sort of that kaleidoscopic image. I don't know if it's 100 percent effective but I'd love to hear your feedback.
Sort of the last thing I wanted to do was read to you what one of my colleagues, I wrote an e‑mail to some people that I work with. I have these lists. I love e‑mail. And for those who are not on my list, don't ask to get on my list. But I just wanted to read to you what Susan Orban wrote to me. She's a part of our Washington County CATCH initiative. "Peter, you asked me to write a list to what you and Mia did to contribute to the success of our CATCH initiative. Although we're still in our infancy as compared to other CATCH projects, for us it's been teaching us the basics of community building. Bob and I were trained to solve individual problems. Neither of us has educational training in public health. I did a clinical family therapy track in grad school, I only had one course as a social work undergrad in community development and focused more on work in Third World countries. We did not know where to look for state data, i.e., slates. We did not understand the importance of putting together a widely representative advisory board to oversee the initiative to give ownership and give it credibility. We did not know we could even conduct the informative reviews or focus groups survey to get some information about our community that we were looking for. Mia shared information about how to do these activities and gave us examples to connect to other CATCH projects and other contacts that might help us. You showed us what was possible and made it happen. TA at its finest."
So there were five action of leaders share vision, go first empower action, encourage the heart and challenge the process. Thank you.