SPEAKER_00 0:00

Hi, so today we're going to welcome Dr. Scott Neely to our podcast. Dr. Neely is the president and CEO of Dignity Health Sierra Nevada Memorial Hospital and the founder of HealthSpan. Thanks for coming on today.

SPEAKER_01 0:15

Oh, thank you for having me. It's always great for us when somebody outside of our little county actually tunes in to what we're trying to accomplish.

SPEAKER_00 0:25

Yeah, it fits really well into our mission. And we're talking to people who care about preventing stress-related diseases and disorders using kind of a health promotion lens. And that's really what HealthSpan seems to be about in bridging that gap between what you're you've been able to do with the hospital for many years to what now you're doing in the community. So curious if you could tell all of us what you're doing in the community, how HealthSpan really bridges some of those gaps between where the hospital system can no longer kind of reach those social behavior lifestyle factors that you're strengthening in the community.

SPEAKER_01 1:04

There's no sound bite that can do this quickly, but thank you for the opportunity to talk a little bit about this, Nadine. I think as you well know, and many of the folks listening are aware, the vast majority of our health outcomes come from factors that are outside of the traditional medical system, outside of the actual health care that we receive. And so if you make it your mission to help people live healthy lives, you have to go outside of the healthcare system. And we are certainly very committed to providing the care that we do here in this community. And I think my organization is committed to that really all across the country. But we also understand that to truly deliver on our mission of supporting people in living healthy lives, we've got to go outside of the medical care system. And when you start to get into that aspect of things, which are the factors that support and promote healthy living, you're in a challenging area because you can connect to the lifestyle factors that we know do support healthy living, but it's not enough to just tell people do these things. It's a far more complex challenge than simply being prescriptive and saying you gotta do this. Because number one, all of us are challenged at times in making healthy choices. And number two, there's a really substantial portion of the population who simply don't have the resources to make healthy choices. And so it's really not enough to simply preach to the choir. You have to develop, I think, more of a systems-based approach. You have to understand the role of policy and resources in helping people to move towards this goal. So you have to create an environment. And what we talk about is making the healthy choice the easy choice. And that means built environment. That means resources for obtaining food. That means environments that are receptive and supportive of activity. And it really means environments that are supportive of social connection. There is so much that actually goes into healthy living that is beyond going to the gym and eating healthy food. So we're trying to build an organization where we really have an understanding of the role of policy, the built environment, these choices, and where we can at least incrementally move the environment towards that place where, you know, making the healthy choice is actually the easy choice.

SPEAKER_00 4:12

Yeah, I think what you're talking about is a few things. We need to understand where people are at. So what types of lagging indicators are there in the social, behavioral, environmental pieces of the puzzle, the non-clinical factors. We need to understand how we can condition healthy behaviors. And that depends on a lot of factors in the environment, geographical regions. I know you're in a rural scenario. So those resources and strategies are going to look very different than Los Angeles County, San Diego, New York City, those kinds of communities are dealing with very different dynamics. And then behind besides behavioral conditioning, kind of have to see before that what the trends are so that we can really pick those vulnerable pockets and invest and optimize those limited resources into the portions, the subgroups of those communities that really need it the most. So maybe you can tell us a little bit about that model, what that looks like so far, and talk about that closed loop a little bit.

