Community Engagement – Harmonizing to the Same Tune #150

The views and opinions presented in this podcast and publication are solely the responsibility of the author, Danny van Leeuwen, and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute® (PCORI®), its Board of Governors or Methodology Committee.

Music by permission from Joey van Leeuwen, Drummer, Composer, Arranger

Web and Social Media Coach Kayla Nelson @lifeoflesion

Inspiration from Mary Ellen Cortizas, Neely Williams, Freddie White-Johnson, Joanna Siegel, Karen Martin, Kristin Carman, Libby Hoy, Dick Argys, Tania Dutta, Russell Bennett, Bonnie Engelbart

Links

Cambridge Health Alliance

CHA Facebook Page

CHA Healthy Now Blog

Katie’s Nutrition blog

Transforming Clinical Practices Initiative

National Collaborative for Health Equity (sponsored by NCQA)

Related podcasts and blogs

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About the Show

Welcome to Health Hats, learning on the journey toward best health. I am Danny van Leeuwen, a two-legged, old, cisgender, white man with privilege, living in a food oasis, who can afford many hats and knows a little about a lot of healthcare and a lot about very little. Most people wear hats one at a time, but I wear them all at once. We will listen and learn about what it takes to adjust to life’s realities in the awesome circus of healthcare. Let’s make some sense of all this.

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The Show

Proem

Lately, the industry chatter about patient engagement has increased. Clients ask me to advise about patient engagement. What is patient engagement? How can we increase patient engagement? Is patient engagement worth it? Where do we find people to engage? What’s the business case for engagement? As time passes, my thoughts and advice change, and, frankly, I find myself at a loss to advise, even though I say patient engagement is my passion. Engagement from whose point of view, to what purpose?

A person engaged in their health – Isn’t everyone engaged in their health? My symptoms affect me. I’m in pain. I can’t function as I’d like to. I’m sad. I’m anxious. I react. I manage, or I don’t. I can accept, deny, adapt. I suffer, I advocate, I overcome. Maybe it’s my parent’s health or my partner’s or my child’s. It’s all engagement. I’m engaged in my health.

A clinician engages in their patients’ health. My neurologist said he’s an expert in what works related to treatments and therapeutics for populations of people with Multiple Sclerosis, but he doesn’t know crap about me and my life. He wants to learn about what’s important to me and about my basic habits and circumstances – transportation, finances, culture, and spiritual values, family, hobbies, exercise, diet…. He’s engaged in my health.

A patient can engage by adhering to their clinicians’ prescriptions and medical plans? Indeed, a paternalistic and common view of engagement. I’m engaged when I follow all instructions, whether I understand them, can afford them, or can get to them.

Patients engaged in governance, design, operations, and learning about medical care delivery, policy, research, technology, and business. People at the center of care (patients, direct care clinicians, and the people that support them) sit at decision and learning tables like boards, advisory councils, departmental meetings, product design sessions, insurance company business meetings.

Lately, my focus has shifted to the engagement of communities. Neighborhoods, towns, virtual, diagnosis-based – any kind of community. Communities engaged in best health for their residents and members.

Introducing Kirsten Meisinger

Let me introduce our guest, Dr. Kirsten Meisinger, an international expert on Patient-Centered Medical Homes and healthcare system transformation. She was National Faculty Co-Chair for the Centers for Medicare and Medicaid Services (CMS) initiative “Transforming Clinical Practices Initiative” (TCPi), an initiative that transformed over 140,000 US practices to value-based, patient-centered medical care. She was co-chair of the National Collaborative for Health Equity (sponsored by NCQA) and a member of the Expert Panel for the Health Care Homes initiative in Australia. Currently she is helping design and implement a national pilot for Primary Care in the Private Sector in Brazil. Kirsten Meisinger, MD is Director of Provider Engagement, Regional Medical Director, Medical Director of Sexual and Reproductive Health, and Operations Lead for Telehealth at the Cambridge Health Alliance (CHA). She cares for an active Family Medicine panel at the Union Square Family Health Center, an award-winning Patient Centered Medical Home practice that was selected as one of the top 30 Ambulatory care sites in the US by the Robert Wood Johnson Foundation in 2010.

Health Hats: Kirsten, thanks for joining us today. I appreciate it. I’m looking forward to this conversation. We met at the Patient Experience Conference. I was disappointed because I went to your session because I was really interested to hear about community engagement in the development of telehealth practices. You might have spent two minutes on that. Not that the rest of it wasn’t interesting, but that’s what drew me in. So, could you introduce yourself and tell me a bit about what it is you do?

