Serving Underserved Communities
Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Kyle Christiason, a physician and Donald Wesson, a physician and health system chief executive, focused on efforts to build trust by understanding marginalized populations.
Kyle Christiason: Don, I’m Kyle Christiason. I worked with UnityPoint Health in Iowa and Wisconsin and Illinois and I practice medicine there about halftime, but the other half of my work is helping lead the Accountable Care organization and one of the biggest in the country. And we’re proud of being heavy into risk and the idea that we get to collectively own the wellness of a population that we serve.
Don Wesson: So owning the wellness of the population you served. I love that because that’s in our name. So I am Don Wesson. I’m a nephrologist by training and a recovering basic scientist, literally. I’m president of the Baylor Scott and White Health and Wellness Center.
Kyle Christiason: I notice that you had the in the title.
Don Wesson: Yes. And that’s by design because we are trying to design methods of population health for this very low income, predominantly minority community in the southern part of Dallas. We recognized a long time ago that the most expensive patients to manage in our system came from these five zip codes that we serve. And so nine years ago, the organization thought, well, why don’t we try some proactive measures to try to reduce the rate of folks with very expensive to manage chronic disease came into our system. And most of these the patients, in fact, 85% of our patient population is uninsured and recognize that Texas as a state that did not expand Medicaid.
And so in addition to the altruistic mission of our organization, has a very pragmatic role of trying to reduce the proportion of patients from this community coming in to see us with very expensive to manage healthcare needs and address them proactively. And we’ve had some success in doing so but continue to try to refine the models that would allow us to be able to manage a community, which I really find interesting because I was trained as a physician to manage individual patients. But now having to scale up to figure out how a health system can manage the health and wellness of a community.
Kyle Christiason: So that, yeah, it goes from a reactive legacy of health care. We’re here when you need us, come to our big shiny and tower to one that you are reaching out to a community to make some connections and be proactive about their health.
Don Wesson: That’s correct. That’s correct. And in order to do so, we have to learn that community and have to be able to gain their trust. And over the decades, we’ve done plenty to earn their mistrust and now we are having to work in a way that allows us to be able to gain their trust. And as we were discussing earlier, there was a time when our community members could not come into our health system to see if they were turned away from our health system and direct it toward the county system that supports the poor in our area. But now, the law says, thankfully, that we can’t turn them away. And so now , the thought is, well, since we can’t turn them away and they’re very expensive to manage, let’s see how we can proactively manage not just the individuals but manage the community in a way that keeps them healthier, such that there is less of a need for them to come in to use expensive services in our system.
Kyle Christiason: Emergency department, admissions.
Don Wesson: Exactly.
Kyle Christiason: I mean, the high cost is high acuity care, maybe conditions that could have been better managed further upstream and before the illness has progressed or you expand that to a population then before conditions become really heavily prevalent within a population.
Don Wesson: Exactly.
Kyle Christiason: So, was it, it fits with our altruism as physicians. Was it a financial pressure that really helped kind of push the effort to seek how we can get ahead of those conditions or reach out to that population? Tell me how the leap was made because that’s different than many, many health systems around the country.
Don Wesson: Well, and in part it was financials. So I’m a nephrologist by training and what we’ve recognized, not just our health system, but most health systems have recognized that measured per patient. Chronic kidney disease is the most expensive to manage chronic disease there is.
Kyle Christiason: More than oncology? More than some of the things we might think of.
Don Wesson: That’s correct. So if you think about oncology or you think about cardiovascular disease as a disease entity, they are more expensive than chronic kidney disease. But if you measure it per individual, then chronic kidney disease is the most expensive chronic disease to manage. So our system thought, well, if that’s the most expensive disease entity to measure, to manage, then the more of those individuals that come to our system, the more expense that will be for us. And as I said, most of our patients are uninsured.
Kyle Christiason: Yup. So that’s on you.
Don Wesson: So it’s on us to try to manage them proactively because as they come into the system, they are very expensive to manage, and we get little to no revenue for these uninsured individuals. So, in addition to the altruistic proactive route, there certainly wasn’t an economic and financial initiative that was related to this because we were trying to figure out how can we lower expenses. So my conversation with the CFO, the chief financial officer, relates to the expense side of the income state. And he is constantly saying, we’re looking for revenue for the system, and my retort to him is that we’re managing the expense side of the income statement.
Kyle Christiason: yeah. And that really connects because you’re talking about better care, earlier care, better care. So, so that of course is better for the population and for the patients. You focused on chronic kidney disease as your first foray into this because of its great opportunity or…
Don Wesson: Actually no. So my particular focus is chronic kidney disease, but my center got started with a focus on diabetes. So as I said, chronic kidney disease is the most expensive to manage per patient. But when we as a system measure it across a disease entity, overall, it was diabetes and continues to be diabetes. And with all of the additional heart disease, kidney disease, blindness, high blood pressure, all of those things that come from diabetes collectively looking at the whole cadre of patients that we measured, it was diabetes. And so it actually started with a focus on diabetes. And when you recognize that much of the management of diabetes that lends value has to do with nutrition and has to do with physical activity. We don’t use that four-letter word: exercise. When it relates to those two things, those are the things that patients do outside of the doctor’s office. And so we recognize much of what was related to improve diabetes management happen outside of that 15-minute doctor visit. How well they ate. Whether or not they increase their physical activity. All of those things that science shows enhances the management of folks who had diabetes.