SPEAKER_01 5:33

Yeah. So there's two things that we have identified as kind of the two work streams that we're going to start with that we are starting with. The first one, perhaps I won't talk about as much, but it's a big one, is health in all policies. And so that involves engaging with our city and our county governments, as well as large organizations such as this one. We in the county are the two largest employers in the county, and engaging with those entities to really look at every policy development as an opportunity for supporting that healthy choice. So health in all policies, and I'll just I'll give you a really quick example because we've used it as we've talked to people about what does this actually look like? Well, for me, it involved getting a hold of our food vendor and saying, we're going to put healthy food in the vending machines. Because somebody pointed out to me, this thing that you're doing sounds like a good idea. Did you realize that you're selling poison in the vending machines? I said, good point. Very, a very tiny tiny example, but one that's practically important for people because there are some times during the day where the only food that you can get in this place is from those vending machines. And can you actually get something that's not ultra-processed sugar? So that's an example of that. The other one that we're working on is the development of closed loop referral system for meeting basically social and physical needs outside of the healthcare system in the community. So, what a closed loop referral system looks like is a broad range of organizations. We're talking about healthcare organizations and clinics. We're also talking about social service organizations. We're also talking about community benefit organizations. So, organizations, for example, that have a purpose of serving the needs of seniors in our community, organizations that specifically exist to serve the needs of young people in the community, organizations that are interested in connecting people with healthy food. We have all of those organizations who have actually basically raised their hands and said, Yeah, we would like to partner with you and to be a part of building health span. And so the next step is that closed loop referral system so that whichever door the individual goes through, that provider, that entity will be able to connect a person to what they need. That might mean us connecting them with two boxes of farm fresh produce a week. That might mean connecting them with a resource that allows a young person to have constructive, safe, supervised environment for two or three hours after school every day. You know, we have community benefit organizations here in Nevada County that are doing those things. And if an individual walks into one of our clinics, one of our health clinics, and the provider actually sort of susses out, well, I can see this is what's going on for this individual, they'll be able to basically log into the system. It is a software program at its most fundamental, but it's a software program with a portal for everybody in the community who's a part of it. And they'll be able to make the referral. And the nice thing about this system is that it's two-way feedback. So once you've made a referral, you'll be able to go back into the system and see, well, did the provider reach out to the individual? Did the provider actually connect to the individual? Was the service that we had in mind delivered? And is the individual receiving it? And that's what the beauty of this system is. I know a lot of folks have seen these systems in other communities. It's not something that we've been able to develop up here before, but we're very excited about the fact that we're going to be able to actually do this. Common Spirit Health, my parent organization, is actually going to support us in installing the software. And we're now in the process of looking for grant funding to support the individual implementation at each location. So it's the development of a network that basically connects a community around social needs.

SPEAKER_00 10:33

Yeah, and I think what's pivotal in all of this is your role in the community, knowing all these partners and players, having this trust already built is understated in this. So that you've been able to amass this social network. And also you're able to influence this health and all policies. And they're both very scalable, right? So once we have these two things going, you talk about a vending machine as a small thing, but then if you're addressing every policy at that level, then you're really able to move the needle pretty quickly when you're talking about small changes over time. And then also with social infrastructure in place and you've got lots of players on board, then you're not have one entity trying to do all of the work, which historically in communities, each entity feels like they are doing all the work within their own bubble. And then you've trying to create these small bridges, and they're really, at least in my 25 years, it's been very difficult to we want to collaborate, but those bridges are very difficult to create and maintain with turnover and things where I think the technical infrastructure is really giving us a way that these organizations can then have this carry over and have people always involved in this over time. So I think from that standpoint, it's more scalable. And then from a technical standpoint, how's that data sharing going? So you're able to do it from a communication standpoint. Who's doing what, checking those boxes, making sure everybody's accountable? But then are you also trying to get a 360 view of a patient's kind of health trajectory over time and the influences of some of those new factors?

SPEAKER_01 12:07

You know, we have existing data sets right now, but they're fragmented, they're not shared. So the Medi-Cal, which is the California version of Medicaid, the Medi-Cal provider for Nevada County has a data set. We at the hospital have a data set. And obviously some of the individual healthcare providers have data sets. But I think that we're looking at a shared impact model. And one of the infrastructures that we have an ambition to build through that shared impact model is essentially a set of shared KPIs. And the reason that shared impact is such a promising and robust approach to this is that we all agree on the same KPIs and then develop an infrastructure and analytics that allow us to basically share that data. That's not there yet. That is in the blueprint for this organization and really a pivotal part of how we're trying to develop it because quite frankly, we think that funders are going to find that attractive. And that is obviously something that we're looking to enhance.

SPEAKER_00 13:27

Yeah, I think that's where our work overlaps is because that's what we've been doing is finding those those indicators, measuring them, addressing them. And so do you have kind of a sense of any of those KPIs or outcomes that you're looking for yet? Or is that something you're still working on with those connections within the community?

