Bridging the Sectors: Integrating Health and Social Care

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Tom Haederle
Clinicians, social service providers and community members make up the health care triangle. Strong connective links between the three create the kind of impactful partnerships that drive progress and advance health. But confronted with finite resources, how can frontline leaders know which tactics and partnerships will bring the best results and lead to the outcome we all seek? Healthy, equitable communities where everyone reaches their highest potential for health.

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Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle, with AHA Communications. Today's podcast introduces the Integrators Toolkit designed to help health professionals forge the kind of partnerships that deliver results. The key, according to Kate Blackburn, manager of practice and prevention at Nemours Children's Health, is to think in terms of link, listen and co-create. That is: link with trusted community partners to determine the best way to get valuable input from community leaders.

00;01;13;20 - 00;01;26;29
Tom Haederle
Listen to what communities say, then co-create the strategies the community can get behind. Kate explains all this and more in this timely conversation with Andrew Jager, AHA’s director of Population Health.

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Andrew Jager
Thanks, Tom. Kate, thanks so much for joining me today. Nemours Children's has been at the forefront of integrating efforts across the communities that you serve to have a greater impact on community health. And I had the privilege of hearing about some of this work in a presentation you did last year's AHA Accelerating Health Equity Conference, where you talked about your integrators initiative.

00;01;50;23 - 00;02;11;09
Andrew Jager
As an aside, I'd like to remind our listeners that this year's AJA Accelerating Health Equity Conference will take place in Minneapolis May 16th to 18, so be sure to mark your calendars if you haven't yet. I really appreciated the way you brought intentionality to your integrators work, and I'd like to ask you to start by explaining a little bit about the integrators initiative at Nemours.

00;02;11;18 - 00;02;15;02
Andrew Jager
What is it? Who does it aim to serve and how did it get started?

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Kate Blackburn
Great. Well, first of all, thanks to you and AHA for having me. And I will second your plug for the conference. Of all the conferences that I attend as a population health nerd who likes to roll up my sleeves and get really concrete examples from others in the field, this is my favorite conference to attend all year. So anybody that's listening, make sure you mark your calendars.

00;02;36;14 - 00;03;01;18
Kate Blackburn
I'm always glad to talk about the work that we're learning about integrators and their function and population health networks. I'm really excited to be here today. So, I guess I would start by saying that HRA listeners already understand and know that moving the needle on measures of population, health and well-being for whole communities is beyond what one organization can accomplish independently, that it absolutely requires collaboration across sectors.

00;03;02;08 - 00;03;25;25
Kate Blackburn
And so at Nemours, we've come to think of integrators in sort of two ways in terms of definition. We think about them as the organization that set the table for cross-sector collaboration to get started by securing buy in from leaders of the organizations needed at the table. But integrators aren't only the organizations that act as those catalysts and conveners to get things started.

00;03;26;02 - 00;03;55;06
Kate Blackburn
We also see integrators as the organizations that agree to share responsibility for that less visible, sort of like behind the scenes network or work that keeps networks working once they're launched. And you'll hear me talk about this sort of collection of behind the scenes essential work as integrative activities. So maybe just to give you an example of the types of things that we think of when we talk about integrative activities, we think of them in buckets, right?

00;03;55;06 - 00;04;22;27
Kate Blackburn
So there's a bucket of a bucket of what we call network governance and approach. So facilitating consensus around the networks vision, like the goals, the mission, the strategic plan. Somebody has to do it. We think of that as an integrators role. Just as another example, I guess when we think about continuous learning and improvement, we've got to have mechanisms in place in these networks for cross-sector data sharing, sharing back with the community.

00;04;22;27 - 00;04;43;07
Kate Blackburn
What are we learning? Again, somebody has to do it. Everybody's there sort of as volunteers, whether they're paid or are unpaid at the table, but somebody has to sort of own it, lead it and make sure it gets done, even though it's not actually maybe the work of the Population Health Network with the goal. It's an enabler of that work, if that makes sense.

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Kate Blackburn
Does that make sense to you?