Kirsten Meisinger: Sure. It sounds like what we are going to do now is just finish that conversation that is annoyingly started but never finished at that presentation. I am Dr. Kirsten Meisinger. I’m a family physician, and I have now been at the Cambridge Health Alliance for 22 years. What does that mean? That means that I am your family doctor, and I can take care of anyone in your family. And I do pretty much anything that comes up. You usually come to me first, and then we figure out together what makes sense to do next, which is fun, I have to say. Because it’s been so long, I have so many families my kids have grown up with, and they’re often at the same schools and having the same experiences. Many of my patients were not born in the US and don’t speak English. And I often don’t speak English, which is also really fun. I have learned Portuguese because of my job, and so many of my patients were not born in the United States, and I learned Portuguese as part of my medical practice. Because it was a lot easier, I realized, speaking your language than working with interpreters. So, I came into medicine speaking Spanish and a few other languages, but now speak Portuguese most of the time, which is excellent. I also have a lot of patients from Nepal, which I just love. So, I get this amazing cultural worldwide experience when I walk into my office every day. This has been part of the inspiration for the work I think we’re going to talk about, which is trying to understand how to best serve the patients that I care so deeply about and how to have a medical system that is not in any way familiar to them. And even if it is familiar to them, it often doesn’t make any sense. Help us serve them and not have them, I think, be sacrificed unnecessarily by so many of the things that I know you have experienced, I’ve experienced. And that’s very joyful. I think day-to-day. I’m quite a happy person, as it turns out.

Provider engagement, loving what you do

Health Hats: You also are the Director of Provider Engagement. What does that mean?

Kirsten Meisinger: Engagement is kind of a funny term, but I think people have settled on it to mean, do you like to come to work? When you arrive, do you give your best? And in the service to a business, it strikes me as a funny paradigm, right? Like I have to show up to work. I must be confident. I don’t have to like what’s what is it, your business if I love what I do, but if you do find joy in work, if you find a job that is joyful and animates you, you do so much more. If you are passionate about it, if your passion and your work overlap, that is genuinely something that will produce amazing results. And in medicine, to me, it makes some sense. It is an honor to be trusted with the knowledge and information that my patients and I share. Honestly, I try to give pieces of my life to them, so it doesn’t feel one-directional when appropriate. And that kind of engagements that we have with each other can be measured in things like Likert scales, which are like, how engaged are you? Again, if you don’t explain what that means, it doesn’t ring true, but there are easy ways to measure how much you trust your doctor or care provider? How much do you respect your boss? So, engagement, I think, is an interesting and sometimes useful term to be the Director of Provider Engagement. All I’m trying to do is help the Cambridge Health Alliance medical institution understand what makes us tick, how do we break? Get the best out of ourselves? How does the organization help us become our best selves? Because we know that medical care is safer, higher quality. And honestly, again, more joyful when you have providers and staff, and patients who love being there have a good experience, feel psychologically safe, and can leave, hopefully, feeling stronger, more centered, and more empowered than when they came.

Patient, provider, community engagement intertwined

Health Hats: So, are you suggesting that patient engagement, provider engagement, community engagement are like an EKG where maybe there are three leads where you’re looking at something central from different windows?

Kirsten Meisinger: I think that’s a very fair statement. And I might say there’s even more. They’re closer even than that. Because I believe they are the same. When people know whether and we don’t know with our thinking brain, we know with our limbic system, or I call it like the lizard brain. Like we know with our lizard brain, when a place is joyful, when you feel safe, when people there also feel safe, when they enjoy what they’re doing, you can walk into a place and there’s some weird energy in the air, and you just know. So, I would argue you create a safe, joyful community, or you don’t. And all of those three things will sing, and this is the same tune, but right. To slightly change your analogy, it’s the same song, but you might all have different parts, right? It should harmonize. That, I think that may be, feel closer to how I think.

Telehealth, up in 60 seconds

Health Hats: Okay. So, let’s take this to the reason I wanted to go to your session, which is about how this engagement, whether it’s provider, community, or patient, influenced the trajectory of telehealth in this COVID world that we’re in?