SPEAKER_01 13:45

Well, I think that there are a number of relatively low-hanging outcome measures that we have access to. And I think there's a lot of work to do in terms of fleshing that out. But I'm truly hoping, for example, that we impact emergency department visits in the community because that's an indicator of folks that are basically exercising a last resort approach to meeting a need. And I think that I have this, I have the only emergency department in the western part of the county. And therefore, I have a really good indicator of who's using that door. And so that's one that I really want to leverage. I'm hoping that we will be able to eventually get good data around the incidence of, for example, young people with high ACE levels, high ACE determinants. I'm hoping that we'll eventually be able to follow something like the incidence of diabetes and blood sugar control, hypertensive control. These are things that it's tough to get broad data sets. And that's why I think starting with something relatively easy, like the emergency department, is not a bad place. But we do want to broaden that aperture so that we're capturing actual health outcomes. Honestly, you know, one of the better outcomes that you can look at for a county is the Medicare spend per beneficiary. But that only impacts a certain part of the population. There's a tremendous amount of data out there, but validity and applicability to your population is a key concern.

SPEAKER_00 15:39

Yes.

SPEAKER_01 15:40

I hope that answers the question.

SPEAKER_00 15:42

It absolutely does. And I think these are the things that we're mulling over. And it's really important that we kind of tease them out and folks can kind of think about how that applies to their own health system, what they're working on. It's absolutely something that we're measuring, both those Z codes, which includes ACEs and those labs that are really critical to pre-clinical trajectories, A1C levels and B12 and certain things we're really focused on the mental behavioral health side. So we've got some of those important indicators. And I think from a health standpoint, we're measuring two things. We're measuring wellness and well-being rather than those clinical factors downstream. So we can do something in advance. And then we're also measuring those trajectory factors and knowing that those vulnerabilities put someone at higher risk. And what can we do? And so you've got these partners in the community that are also supporting on the individual level. And then we're creating this system architecture around that, which I really love. This is exactly what we're going for. And you talked about what the future would look like, being able to get the funding to measure and address these things upstream, then it influences the hospital care so that the hospital care is not so impacted. Can you talk a little bit more about how you see that changing, at least in the space that you're in, how you see that changing those downstream models and systems in the medical care if we are able to do this really well?

SPEAKER_01 17:12

If you visit our emergency department any time of day, any day of the week, you'll find a number of folks who are having behavioral crises. Yeah. Who are in a certain part of the emergency department with a sitter typically. And you know, there's two things going on there. A really key place for life-saving care is actually being burdened with a type of care that it's not well equipped to handle. And the other thing that's going on is even more important. You've got somebody who's really suffering. They're really suffering or they're in the wrong place. Again, that's one example. But I mean, I can envision a world where that's not what emergency departments are for. And I could also envision a world where that individual has been able to get appropriate care before there's a crisis that ends up with them being on a on a hold in an ED with uh a guard sitting next to their bed. So it's kind of a dramatic example, but it's also an example that's going on in emergency departments all over the country every single day. The other thing that I can see in terms of the impact on us is can we get to a place where folks who are sort of poorly resourced, poorly supported, are spending less time in hospital beds dealing with the sequelae of chronic diseases that they've been handling in some way or shape or form for many years. Can we get to a point where that's not what we see if we survey every hospital in the country? There are countries in this world where that looks very different. Where the incidence of chronic disease like diabetes, hypertension, heart disease, etc., is less, where there are fewer people who are impacted by multiple chronic diseases. If you look at the incidence of adults who have multiple chronic diseases, that's around 35%, 35 to 40 percent in the United States. That is the highest incidence in the world of adults with multiple chronic diseases. So that's a great big number, but that is a direct result of the fact that we invest really well in handling the downstream impacts of these things, but we're not investing upstream. And I think that we can envision a world where fewer people are dealing with these kinds of sequelae and fewer hospitals are burdened by folks who are basically experiencing the end of the line for these chronic diseases, the downstream impact. We're completely focused now on that downstream impact, which is truly valuable work. I'm always trying to reassure folks in the community. No, we're going to continue to run a really great hospital and a really great medical clinic here because we're going to be here to care for you. It's very valuable work, but it's rescue work, it's sick care. You know, the world can look different.