But that was not occurring. And since those things were incubating in the community, outside of our control, that influenced them coming in to see us. And so we looked at ways by which we might structure nutrition management, structure physical activity management, outside of the health system. And so that has been the predominant focus of our system, working proactively in the community through what we call trusted agency institutions in the community.
Kyle Christiason: What would be some examples of that?
Don Wesson: Well, we have focused primarily on churches and with the realization that we had a bad history in our trust from the community as I mentioned. However, we figured if we partnered with institutions in the community that already had the trust of the community, then we could leverage their trust for our benefit in terms of the service delivery of the care that we were providing. But also in terms of our research enterprise. Because as I mentioned, we are trying to design effective models of care, and in order to show that this care is both effective and cost effective, we have to have our research enterprise document that. And so in an effort to do that research in the community, we needed the trust of them. I mean, recruiting patients for these long-term studies requires that we have the community’s trust to be able to do that. So I’ve talked a lot about what we’re doing and the struggles that we’ve had and the struggles that we’ve had to overcome. So Kyle, tell me about the challenges that you’ve had and how you’ve gone about addressing them.
Kyle Christiason: Now, one of the things that, that I think resonates with what you describe is the focus. You chose diabetes as a very intentional focus. We were recognizing in in our community, which is Northeast Iowa, relatively rural, we were seeing a significant marginalization of the LGBTQ population. These folks were traveling two hours, three hours, six hours, just to access basic primary care. And so the research that we did was consistent with what the national findings are, which are really appalling, as in addition to the social stigma LGBTQ folks also experience discrimination within healthcare. And it’s along the lines of the perception that physicians are using harsh or abusive language that, that we blame patients for their health conditions. And even up to one in five physicians flat out refusing to care for someone because they identify as transgender.
And it was these types of disparities then that lead to all kinds of health complications. So increased risk of depression and anxiety and suicide attempt, utilization of hospital services, similarly delaying basic care until a very high acuity at high cost need was there. So it was these disparities and really legacy of poor experiences that prompted us to explore, see what we could do. And so with the effort of focus groups, trying to understand what would be the ideal scenario, if we could create something from scratch, what would that look like? And that led to the creation one and a half years ago of a dedicated LGBTQ clinic to stage a safer and more welcoming place to access healthcare, primary care. So a lot of the care we do provide is transgender related. But it is a full primary care clinic. Immunizations preventive screenings for cancers along with comorbid conditions.
I think the exciting part of the clinic experience has been very affirming for patients, new for many of them, never having a provider asks them about their pronouns or honor the name that that person would want to use. Just really kind of food and shelter type of things. You know, when that core hierarchy of need is not met, in other words, you in health care not seeing my most authentic self, then you’re not, you’re showing that you don’t care about that part. Well, then that neither should I care about my health. The flip of that then is our patients tell us that when you honor simple things like my pronouns or my name and see me for my authentic self, show me love and compassion as an institution of healthcare, I now flip that equation and that translates to me as I should, I will also show myself love and compassion and care for myself and wellness. So it’s been a fantastic experience for our patients. Another important benefit, although truthfully unforeseen, is for the caregivers themselves.
Don Wesson: That’s was going to ask about. I can imagine.
Kyle Christiason: It’s been amazing.
Don Wesson: The recipients of the care being excited, but I was wanting to ask about what the providers of that care, what their experiences are like.
Kyle Christiason: So it’s kind of our own little contribution to fighting burnout, what we’ve learned is that when we are very intentional about many steps in the clinic process, we begin the clinic with a centering exercise of some sort. We all come in from busy days and we kind of descend on one space where we’re co located with the full team that’s done all of the sensitivity training and bias training. So that’s kind of the core training for this group. But we’re busy. We come together and we’re just, we get our clinic rolling. We center with something like an education or a quote or something that brings us together and we practice this enough that we get right into our groove and we’re ready to go.
Don Wesson: All right.
Kyle Christiason: And then after the clinic has done, we finished with two steps. One is a rapid cycle improvement process. What didn’t go well tonight. We call them pain points, and we not just encouraged, but we expect each team member, from scheduler to the lab tech to the pharmacist to the nurses and physicians, look relentlessly, seek out inefficiencies, moments where there was a near miss and the experience, so to speak. What didn’t go as well as it could have been. And it might be simply how we write down vitals. It might be how we communicate someone’s pronouns to someone else on the team. So again, we’re looking for ways to improve the experience. At the end, we finished with what we call joy bombs.
Don Wesson: Joy, J-O-Y? Joy bombs? Okay.
