Slides from masters defense presentation - Josina Vink. Masters of Design in Strategic Foresight and Innovation, OCADU. It has been suggested that as much as 50% of population health outcomes can be attributed to social determinants of health (SDOH), the conditions in which people live (O’Hara, 2005). Despite widespread recognition of the importance of SDOH, little has been done to support primary care in effectively responding to the social aspects of patients’ health (Bloch, Broden, & Rozmovits, 2011). Using a variety of design research methods, including interviews and observations, this study investigated why rural family physicians are unable to successfully address SDOH of low-income patients. This exploration revealed underlying cultural and systemic barriers that inhibit physicians from meeting the social needs of their patients. After understanding the gap around the social aspects of heath that exists in medicine, recently dubbed ‘health care’s blind side’ (Robert Wood Johnson Foundation, 2011), and the related design opportunity, the Community Health Accelerator (CHA) concept was developed. A CHA is a system innovation that catalyzes connections and conversations about the social side of health by leveraging the role of primary care and catalyzing community action. This concept has the potential to create significant population health improvements and long-term reductions in health care expenditures by reorganizing existing resources.

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FROM BLIND SIDE TO UPSIDE
REDESIGNING OUR RESPONSE TO PATIENTS’ SOCIAL NEEDS
JOSINA VINK
MRP DEFENSE
APRIL 12, 2013

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THANK YOU.
ESPECIALLY TO MY INCREDIBLE ADVISORS KATE, ALLISON AND ROSE.
AND TO IRMA FOR COLLABORATING ON THE ILLUSTRATIONS.

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PRESENTATION OVERVIEW
DEFINING THE PROBLEM DEFINING OPPORTUNITY Design
Concept
[DIVERGE] [CONVERGE] [DIVERGE] [CONVERGE]

4. There is widespread recognition
4
of the importance of social
determinants of health . . .
http://psc28.wordpress.com/2012/09/20/progress-report-on-social-determinants-of-health-presented/

5. But little has been done to ensure
5
the health care sector in Canada is
responding appropriately . . .
http://www.healthpolicysolutions.org/wp-content/uploads/2011/09/Dr.-Kim-White-examines-a-patient-while-speaking-in-Spanish-to-her-mom.jpg

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“HEALTH CARE’S BLIND SIDE”
[Robert Wood Johnson Foundation, 2011]
http://www.rwjf.org/en/research-publications/find-rwjf-research/2011/12/health-care-s-blind-side.html

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THE SOCIO-ECONOMIC GRADIENT IN HEALTH
8
7.6
7
% of Canadians Reporting Diabetes
6 5.6
5 4.7
4
3.4
3 2.7
2
1
0
Lowest Income Lowest Middle Middle Income Highest Middle Highest Income
[Statistics Canada, Canadian Community Health Survey, 2005]

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RESEARCH QUESTIONS
1. WHY ARE THE SOCIAL DETERMINANTS OF HEALTH
OF LOW INCOME PATIENTS CURRENTLY GOING
UNADDRESSED BY RURAL FAMILY PHYSICIANS?
2. WHAT CAN BE DONE TO BETTER ADDRESS THE
SOCIAL DETERMINANTS OF HEALTH OF PATIENTS?

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WHY DOES IT MATTER?
Health of a Population
50% Social & Economic Environment
25% Health Care System
15% Biology & Genetics
10% Physical Environment
50% Social & Economic Environment [Adapted from Canadian Institute for Advanced Research (2002)]

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THE COST OF INACTION
CANADIAN PERSPECTIVE AUSTRALIAN CALCULATIONS
A HEALTHY PRODUCTIVE CANADA COST OF INACTION ON SDOH
“The benefits extend beyond im- • 500,000 Australians could avoid suffering a chronic
illness;
proved health status and reduced • 170,000 extra Australians could enter the workforce,
health disparities to foster economic generating $8 billion in extra earnings;
growth, productivity and prosper- • Annual savings of $4 billion in welfare support pay-
ments could be made;
ity . . . A lack of action will be very • 60,000 fewer people would need to be admitted to hos-
costly in terms of direct health care pital annually, resulting in savings of $2.3 billion in hos-
pital expenditure;
costs, social costs related to welfare • 5.5 million fewer Medicare services would be needed
and crime, lost productivity and re- each year, resulting in annual savings of $273 million;
duced quality of life.” • 5.3 million fewer Pharmaceutical Benefit Scheme scripts
would be filled each year, resulting in annual savings of
$184.5 million each year.
[Canadian Senate Subcommittee on Population Health, 2009] [National Centre for Social and Economic Modeling, 2012]