SPEAKER_00 20:59

Yeah, I think that you're painting the exact picture of what we have, where we're going, how it can look better. And we were at the World Wellbeing Forum in Rome. And our biggest takeaway is that 75 to 90 percent of all preventable disease and disorders that are non-communicable are stress-related. And that gives us the hope, the optimism to say, okay, well, these stress is gonna exist. But chronic stress leading to disease and disorder is preventable. And if we can provide that infrastructure and that support in the community as a regular, behaviorally conditioned environment that's just healthy, healthier and supportive, then we're going to be able to support people and give them the care they need downstream when they need it, that emergency care, without overburdening our communities. And I think you've got a great model started. I'm very excited to see where this goes. Hopefully we can have another conversation in the future just to kind of keep touch and keep everyone up to speed. With this. And I know you had one takeaway that you wanted to share. And I think, you know, while people are looking at your model and maybe not quite ready to start health span of their own in their communities because that's quite an impressive, progressive undertaking. But maybe there are some things that people can do, providers and professionals in the community can do at this point. Is there some takeaway you want to leave everyone with? I know you were telling me last week when we were chatting that when we were talking about we don't need another mop, we need to fix the leaky roof. You were saying that everyone needs to be a part of fixing the roof, something to that effect. Yeah. When I was asking you about this and people's small part in the upstream model or maybe being part of that in some way.

SPEAKER_01 22:43

I think the reason that I sort of struck on and continue to talk about that analogy is that I think it helps people to open their eyes to a different way of seeing health and what it means to pay attention to health in a community. I think that as I got to know this community better, and it's different working in a rural community, I spent my entire career basically in fairly urban medical settings, but getting to know this community, one of the things that came to me is that there were a lot of people who really cared about the fact that we have a hospital, that we have medical facilities, physicians, other types of caregivers. That was really important to them. But using the leaky roof analogy, we started to be able to have conversations about the fact that as wonderful as it is to have these medical resources, they are essentially rescue resources. They are sick care. And we do sick care better than any country in the world. But despite that, basically because of the leaky roof, because of the way our society is structured, because of basically the cultures that we live in, we're not supporting people for the long journey, that long downstream journey before they get to the point where they need to be rescued. And when we start to look at it that way, now health is not specialized and kept in one building that has X-ray machines and operating rooms. Health actually starts to be a community-owned resource, something that we actually get to do together. And I think that the you know, the home of HealthSpan is in the community. It's a very sort of uplifting thing to be working on because we get to do it together. I'm sitting at the table with an individual who has had a vision of keeping children safe and has built a wonderful organization that does that here. And I'm sitting at the table with individuals who have a vision of providing people with safe and healthy food and having it grown in this community. And all of these folks are getting to move from sort of their beautiful vision, but it's a single kind of a single issue vision, to a much more global coming together around this idea that if we take all of these things, the social connection and the social support, as well as activity and food and just safety for people, uh, now we're actually all working on this. It's not specialized in a hospital or a clinic. It's actually something that we own together in the community. That's something that is inspiring for people and it's an invitation to kind of come on board. And that's what I love about that analogy because it sort of breaks open the model a little bit and helps you to understand that having a healthy life, it's achievable and it's something that we can kind of own together as a community.

SPEAKER_00 26:15

Yeah. I love that you're building a true health collaborative. And what kind of strikes me as you are talking about these relationships is that it sounds like it's doing a lot for you and probably a lot for all of these other people too, and feeling like when we're on these islands that we were talking about earlier and siloed care, bringing people together with a like-minded mission really does a lot to support our own well-being. Feeling like we can do more with that shared resource and shared mentality is probably can reduce stress in the provider community as much as it can reduce stress in the community you're serving. So I love that.

SPEAKER_01 26:52

It's very sourcing. It's very fulfilling. And you can use a sports analogy. What is it like to be a part of a great team? You know, if you're watching the Warriors after they won their third championship, you can see the power and the fulfillment and, you know, a life's vision kind of fulfilled by being a part of a great team. We can't all dunk or hit a three-pointer, but it's still really fulfilling for people to be a part of a team, especially when you have a shared vision that's a very positive one. So I get where you're coming from, and I couldn't agree more. It's very fulfilling work.

SPEAKER_00 27:31

I love this. Well, thank you so much, Dr. Neely, for coming on, sharing your experience with us and painting a picture of what this community change could look like for all of our audience. So it was great to connect with you and we look forward to chatting again soon.

SPEAKER_01 27:44

I enjoyed the conversation. Thanks, Nadine.

SPEAKER_00 27:47

Thank you.

SPEAKER_01 27:48

All right, take care. Bye bye.

SPEAKER_00 27:50

Bye.