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Andrew Jager
That does. Thank you so much. I really like the way you described it in simple terms that this is the, you know, behind the scenes work that's essential to make partnership work, to make population health work possible and have the impact we all try for. And I wonder, you know, where you are in the stage now. Do you have any new partners or other partners that you think about bringing in to this work?

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Kate Blackburn
Well, right now, our focus, we're doing a lot. We recently joined the National Health Care Anchor Network. So a lot of that work that we were doing, I would say, with the partners around the table and cross-sector our networks, we're really currently exploring if those same tools and strategies work across departments internally. So right now we have at the table folks from our purchasing department, folks from our communications department, government relations, the ARC folks that do our community health needs assessments, the implementation plans for those assessments.

00;05;41;14 - 00;05;56;03
Kate Blackburn
There's a whole range of departments that don't necessarily always work shoulder to shoulder together. And we're coming together to align our strategies around being a health anchor. So that's kind of our focus of how we're applying this in the real world right now.

00;05;56;17 - 00;06;21;29
Andrew Jager
I really love that. Kate. I think, you know, the importance of partnering not just with folks in the community, but also those within our own organizations. Really important. Something that I think folks, you know, should think about how they're doing it. Another question I have is, you know, when we think about these types of cross-sector partnerships to co-produce community health, the voices and perspectives of those people and communities that we serve is really important.

00;06;21;29 - 00;06;29;00
Andrew Jager
So what are some of the approaches that you've thought about taking to really help understand and amplify those voices and perspectives.

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Kate Blackburn
So when I think about approach, I think the headline here really in terms of amplifying those voices has to be link, listen and co-create. So we really need to link up with trusted community leaders, pay them comparably to what we pay other consultants for their expertise, and let them guide us on the best methods to use to get broad, authentic partners or broad authentic input from the community.

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Kate Blackburn
And as a side note, I think this is a great way to involve community health workers as well as other members of the community that don't work for the health care organizations. So that is the link part. I think we also need to listen then to what the community is saying. So we convene them and we really need to authentically listen in terms of what they see as strengths to build on and what they see as their most pressing priorities to tackle.

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Kate Blackburn
So after linking, after listening, we've got to co-create strategies with the that the community can get behind. So I think that the co-creation step to me is essential because if we stop at listening, we could come up with a solution that's a well-intended flop as a way to describe it sounds great on paper, isn't really what the community wants.

00;07;41;16 - 00;07;56;27
Kate Blackburn
And I was thinking as an example of back when the phone companies that Apple's and whoever would roll out new cell phones and they'd tell us how great the camera was and we'd look at each other and say, but if you could just make a cell phone that the screen doesn't shatter every time I drop it, that's my most important thing.

00;07;57;07 - 00;08;24;17
Kate Blackburn
So again, I think that that whole piece around linking, listening and co-creating is the headline. And in terms of concrete, like, okay, that's great, but how do you do this? I would encourage the listeners to follow the links to the tools that there's links that will be shared in the episode notes. And those are tools that we created and we used in the learning lab in terms of actual rubber hitting the road implementation on all of these ideas.

00;08;24;21 - 00;08;44;18
Kate Blackburn
So just two examples to give you an idea of what's in the collection, we have a tool that well-being and equity in the world used with some of the teams in the lab. They gave us a step by step tool for mapping stakeholders and developing an engagement plan with them. Another example I'll share is that we have a tool from the Ripple Foundation's Rethink Health Initiative.

00;08;44;26 - 00;08;59;27
Kate Blackburn
That's a great tool that includes a step by step guide for the meeting facilitator thinking about how they're going to run a meeting that's focused on co-creating a shared vision and then what the strategies are for that vision. So very like step-by-step concrete.

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Andrew Jager
It does. I love that. I think having those step by step guidance is really important because no one wants to have that, you know, well-intentioned flop. So listening.

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Kate Blackburn
Right.

00;09;11;06 - 00;09;35;26
Andrew Jager
And the co-production is truly essential. You hinted at this in your earlier response, but at the HRA, we do a lot of work in supporting our members community and Population Health partnership efforts and the reality is partnership is is challenging. And no one wants to have that well-intentioned flop that you describe. But there are challenges and bumps along the road.