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PROCESS
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PROBLEM FRAMING INVESTIGATION SYNTHESIS PROTOTYPING PRESENTATION
Understanding the Researching the Combining insights to Making concepts Sharing project findings,
METHODS
context and defining the opportunity for new develop potential tangible, iterating, design ideas and
• Literature review
problem value creation
• Semi-structured interventions
• Concept mapping evaluating & testing
• Prototypes recommendations
• Design description
ideas
• Trend & driver interviews and visualization • Co-creation • Strategies for
analysis • Observations • Opportunity dialogue implementation
analysis • Ongoing feedback • Sharing results
• Design framework • Concept
• Concept refinement
development
PARTICIPATION
NUMBER OF PARTICIPANTS TYPES OF PARTICIPANTS
• 15 participated in interviews • 10 health service providers
• 2 participated in observations • 9 experts and other key informants
• 11 participated in the co-creation • 4 patients
dialogue

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FUTURE THINKING
TRENDS DRIVERS
weary workers. a new name for
everything. youthless towns. URBANIZATION
the rise of aboriginals. doc in a
box. there is an app for that. pill COMMUNITY
SUSTAINABILITY
pushing. virtual connection. pay for THE FUTURE OF
RURAL MEDICINE
performance. snip. snip. the growing
gap. cheaper. faster. better. golocal. THE CULTURE
OF MEDICINE
FINANCIAL
water war. smart streets. integrate CONSTRAINTS OF
THE SYSTEM
or die. cut off. the doctor is out. NEW ENTRANTS
TECHNOLOGICAL
ADOPTION IN
MEDICINE
pulling out the rug from under us. IN HEALTHCARE
prove it. ipatient. do gooders.
Having a deep understanding of critical forces that may play out in the future
contributes to more strategic and relevant design.

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WHY DOES IT CONTINUE TO EXIST?

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“SDOH are a hornets’ nest that must
ORIGINAL PROBLEM be avoided to stay on schedule.”
– Rural Family Physician, Ontario
GIVEN A BAND-AID SOLUTION
GETTING HEALTHY FOOD
HYSICALLY
E STS P
SDOH FACTORS
FINDING A JOB MANIF
MOLD IN THE HOUSE
CARING FOR KIDS
Family physicians recognized the need to deal with social needs, but found
themselves avoiding social complexities in medical visits.

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“When I go to my family doctor, I
HUMAN EXPERIENCE expect them to deal with prescriptions
and test results.”
– Patient, Ontario
Both physicians and patients felt uncomfortable with the interaction and
there was a lack of connection between individuals.

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CULTURE “There is certainly a stigma around
poverty that contributes to it being
ignored.”
S – Family Physician and SDOH Expert, Toronto
T
I
G
M
A
CLASS DIFFERENCE
INCOME
KNOWLEDGE
POWER
There is a cultural divide between physician and patient driven by a significant
class difference and the stigma associated with poverty.

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STRUCTURE “Our system rewards quick and easy
visits not spending time going through
a patient`s complex non-medical
issues.”
– Rural Family Physician, British Columbia
THIRD YEAR EROSION OF EMPATHY
LACK OF EXPOSURE KNOWLEDGE / EXPERIENCE GAP PRESSURES OF THE CURRENT SYSTEM
EARLY LIFE MEDICAL SCHOOL RESIDENCY PRACTICE
CLASS DIFFERENCE
There are critical system barriers that influence physicians, reinforce classism,
and limit their engagement with social complexity.

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“The propagation of wealth has
STRUCTURE implications.”
– Family Physician and SDOH Expert, Toronto
The disease management system involves a reinforcement loop that
contributes to poor health and acts as a self-preserving mechanism.

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PURPOSE “In the medical model of health,
the body is seen as a machine that
is either running well or in need of
repair.”
- Raphael, Social Determinants of Health: Canadian
Perspectives (2008)
MEDICAL MODEL SDOH CONCEPT
At the core, there is a significant disconnect between the purpose of medicine
and the social determinants of health approach.

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MEDICINE CURRENTLY IS
NOT WELL ALIGNED WITH
THIS WORK DUE TO DEEP
SYSTEMIC BARRIERS AND
THE ORIENTATION OF THE
PROFESSION TOWARD THE
TREATMENT OF DISEASE.

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“Not only are family physicians treating
KEY LEVERAGE POINT these patients, they are leading physician
associations, influencing government,
heading up health care teams, teaching in
medical schools and are respected voices in
communities.”
GOVERNMENT
POLICY PUBLIC - Family Physician and SDOH Expert, Toronto
MAKERS HEALTH
SYSTEM HEALTH RELATED COMMUNITY
ADMINISTRATORS BUSINESSES LEADERS
PHYSICIAN MEDICAL SOCIAL
ASSOCIATIONS PHYSICIANS SERVICES
SCHOOLS
OTHER HEALTH OPERATIONAL PATIENTS
PROFESSIONALS SUPPORT STAFF
Physicians are a critical connection and leverage point within the system.

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THE INSTITUTIONAL ASSUMPTION
Rather than start with a question of institutional change, start with
the condition. If we do that we will almost always recognize that
the primary working area is community life.”
- McKnight (2012)

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BRIDGING THE CLINIC & COMMUNITY
There is an important opportunity space between the community (where
health is defined) and the clinic (where patients are treated).