Kirsten Meisinger: So, telehealth, I would say, is just the latest place that I have been doing this work, but I have to say, honestly, hands down the most fun. I love IT (Information Technology) people. They’re passionate and cerebral and just a joy for me. That’s just a joy. I like smart people, it turns out, and if you have a sense of humor, we’re going to get along great. So, bringing in all three members of that kind of triad we’re outlining is essential. If you’re going to be trying to make a place safe for everyone. And if you’re going to make it worth visiting you. It has always been one of those truisms, right? Everyone always says you have to involve what they call the end-user. And everyone thinks of the Apple Store because they have done such a wonderful job of taking a little rectangle and turning it into an obsession. And they had to do that with the people who were using it. I feel like any phone you buy, not like a cell phone, but like a landline phone, had no end-user input. Cause I cannot use those things. I cannot figure out the buttons I can barely listen to messages. Like I am a mess when it comes to landlines now, and I’m old. I had landlines. I had the rotary phones, but anyway. The idea then in healthcare IT, the idea just with televisits was, we had overnight to say, okay, whoa, stop coming in because no one safe around anyone else for a short time. It turns out, not a short time. We now have to do everything either over the phone or over video. That’s a considerable project. Fortunately for us, we had already been looking at how we communicate using our little rectangle computer, also called a cell phone or a mobile phone, because we’re all obsessed with these things. So, we’d already tried to figure out how. How can we get healthcare on that? How can I help you without you having to lose half a day and come to an appointment? Because that has always just felt a little disrespectful to me, and I am going as fast as I can in clinic. And I’m never going to get there on time because everybody never has. Doesn’t have enough time in the schedule in the first place. Like I can barely get through how your family’s doing in 20 minutes, much less actually what you need to leave feeling more empowered and healthier.

Long-standing patient experience partners

Kirsten Meisinger: So, we already had patients by our side. We were already working with them, saying, please tell us your experiences, right? When you send an email, what happens when you call?? How can we get better? How do we improve? And I have to say, people are usually way too nice. You have to pull out of them any negative experiences. So, thank you, People. Thank you, human beings, for actually being lovely. But we can, over time, as you develop these relationships, right? They start to feel like they can tell you things because every time they tell you something bad, the only thing that happened was you thanked them, and something got better. Or you just thank them because we couldn’t make it better just to be fully transparent. So, when COVID hit, we could keep those relationships, which had also been virtual. It was so fashion-forward, and we were so clever right before COVID; you’re like, Oh, we’re going to do all these meetings just virtual. Isn’t it? Everyone was like, oh, I don’t know. And of course, now everything’s virtual, and we’re all okay with it. So, we had this infrastructure. It was fabulous. We just kept rolling, and we said, okay, help, what do we do? How do we communicate with you? What do you, where are you getting information about COVID, right? The world just blew up. No one knew anything. So, we quickly were able to find out that we are not just the future, the patients on our IT committee, we’re getting information, and our trusted community partners are getting information. So, because then, CHA has reached out to the significant numbers of people in our community for a decade. Meaning, there’s a very large group of patients that come to CHA from Brazil. A very large group of patients come to CHA from Bangladesh, from Nepal different parts of India, India is a big place. So, we have communication with the community agencies that are also coming up to try and help people as they change countries, languages, and healthcare systems. So, we just quickly pivoted and said, okay, where are you getting information? How do we help you? It turns out Facebook was a big thing. So, we just started doing sessions on there. CHA has a great Facebook page. If anyone is interested, it’s in many languages. If you would like to read about COVID in five different languages, that is the place for you to go. All those relationships came, I think, into play when we had almost no time to get these things done, and we’re just incredibly useful, right? The most efficient way to design something is to ask the person you’re designing it for, which we already had in place. We did a pretty good job. We wound up doing many of our visits over the telephone because it turns out it’s tough for people to download an app onto whatever they have in a different language. That should have been obvious. But we just used the tools that we had. Now we’ve used the same structure and committees and tried to move forward with a kind of video visit where you just push the link, and you’re boom into the video. So, like a Zoom, you have to download an application to get that link to work.

When the world blows up

Health Hats: Okay. What I’m hearing is that you already had relationships on different committees in the organization. You had relationships with community organizations, and that you leveraged those existing relationships into sort of the urgency of the day.

Kirsten Meisinger: Yes, and directions. So again, right when the world is just blown up, you don’t know which direction to head. If you at least know who you’re heading towards, you can then right. They can at least call out. I call out, you can Marco Polo – try and figure it out. Which is precisely what it felt like. It felt a lot like Marco Polo. We’d be like, is that it? And they’re like, no, not yet. I’m over here. Oh, am I closer yet? You’re closer, but you’re not here.

Public health superpower

Health Hats: Yeah. Oh, interesting. It is one of the things that come with it. It’s often about control when you talk to people about partnering with patients, caregivers, and communities, especially when you talk to the patients, the caregivers, and the communities it’s about control, it’s about power. It’s about a shift in power dynamics, which is hard, really hard. And so, what I’m hearing is that Cambridge Health Alliance already had a culture of sharing that power. So, you’ve been there for 20 years. This didn’t just happen fully birthed. What was the evolution that got to where the organization was comfortable and therefore could take advantage of that culture to manage this disruption?

