At its core, population health has the dream of creating sustainable, healthy living conditions with equal access to great health care for everyone. We aren't going to get there quickly and we're not going to get there by working alone. In this module, we're going to talk about partnerships, collaboration, and trust. We're also going to describe the steps to change across the community health and clinical health continuum using multi-sector partnerships. So what does it really mean to partner? Well, partnership has a pretty simple definition. It's an arrangement between parties that agree to cooperate and they're cooperating to advance their mutual interests, and that's why we tend to think about what we're doing in population health as partnership. There's a mutual interest in improving the population's health. So much of what we're going to discuss is partnering, but there's more to partnership than just this mutual arrangement and one of the key factors is trust. So trust can mean a lot of different things. In its simplest form, trust is really when one party or one person is willing to rely on the actions of another. This can be difficult when we think, "We really have to forward our own purpose here and can we really trust somebody?" Trust takes time to build and one of the things that happens in partnerships is that you have to start with a certain level of trust and then work to actually build it into a much richer, I'll call it long term relationship if we're going to improve population health. The last level of partnership and trust manifests as collaboration. It's actually pretty difficult to create collaborations. One of the reasons why is that collaborations really at their core are recursive processes, where multiple organizations are working together to realize shared goals. That can be difficult because this recursive, shared goal process often splits apart where the collaboration's actually differ because of their disciplines, or because of locations, or because of different missions for different organizations manifesting in slightly different goals. So collaboration can be basically our highest standard and we'd like to actually aspire to it. But one of the things I just have to be clear on is that sometimes we use that word collaboration and we don't really mean it when we're talking across organizations and agencies. A big challenge in population health is integrating human resources and expertise altogether across so many different sectors. Public health, social services, community organizations, healthcare are all going to be important players and going to make significant inroads into the upstream root causes of the disease and they're going to be necessary to ensure no one falls through the cracks of the system when they do get sick. So in this slide, we show an overarching map or the phases of prevention across the health continuum, and this includes a new pre-prevention step that I've called focused protection. This map is embedded in the social determinants of health framework because all health issues and all healthcare really happened inside of society, inside of a community. So we're going to use that framework in order for us to better understand what is happening across this continuum. For example, it's well-known that adverse social conditions create vulnerabilities, no matter where you are in the health continuum, healthy or sick, those adverse social conditions make it worse. So to reduce those vulnerabilities, we need resources and they have to come from the society or the population or community we're living in. So it's things like safety, education, employment, access to services. Those require a mindset of equity and social justice in order to cost effectively design upstream approaches that are going to solve those problems. Those upstream approaches are things like building social cohesion and capital, and really the infrastructure that makes people feel like I have the resources I need in order to thrive. We also have to think about the downstream approaches that ensure that everybody has got access to clinical services. So that includes an understanding of the patient's social context when we're thinking about treating them within a particular clinic. Simple examples are things like sending somebody home with a prescription that they can't possibly fill or giving them instructions that they can't possibly follow because of their jobs, or their families, or their living situations. In order to really make an improvement in population health, we have to put these different parts of the spectrum or different, I'll call it attributes altogether into the same picture and mindset for everybody in this whole framework. Population health work can feel pretty daunting at times and sometimes disorienting, to be honest, because populations are so big and the problems are so big. So we always have got to break it down into manageable steps. If we can pull it into manageable steps that everybody can see where they are or where we're going, but it's amazing how far we can actually go when we're working together. Here are four key steps to keep in mind when doing this work. First, we have to pick a small obtainable goal. It doesn't really work to engage partners on something that we have no chance of actually attaining. So maybe a small doable goal might be to improve diabetes screening in a small town. Something that is very discrete that you can do that has geographical boundaries, people can see how you might get it done. From that goal, you can now gather partners, who will you actually need in order to obtain that goal? Once you've gathered those partners, that next phase of jointly planning, acting, analyzing, refining, we've talked about some of the systems underneath of actually rolling out a plan. The keyword here is jointly. It can't just be a top-down operation or the partners can't see how they fit in or where their expertise is needed, and sometimes we miss the boat because we really aren't taking into account what other people know are going to be hurdles, or potholes, or things we're going to run into, or resources that we have access to because we didn't really engage them in the actual planning, and we didn't pull them into the analysis or basically the refinement of what we learned on our first run. So after some successes in steps 1, 2, and 3, then this next step of scaling up to the next level is a key step. Many of us fail to do this fourth step because it can be intimidating. You have to go all the way back, gather more partners or have an even bigger enterprise and it can be, as I said before, a pretty daunting task. We talked a fair amount about partnerships in generalities. But in many ways, the whole population health improvement emphasis is going to take the whole social fabric in order to make changes. So what I've got demonstrated here is the multisector partnerships and we use that term, multisector, because all sectors of society are likely to be involved in population health improvement. They're all essential to the, I'll call it changes in mindset and in creating cultures of health. So it means everybody from elected officials and public health agencies to the food industry and businesses, and urban planners, and certainly our providers and hospitals and insurance companies. Community organizations are vital, but so are people that are within other sectors like higher education and mental health professionals, unions, schools, they all actually have something to contribute to these partnerships. So being able to envision who is actually going to be at the table makes a big difference to the ultimate success of some of our population health improvement plans. Another key part of building partnerships is having some agreed upon interventions. We've suggested overall using an evidence-based approach, using recommendations that have already been well-vetted by national or global agencies. So for instance, two great resources are the Community Preventive Services Task Force and the US Preventative Services Task