00;09;35;26 - 00;09;45;14
Andrew Jager
So I wonder if you could describe some of the challenges or stumbling blocks that that you see these types of partnerships most often encounter?

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Kate Blackburn
Yeah, that's a great question. So when we work ... the most recent initiative that we did in terms of like a learning and action collaborative format, we supported nine communities from around the United States that were that had these big population health cross-sector networks. And we asked with coaching and everything, we walked each team through a process of assessing their networks, current use of integrative activities and then reflecting on them alongside of their network strategic plan to identify maybe like the top two or three that if they used more deliberately, would strengthen or accelerate the networks ability to deploy its strategic plan.

00;10;27;16 - 00;10;52;01
Kate Blackburn
Right. So the most the for most common integrative activities, they really hung together as a pattern. The four most common that they chose to focus on or your challenge areas like to reference your question Andrew were advancing equity, developing internal champions, breaking down silos and expanding partnerships and resources. And I can say a tiny bit about each one, to give an example, if that's helpful.

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Andrew Jager
That'd be really great. Thanks.

00;10;54;01 - 00;11;21;18
Kate Blackburn
Okay. So under Advancing Equity, just two quick examples of the types of things that they focused on under that heading. That work included action planning related to increase in community voice and decision making in their networks. And also there was a number of networks that focused on developing broader, bolder goals that focused on systems change in addition to programs and interventions. In the bucket that we thought of as developing internal champions,

00;11;22;04 - 00;11;45;15
Kate Blackburn
That area of work for our networks included action related to, I want to say, reigniting the spark of networks that had already been in existence for a while. So bringing them back to the table, revisiting their shared vision, refreshing how they framed their collective why, and kind of reigniting that energy. There was also a lot of work for people that requested coaching around developing and internal champions.

00;11;45;15 - 00;12;16;25
Kate Blackburn
There was also a lot around increasing voice, increasing decision making and shared ownership among network members. That could include organizational members or community residents that you've included as decision makers and leaders within the network. In the third bucket, which was breaking down silos, a lot of the work there that they requested coaching on and a lot of those challenge areas were about really nitty gritty data sharing agreements between members, opportunities for data sharing with new partners, pulling new people in.

00;12;16;25 - 00;12;37;26
Kate Blackburn
What could that look like? How do our platforms connect with each other? And then also a lot of work around sharing data back with communities. Do we need a dashboard? How often, how much depth, that kind of stuff. So that was a big kind of a technical bucket of challenges that folks experienced. And then the last area was around expanding partnerships and resources.

00;12;38;07 - 00;12;59;12
Kate Blackburn
So it wasn't really about finding dollars necessarily in that bucket. A lot of the requests and a lot of the challenge areas where work focused on cultivating new network partners and not just like it's a big table get everybody. But being very intentional about here is where we're trying to go. Who can we use differently with who's already here at the table?

00;12;59;12 - 00;13;21;07
Kate Blackburn
Or who's missing? If we just pull in these two other people, they could really amplify the work that we're doing or accelerate that. So we really had folks think about their clear assets and roles of partners and then creating and improving case making materials was the other big area of challenge in that expanding partnerships and resources area.

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Kate Blackburn
So, you know, putting together like a really compelling why does this network need to exist? Why is the network that great example of the the whole being greater than the sum of the parts or whatever that expression is? But really, like, why does it matter that this network exists? And making a really compelling case was a definitely an area of challenge across almost every one of the networks we supported.

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Andrew Jager
I mean, we see these same challenges oftentimes. And the reality is, you know, this work is so important and at the same time, we're going to experience challenges along the way. But as I said, the work being so important, it's just we have to move forward. The good news is there are tactics that I think works. And what have you seen at that really tactical level?

00;14;07;29 - 00;14;21;12
Andrew Jager
You've seen frontline leaders, the folks who run community engagement, population health efforts at hospitals and health systems. How have you seen them address these challenges at a real, you know, tactical level?

00;14;21;25 - 00;14;49;08
Kate Blackburn
Yeah, that's a great question. So again, I think it try to think in headlines before I bore you with a million details. And I think the headline here is that you really can't boil the ocean and I know that's another kind of widely used expression but there's a million strategies that networks could propose, you know, in order to move the needle on, say, safe or affordable housing or any other domain in relation to population health or social determinants.