Kirsten Meisinger: I think one of the big pieces that we were fortunate to have with us for now decades is that Cambridge is the Cambridge Health Alliance. The CEO’s job is the same as the Cambridge Public Health Commissioner. So, it’s the same. And what that means is that we have a superpower that most health organizations don’t have, which is we are responsible for the health of our community, whether you’re a patient or not. And so, in public health, I think people know a little more about public health now from COVID, but a lot of COVID didn’t get to be directed by public health, which is still shocking to me. What a missed opportunity in this country. Because the whole job of public health is to look at the greater good and say, what do we do for the people who live in this place to make sure that they are happier, healthier, and more empowered. It’s that kind of invisible work a little like primary care, right? So, if I do my job, nothing happens, you live to 90, you’re happy. You’re healthy. You feel great. See me every once in a while. That is my definition of success, right? That is never going to get a syndicated TV show. That is so boring. And how public health is even worse, right? If public health works, like you, never die of dysentery; it’s all these series of non-events. We are also a multi-specialty organization. We have hospitals that we have ERs, and we have those surgeons, and we have thoracic surgeons. We have all the things that you have when things go wrong. But our perspective, our viewpoint comes from the community, not from the medical system. And that makes all the difference.

Health Hats: That is huge. Oh, my goodness. That’s huge.

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Recognizing when it doesn’t work

Health Hats: Let me ask you a different question. The question I was going to ask you was how do you recognize success? But I think I’m more interested in how is it that it’s not working?

Kirsten Meisinger: So, let me take that on two different levels if it’s okay with you. Part of why we’ve always shared power is that you come in, and I patiently explained to you that you’re a complete mess. And here’s what you have to do, and you likely just nod and smile and thank me and go off and do whatever you’re going to do anyway. And because you’re tied to me in our primary care system, you do come back. Some people make an effort to get away, but it’s so much work to change doctors. You never really like most people don’t do it. Even if you have to dislike your doctor to change your doctor, and I say, doctor, because so many other health professions are not allowed to be PCPs (Primary Care Physicians). I’m hoping that’s changing. I’m hoping that we can let physician assistants, for example, become PCPs soon. And some nurse practitioners are, but they’re always supervised within the system. And what’ll happen is that you’ll come again next visit. It’ll probably not be when I asked you to, because you’re already resentful. And then I will compound my failure by lecturing you about how bad you are. This is what the medical system has set up as great medical care and people who genuinely care and want to make a difference in people. I quickly realize that this is not of a plan, not going to work, just to have high emotional intelligence. This is not ever going to work. So, you know that you’ve failed in the air, right? So, the person’s body language is collapsed, and they’re not happy that you’ve failed. When people are not getting better, and you’re working harder than they are, or you think you are, right. They’re not working at all because you haven’t helped them change in any way. That is how we know on the individual level, right on the one-on-one level, that we failed. When we failed in the community, people just don’t show up. You can have this wonderful event. You can put so much thought and planning into it. You’re so proud of yourself. You’re convinced that just, like putting in a few more hours of vaccine access, people are going to flood the hospital, and then no one comes. So, they’re a flip of each other.

Health Hats: People vote with their feet. Yeah. Yeah. Interesting. What should we be talking about that we’re not?

Leadership at many levels

Kirsten Meisinger: I think your last question leads me naturally towards a feeling of equity and hierarchy. I tend to view the world and structures. I like structures. I like changing them, but I like making flat structures. I don’t like making structures that have a hierarchy. I have no affinity to hierarchy. I find the idea that a single person gets control over an entire organization or a nation or the opposite of what I think is the most effective way to get the best results in any given system. Not that leadership isn’t important, but I think there are leaders at so many different levels of organizations that you want to have; what you want as an organization that calls on the natural leaders, the people who will work harder for their internal motivated motivation and let them shine. And when you don’t, those very same people who are back to engagement are their biggest critics because they’re so profoundly disrespected and so deeply angry that they’re brilliance is going nowhere. They don’t want to. No one wants to feel like they’re failing all the time. And if you feel like you have a great way to succeed and no one’s listening, that is maddening. And that is that to me is all about equity, right? That is equity, quite frankly.