Force. Both of these are groups of people that are at the top of their field, that are evaluating the work on interventions, seeing what has the best significant improvements statistics, and then presenting them out in easy to understand and often toolkits for interventions that will improve people's health. Now, there's two different dimensions to evidence-based solutions in this space. One is the type of preventative services. So for instance, are you talking about screening tests or is it preventative medications, or counseling, or is it something a little bit higher and a little bit more geared to a larger populace like education, public service announcements? Or is it really something that's much more overarching, like public policies? All of those are different type of preventative services. You'll see from this graph that the US Preventative Services is much more, I'm going to say, in localized settings. Whereas the Community Preventive Services Task Force is much more in the, I'll call it more community-based settings. These settings for prevention can be everywhere from the primary care office in the health system to the built environment, work sites, schools, whole communities or states, or you can even expand it out to the whole nation using a particular preventive service. These evidence-based solutions also help partnerships because there can be a single source that people can all point to, they can share the information, and so it can spread throughout the partnership without somebody having to, I'll call it, man the plan. So we pull this into this idea of partnership every chance that we get. Once there's been a decision about what evidence-based approach to use, it's really important to map that approach so all the partners can see the work, who is doing what, so that nobody thinks, well, I just am doing this and I don't see anybody else's work. So in this slide, what we have is a representation of the spectrum of health promotion interventions that are happening around, for instance, a diabetes program. So there's some people that are taking the socio-environmental approach. So they're really working in workplaces around food and nutrition policy, or they're working within communities to get chronic disease stories from people out to people. Other are taking a more behavioral approach on health education, like getting a diabetes day program in churches or schools and then using their talents in social marketing, so health theme days, neighborhood walk weeks, something that is being pumped out through Twitter or Facebook, or other social marketing that can raise the awareness. Then also now incorporating the clinical or medical approach. Getting people to be alerted that all of this is happening out in communities so that they're ready to actually have diabetes screening and maybe they've picked a day like having diabetes screening Saturdays in local malls or other locations where people are going to come. So these prevention approaches, if they're mapped across all the different partners, really help people to see that they're moving to the next level together and they actually are part of something much bigger than their own particular lane. So this idea of mapping what is being done by each set of partners can even go down into greater details. For some of the common chronic diseases in which we really are not meeting the standards that are recommended, so we've got big gaps, this explicit, detailed understanding of who is doing what often trickles down to a benefit to the individual patients or people within communities. So I give the example here of the American Diabetes Association standards of medical care, which is recommending that all patients be assessed and referred to a dietitian, a health educator, and mental health professionals when they need it. What is most important is not just that those recommendations are there, but that the dietitian knows that there is a health educator on point and a mental health professional, and who is that that they can actually refer when something comes up within a conversation with a patient or a person and say, "Oh, well, here you might want to check in with this person who's in your support network so that you can get the mental health support that you need." These created plans actually helped the vulnerable patients that we've been talking about and make sure that everybody has access to an understanding of who is doing what. One of the other important things to remember in creating plans that are going to improve communities health in a domain like diabetes, is that things change over time. Individuals go through different changes in their lifestyle, their job, or even in their disease management. So mapping out what might happen at different times in different transitions can make a big difference to not having somebody and their health experience fall through the cracks either in a community, community health or a clinical situation. So here's an example of four critical times where somebody's diabetes self-management has to be either assessed or adjusted. So the four key things that are on people's radar are at diagnosis, annually what needs to happen. So for instance, tests for eye exams for retinopathy, or having their hemoglobin A1C tested so they can figure out whether or not the diabetes is still in control or still out of control, but then also when other complicating factors arise. So for instance, maybe something has happened in their life and they can no longer get around. They can no longer do the exercise that they were doing as a part of their prevention of other downstream health effects. Maybe they've had a change in job and they no longer can meet their basic living needs. So when those complicating factors arise, it really is time to actually pull in the supports to help people. There's this fourth phase, which is really when transitions are occurring and those transitions often are big transitions. So somebody has lost their insurance coverage or maybe they've moved to a living situation that is much more complicated, like rehabilitation or now they're living alone or maybe they're in some long-term care facility. Any of the big age-related changes that are affecting cognition or self-care would fall into this domain as well. In many ways, what we're trying to represent here is that prevention takes planning ahead and knowing when change matters. Lastly, I want to talk about one of the key, relational ethics to remember in any of these partnerships. That is letting differences exist, holding that space that allow people to be who they are within the partnership. So public health professionals are always going to be thinking about the total population health, about preventing diseases for everyone, meeting people where they live and they work and really that total population mindset. They bring something to the table from that, but it shouldn't exclude health care professionals that are bringing the patient population health mindset because they're thinking about closing those gaps within the clinical experience, meeting people in the doctor's office and they can learn something from each other if they're working together in these partnerships. So for instance, all people who are entering into their doors, maybe the health care professionals are starting to think a little bit more like public health professionals and vice versa. So hope that you've seen that bring people together from different parts of the social and healthcare sectors is really essential to making population health improvements. As most of you probably already know, a big part of it has to do with creating shared vision. Knowing where you're going, what are the next steps of the process, clearly mapping them out so everyone can see them. Remembering we have differences and respecting them and I would say even celebrating them. Then keeping an eye on, I'll call it, the greater goal that we are creating something much larger than ourselves. It's always going to take partnerships to improve population health.