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DESIGN FRAMEWORK
VALUES PURPOSE
• Health
• Community To support transformation toward community
• Equity health.
DESIGN PRINCIPLES CONSTRAINTS
1. Take a systems approach • Time – Take action in two years
2. Seek large-scale transformation • Resources – Leverage available resources
3. Start small • Money - Require minimal funds
4. Leverage physicians • Scope – Implementable by a small team
5. Empower patients • Scale – Initiate at the community and/or
6. Enable community ownership clinic level
7. Build on what works
8. Embrace multi-disciplinary teams
9. Impact health

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COMMUNITY HEALTH ACCELERATOR (CHA)
A CHA is a catalyst of connections and conversations to address SDOH. It
leverages primary care and empowers the community to animate health.

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THREE-PRONGED APPROACH
HEALTH INQUIRY ANIMATEHEALTH COMMUNITY HUB
DIALOGUES TOOL BOX OR POP-UP STUDIO
These three components essentially reorganize existing assets to support
health in a new way by shifting the focus from illness to community.

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HEALTH INQUIRY DIALOGUES
These dialogues are monthly collaborative conversations that engage students
in a immersive and reflective exploration of social health issues in community.

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ANIMATEHEALTH TOOLBOX
It is a box filled with conversation, assessment, and referral tools to support
primary care professionals or volunteers in a primary care setting with SDOH.

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COMMUNITY HUB
The hub is a pharmacy with people instead of pills, where community members
utilize their strengths and relationships to address social health needs.

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A SYSTEMS INNOVATION
Exposure and Skill Development of Students Identification of Community Health Patterns
Shared Community Network Prescriptions and Subscriptions
Support in Addressing
Student Volunteers Health Needs
COMMUNITY HUB
COMMUNITY
HEALTH
Aware Graduates with Need for Clinical Tools
Health Professionals to Share Experiences
HEALTH INQUIRY TOOL BOX
DIALOGUES
These interdependent interventions create a system innovation that
strengthens the benefits of each component and amplifies the impact.

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BACK STAGE
Mapping & Faciliation Interests & Assets
COMMUNITY HUB
SUPPORTING INFRASTRUCTURE GUIDING COLLABORATIVE
Topics & Participants Resources & Support
COMMUNITY ANIMATORS FACILITATOR
Health Expertise Patterns & Referrals
HEALTH INQUIRY TOOL BOX
DIALOGUES
In addition to the connections between components, there are a number of
back-end roles and systems that link and enable the front line components.

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DIFFERENT JOURNEYS
PATIENT
Stakeholders link into
STUDENT
and engage in the system
in a variety of ways, all
collectively working at
PROVIDER
improving community
health.
COMMUNITY
MEMBER

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IMPACT
IMPROVED HEALTH OUTCOMES STRONGER COORDINATION
REDUCED HEALTH CARE COSTS GREATER HEALTH EQUITY
INCREASED RESILIENCE SHIFTED HEALTH CARE SYSTEM
ENHANCED QUALITY OF LIFE HEIGHTENED PROSPERITY

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BUSINESS MODEL
KEY PARTNERS KEY ACTIVIES VALUE PROPOSITIONS CUSTOMER RELATIONSHIPS CUSTOMER SEGMENTS
Primary care clinics Animation, tool dev., Support for health Personal assistance Impatients
Health care students hub maintenance, improvements & connection to Primary care
technology dev., Assistance meeting community clinics/providers
Community leaders training, reporting, patient needs Professional Health
Social services & communication
Student Schools
Inpatients development Local Health
Tech. partner(s) KEY RESOURCES
and community CHANNELS Integration Network
Colleges or investment
universities Animators, Cost reductions & Hub, clinics, web,
relationships, population health schools, and
LHINs community partner channels
leaders, space,
& information
COST STRUCTURE REVENUE STREAMS
Community facilitator salary, tech. development and Free service to impatients, sales of tool
maintenance, hub space, tools, training, and admin. kit and subscription from primary care,
lump sum investment from schools, and
funding proportional to health outcomes
The innovation is financially viable while at the same time modeling a
collaborative, innovative structure within the health care industry.

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MOVING FORWARD
Full Implementation in
Business Plan 500 People Reached One Community
2013 2014 2015
Experiments Begin Pilot Begins Initial Evaluation 2,500 People Involved
To move the CHA concept forward, a lot more work will need to be done on
development, planning and implementation.

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THE HOPE IS THAT WITH
FURTHER EXPERIMENTATION,
FAILURE, AND RAPID ITERATION,
THIS MODEL COULD
CONTRIBUTE TO A
SYSTEMIC SHIFT FROM
ILLNESS TO COMMUNITY.

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QUESTIONS?
Josina Vink,
MDes Candidate