00;14;49;08 - 00;15;17;01
Kate Blackburn
But the reality is that there's a limited number of time and resources among network partners. You know, being at the table as part of a network is usually like other duties as assigned for people. So choices have to be made or the work can get diluted if you really try to tackle too much as a network. And I would say that the networks we supported in the lab, we asked them to prioritize two or three integrative activities that they felt would be most useful and moving the network forward.

00;15;17;13 - 00;15;36;17
Kate Blackburn
And when they narrowed that scope, they were really able to make substantive steps forward in those areas. And again, the tools they used to set the priorities and implement the action plans are available in the show notes and we'll talk about one of them, I think, in a second, if I can mind read and know what your next question is.

00;15;37;06 - 00;16;01;17
Kate Blackburn
But as an example, well, just in terms of tactics that we've seen used to bring that to life, Bridgeport Prospers is one of the networks that was at the table in our integrator Learning lab. They're from Bridgeport, Connecticut. They chose to focus on data sharing and they chose to become laser focused at that. So they really wanted to strengthen that sort of bucket, if you will, of their integrative activities.

00;16;02;02 - 00;16;28;05
Kate Blackburn
So as a result of working with us, getting the coaching, really putting their plan together, Bridgeport prospers and then their local health improvement alliance, two separate networks, so we're talking about networks combining that like two organizations. So these two networks came together, fused their efforts. They signed formal data sharing agreements under the umbrella of this other entity, the local health enhancing community.

00;16;28;13 - 00;16;52;09
Kate Blackburn
It's sticky work to braid together three networks and all of these goals and all of that kind of stuff. But that decision to narrow that focus to make that the thing that they thought could move the whole network forward faster was really strategic and an improved everybody's ability to track their progress towards eliminating the health disparities for Bridgeport children and their families.

00;16;52;24 - 00;17;18;17
Andrew Jager
Really great example. Thank you for sharing it. And at the same time, this work we know is not happening in a vacuum. And there have been a lot of lot of things happening the past few years. So what have the pandemic, as well as the racial and social justice movements contributed to, I guess, increasing the urgency of taking that more intentional approach to collaboration or integration across the sectors.

00;17;18;27 - 00;17;28;29
Andrew Jager
And I think if you could share an example here, it would be really helpful to think about how success can be achieved despite all the myriad things that are going on these days.

00;17;29;07 - 00;17;53;19
Kate Blackburn
Right. Well, so I would say that everything is happening in the landscape of our country forced people ... and then for the purpose of this discussion, people involved specifically in population health networks, to recognize that the huge differences we see in the U.S. in who's more likely to be healthy, to be safe, to have financial and other resources they need to thrive.

00;17;53;23 - 00;18;28;01
Kate Blackburn
Those differences aren't arbitrary. You know, they're largely the result of systemic racism and discrimination. And the networks that we engaged with through the lab had increased awareness among their members that achieving health, equity and equity and any other realm can't happen if networks are limited to thinking about their work in terms of like programs and services. No matter how outstanding those programs and services are, they're not going to move the needle on equity for a whole county, state, whatever, through programs that serve individuals and families.

00;18;28;08 - 00;18;53;10
Kate Blackburn
So networks had this broader realization that they have to begin to include strategies aimed at policy and systems change. And for a lot of networks that was new. They didn't necessarily have like government relations people at the table and that sort of thing, kind of policy thinkers. So I guess to bring that to light with an example, I'll share an example from the team in Guilford, North Carolina.

00;18;53;10 - 00;19;19;18
Kate Blackburn
So we worked with a network called Get Ready, Guilford. That was what they were called at that time. We've since changed the name, but they took advantage of what was happening in the country to create a new shared understanding among members. So in a really level setting with all their network partners around the ways that systemic racism and other forms of discrimination are drivers of the disparities in measures of child health and thriving that their network was focused on.

