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IN THE STATES: Creating a Picture of Health(y) for the Nation's Capital

Washington DC is not the picture of health.

I'm not talking about political dysfunction. I'm talking about the health of the people who live here.

That may be changing.

The city has gotten lots of attention for its edgy school chancellor and education reform; it's also begun (with far less fanfare) a pioneering attempt to address health challenges in a city with a serious, and costly, burden of chronic disease.

Life expectancy in the nation's capital is eight years lower then the U.S. average. Mental illness, HIV/AIDS and cardiovascular disease rates are high. Lots of people are overweight; diabetes is a big problem, leading to a high rate of serious kidney disease and amputations. Costs are high (although the uninsured rate at under 11 percent -- 2007, pre-recession -- is lower than the national average of about 16 percent.)

The city several months ago brought in Dr. Joanne Lynn, a nationally-known clinician, writer and researcher.

Dr. Lynn is an articulate champion of dragging health care into the 21st century and making the system respond to the needs of patients. She wants to start with Washington DC. Not in another 20 years. Now.

She now heads the Chronic Care Initiative in the city's department of health. So far the city has allocated $10 million in tobacco settlement money to the health initiative.  About a dozen programs are underway; more should come on line later this year and next.

It's an ambitious project, basically taking the lessons of quality improvement and the goals of population health and applying them across an entire city with an unhealthy population and a fragmented health care system that in its current form is not conducive to managing chronic illness. The Chronic Care Initiative is, in essence, an attempt to reinvigorate primary care (and common sense) in Washington, and to apply city-wide what quality improvement wonks called the Triple Aim goals:

1) Improve the health of the population

2) Enhance the patient experience

3) Get Value

That's a tall order in the best of circumstances. Here they are trying to achieve the Triple Aim for an unhealthy population that includes lots of  people who are poor, sick, and members of racial or ethnic minorities.

The initiative involves several of the city's big teaching hospitals as well as smaller clinics and mental health centers. Dr. Lynn calls them the pioneers. They are starting small,  reaching finite numbers of patients in specific clinical and community settings. But they are aiming high.

The programs aren't occurring in isolation, one in this clinic, one in that hospital. They are part of a collaborative, designed to share knowledge (failures and missteps as well as successes) and to try to knit Washington's very fragmented health care system into one that can better coordinate care. If you can tolerate a really mixed metaphor, they are trying to weave "silos" of care into a community-wide tapestry of care (with primary care at the core). The goal isn't just to lower the blood sugar of a few hundred diabetics, or to get a hospital in a poor neighborhood to alert the nearby community clinic when a patient shows up in the ER. The goal is to make Washington healthier while getting more bang for the health care buck.

Through Dr. Lynn, I've had a chance to meet some of the doctors and nurses, social workers and translators,  running these chronic care pilots. During the coming months, I hope to write about them more in depth. They include:

  • Putting a nurse-practitioner into a mental health clinic, because people with severe mental illnesses tend to have other chronic disease that often end their lives prematurely.
  • Enabling diabetics to do self-care through applications on their cellphones. (First you have to make sure they all have cellphones, and the cellphones are compatible with the health software).
  • Turning an ER crisis visit into a teachable moment, by making sure a diabetic gets to a patient-educator before leaving the hospital.
  • Doing a better job of treating HIV-positive people who also have chronic heart or kidney disease, trying to figure out why sicker and more complicated patients are less "compliant" about medication and appointments than healthier ones.
  • Setting up computer health kiosks in community centers in low-income neighborhoods where people may not have the latest laptop technology at home. (And to make sure they know how to use the technology).
  • Improving health information technology citywide, so all doctors treating a patient can get a full picture,  no matter what clinic or center or hospital the patient turns up at.
  • Addressing high rates of hospital readmissions by some simple steps like having the hospital notify a community clinic when their patient shows up. (Early attempts to address this seemingly simple task have been frustrating and slow).

I hope the "pioneers" are open about their failures as well as successes; because failures hold lessons too, and they can lead to success. What needs to be tweaked, what needs to be scrapped, what needs to be looked at from a fresh angle. No sense in Clinic A learning that such and such an approach doesn't work, without making sure that Clinic B doesn't go down that fruitless road itself in another year. That's part of the "collaborative" as Dr. Lynn has designed it. Every few months, they all get together and swap stories, share insights. They learn.

This isn't the health reform that's being discussed on Capitol Hill. But comprehensive national legislation -- expansion of coverage, re-alignment of incentives, emphasis on primary care -- all those elements will make it easier for this initiative to achieve its goals, to lead the way. But the national legislation is, to a certain extent, about money and financing, the backbone of health reform. The work going on in this city may prove to be its heart and soul.