Kyle Christiason: And it is a moment where everybody can share something that really brought them joy.
Don Wesson: And everybody being who?
Kyle Christiason: Anybody on that team. So this is a full team, robust huddle. Again, from scheduler to a provider.
Don Wesson: Wow..
Kyle Christiason: Anybody is encouraged. And so it’ll be moments, it’ll be moments like I remembered it was somebody’s birthday today and I said, happy birthday. And she loved that. To a patient’s sharing with a provider recently that I want you to know because you showed me love and compassion in this setting, I want you to know that I chose to not kill myself. Because of what you’ve done for these last few months for the first time in ten years, I don’t feel suicidal. And it’s those kinds of affirmations that we actually think are just as important as the objective measures of success that we have. Because those moments, again, they really connect our physicians and everyone on the care team. We’re all vulnerable to burnout, but this is how we finish our clinic.
And so at the end of the day, we finished with joy bombs and that’s how the team is going back to their homes, engaged, you know, and refreshed already, instead of this typical or traditional model of working like crazy all day long, tired, a little bit upset and frustrated going home to my family with that mindset. We flipped that. Now, we’re sending everybody back home feeling something that’s really reconnecting them to medicine and their purpose in what they’re doing in a way that they hadn’t been feeling for quite a while.
Don Wesson: It’s interesting, Kyle, that the experiences are similar, and I mean we’re both dealing with an underserved community and each of us had to make a proactive on treaty to that community to try to gain their trust. And so it sounds like you’ve reached out to the community. What have you heard from them that says this is the way by which we would like for you to conduct our care?
Kyle Christiason: It’s been an intentional bi-directional dialogue from the very get go. So with the launch of the clinic, we started with focus groups. What would this clinic look like if you could idealize it? If you could create it from scratch, what would it look like? What would be necessary? And so that continues to inform us. So we seek input from patients every visit. So we have, we created a survey, short survey, only three or four questions and right to the nuance of what we’re trying to get at. More or less, how was your experience and what be done differently next time to make it better?
Don Wesson: Wow.
Kyle Christiason: And so we have a greater than 60% return rate, which is really high by survey’s standards. And yes, we like the numbers and the scores, but it’s the sentences that people write in at the bottom that really influence us and make us change things. So their input continues to be essential. And I think that’s important for all of us. In medicine, we often measure our success by our own industry to find standards. And we’ve often left the center of the whole reason we do this out of the picture. And we focused on our measures, our assumptions.
Don Wesson: You know, I didn’t realize it. Well, certainly, we get individual input, but it reminds me of an interesting story. So we meet with the pastors of these churches. So there’s 31 churches that we partner with now and we meet with them quarterly. In fact, we just met with them last week before I came. And we solicit their input as a group, as to how we can best deliver the care, much of which is being done at their churches. And I can remember, this was a couple of years ago, one of the pastors said, you know, Doc, we love this, these physical activity classes that you do, that Zumba stuff. We like it, but that secular music that you guys use for that, that ain’t working for us. You think that you can do the classes using gospel music? And we said yes because gospel music rocks as well. And so we changed the music format, but the same activity we were doing, we did not change. We just changed the music format to gospel music, and they changed the name of it from Zumba to Praise and Flow. And that’s now our most popular physical activity class that we do within the system. And so I keep reminding myself of that because that’s an opportunity for us to gain input from those that we serve as to how best we can serve them. And had we not been having these quarterly meetings and they felt comfortable enough to offer it.
Kyle Christiason: That’s why I’m curious about. So you made it safe, comfortable, almost an expectation that we want your feedback. What can be better about this? Okay. That’s something that I think we need to continue to think about and keep front of mind is how do we make this, make sure that we are getting the connection there and something that we’re seeking the input of patients and families and the community that we serve.
Don Wesson: Absolutely. And so that’s an ongoing process right now because we recognize that in order to gain the trust, we have to do these proactive measures that we’ve just talked about. But to maintain the trust, we need to have it be a continuous process and not just episodic.
Kyle Christiason: Yeah. Yup. You got to keep showing up.
Don Wesson: Yup.
Kyle Christiason: That sounds like partnership. And again, I’m inspired really by what you describe as nontraditional partnerships in medicine, and you know, that when we, in healthcare, to lead the journey to transformation of that experience and redesign that experience that we do collectively own the wellness of the communities in which we live. And we should be the ones leading that, but we can’t do it alone. And you’re describing partnerships with our community that is just, it’s a wonderful thing.
Don Wesson: Well, and I liked the marginalized community, at least the previously marginalized community, that you have been working with. You’ve also given me some insights as to how we might use some of the techniques that you’ve just described in our community back in Dallas. And so, thank you.
Kyle Christiason Yeah, likewise. It’s been a real pleasure. Terrific. Thank you so much.
Don Wesson: Thank you, Kyle.
Kyle Christiason: Appreciate this conversation.
Don Wesson: Absolutely. Thank you.
Narrator: Visit buildingtrust.org to learn more