00;19;19;28 - 00;19;48;26
Kate Blackburn
So then from this sort of newly established place of shared understanding and level setting, they were able to really move forward in like big steps. Once that was underneath them, they really went they hosted several trainings for network partners and the broader field related to health equity and racial equity, and they formally incorporated the use of equity impact assessment tools into their network decision making processes.

00;19;49;10 - 00;20;15;04
Kate Blackburn
And those, if anybody's unfamiliar with equity impact assessment tools, those are available through the links that are in the show notes we used in the lab, a really great tool by the Institute for Population Health Innovation, and it really helps you to make sure that a well-intended policy or strategy that your network is about to roll out doesn't have unintended consequences for the population that you were.

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Kate Blackburn
We're trying to do great stuff here, so it kind of acts as like guardrails before you put something into action or even if you have something in action to double check it.

00;20;23;29 - 00;20;57;01
Andrew Jager
Yeah, that's a great resource and we'll be sure to put it in the podcast description so folks can check it out. Thank you. You know, we're coming to the end of our time together and there's a concept I've heard you describe that I think is really insightful. So I've heard you talk about being present with purpose. So I wonder if in the last few minutes that we have together today, if you could highlight how this concept of being present with purpose can be so key to creating successful partnerships and how it can really strengthen partners relationships?

00;20;57;19 - 00;21;25;12
Kate Blackburn
Yeah, this is something we really learned a lot about in our most recent initiative with this Integrator Learning Lab and supporting these communities from around the country, but also with our own internal work at Nemours. So what we see often happening in networks, and I know it like my own experience as being the person at the table and different networks is that people are often at the table for network meetings as delegates of their organization.

00;21;25;24 - 00;22;05;24
Kate Blackburn
But maybe there hasn't been a formal internal discussion about how the organization's broad goals align with the goals of that network, or the kinds of ways that the organization is willing to support network efforts. So often what we see and often what I've experienced personally, is that the person at the table may have the authority to talk about what their department could do to support the network, but they haven't had those, you know, internal conversation with colleagues to explore other potential resources and supports and make the case for, hey, by doing this, we align with our hospital's values, our health system's values, and we're helping move this network forward.

00;22;05;24 - 00;22;33;25
Kate Blackburn
So it's win win. So we've seen that networks are strengthened when the organizational representatives at the table from, you know, whether it's a health care person or somebody from another community-based organization, when they're at the table and they're, like you said, present with purpose. So that meaning that the organization's contribution of time, people, power funding or other resources is a deliberate part of that of the organization's own strategies.

00;22;34;04 - 00;23;06;07
Kate Blackburn
So we developed a tool that organizations can use periodically to reassess the scope of their participation in whatever networks they're active in. So if you're facilitating a network around population health or anything else, we think this is a great tool that you can use to to prompt members to use a tool like this before coming to the table for strategic planning so that when you come to the table, you've kind of done your internal homework back at your organization, you come to the table with a full sense of what your organization can contribute in ways that again, are win-win aligning with the goals of both entities.

00;23;06;19 - 00;23;32;22
Kate Blackburn
And then kind of on the flip side, in terms of usage, we also suggest that people who are the face maybe of their organization in a network, they're the ones like at the meetings, at the table that they take a tool like this and they use it for periodic check ins with colleagues to see if there is new or different ways that the organization could collaborate with the network in spaces where those goals overlap. New ways to contribute, new people to bring to the table, whatever.

00;23;32;22 - 00;23;38;07
Kate Blackburn
Again, in ways that accelerate both entities towards that. The space where the goals overlap.

00;23;38;22 - 00;24;12;13
Andrew Jager
That's really great guidance and I can't thank you enough, Kate, for sharing your experience with us and our listeners today. You can learn more about the Integrators initiative at Nemours by going to www.movinghealthcare upstream.org/population-health-ntegrators and we'll put that in the podcast description. Really appreciate the work that you and your colleagues do and thank you all for the work you do in your communities every day to support population and community health.

00;24;12;20 - 00;24;41;25
Andrew Jager
And as I said at the outset, please mark your calendars for the AHA Accelerating Health Equity Conference May 16th, 18th in Minneapolis. You can register and learn more at equity conference .aha.org. Thanks so much and be well.