Health Hats: As I’m listening to talk, is that my view about leaders. My personal view about leadership, and I’ve been a leader in many different venues, is that the first job is to get crap out of people’s way so that they can be leaders themselves. And so, I think that looking at the energy behind engagement. Whether it’s clinician engagement or patient engagement, community engagement, whatever is that I like that uncovering the leadership wherever it happens and then leveraging that forward, which is a tricky dance because people have different motivations and different priorities and different expectations and different bosses themselves. Whether it’s in the family or the organization So yeah, the power dynamic.

Equity. Giving people what they need.

Kirsten Meisinger: I would say any is not to derail you too much, but one of the things that unite people is a common purpose, right? And I think people confuse that with uniformity. So, one of the ways I’ve seen people become their best. And I view my leadership as actually helping, not just getting things out of the way for people. And I think it’s interesting. You would say that because you’re someone who’s going to go somewhere no matter, regardless, right? You’re either going to have to run them over, or people can help get things out of your way, but not everybody is like that. And so, my actual personal view of leadership is to help people achieve their goals as long as they’re aligned with the common goals that we’re all sharing. If you, and so I’ll just, some examples. So many of the providers at my practices have a sort of passion that they rate that brought them into healthcare. One of my providers has an incredibly well-known nutrition blog actually and is incredibly successful at that. And she brings that passion into her patient care. Part of my job is to make sure that part of her, that brought her here in the first place is not destroyed as part of, we’re not going to have it be the Borg and the sameness and right. But now that’s nice, but that’s not your future. You’re going to have to do it this way. Wait, other people actually can’t do much more than what they’re doing for whatever reason in their lives. And so, what I want to do then is allow them to have the space to have their life step forward and then have the job. They are in the backseat for a while. Because remember, we’re in this for the long game, right? All the people here, I’m hoping you will be here for 20, 30 years. So, if I need to give you a little space and you’re not moving, it’s not like I’m getting things out of your way. They can be in your way. You’re not going anywhere. You just have to hold your work almost in stasis while your life progresses. That’s also fine. So, to me, it is complicated. Just like you said, it’s incredibly complicated. And the basis of equity is that you give people what they need. You don’t give people the same thing because they’re not the same.

Key points

Health Hats: Okay. Here’s how I want to end this, I think what you just said, if we were going to say that there are three things that we hope our listeners get out of this conversation. I bet that last statement you made about equity, getting people what they need, which is not the same for everybody, is one of them. I think that the public health view of the organization might be another one. So, do you agree with those two, and what one or two would you add?

Kirsten Meisinger: Oh, I think I agree. I think I might get even a little sillier and say public health and primary care are a superpower, and they’re just a silent superpower. And then I would, I think where we started right, is a deep love and respect. For the patients in patient care that without that, it’s not something worth having. And everyone in the office has an important part in that I often say we don’t know who patients are going to fall in love with. So let them fall in love just to get right. This is where I would say get out of the way.

Health Hats: It’s funny. I worked for a while at Boston Children’s Hospital. I led their patient family experience initiative. And one of the things that amazed me is I would spend some time in the lab. And there were some phlebotomists. People are sticking needles in these kids, who were their favorite person. That just totally blew me away.

Kirsten Meisinger: And to allow everyone to become that favorite person to someone is joy. That is what I hope to achieve someday. I think we’re pretty in love with each other at my cute little site at CHA, and we do genuinely care for each other and our patients. And I do think we have those moments of grace, and it is difficult. To maintain that even within a much larger, less friendly medical system. So, it does sadly feel a bit like a struggle every day, and you have these just unforgettable moments that keep you going

Health Hats: Well, thank you. This has been lovely. I appreciate your time.

Kirsten Meisinger: You’re very welcome. I appreciate you.

Health Hats: Be well, thank you. If there’s anything I can do for you, let me know.

Kirsten Meisinger: It is a pleasure to get to know you better. Thank you for the time. Take care.

Reflection

The challenge of giving a serious nod to engagement is that few of us are prepared for success. Being super engaged in my health means that I’m the CEO of my health team and manage myself and my subcontractors well. It means I have a care partner who can step in when I can’t – a succession plan. It means that I do everything I can to operate at peak performance. All while I’m sick or disabled:( The clinician engaged in their patients’ health means that they solicit and accept their patients’ expertise, and they have the humility to admit how little expertise they have in non-drug, non-surgery treatment, or actually, much outside their specialty – like the reality of people’s day-to-day life challenges. Increasing community engagement in governance, design, operations, and learning leads inevitably to pressure for transparent price lists before service; seamless transition from one setting or clinician to the next; on-demand self-scheduling; patient and clinician-controlled health data sharing; easy, friendly telehealth; access to and payment for non-drug, non-surgery treatments; funding research about outcomes that matter to people, and on and on. Perhaps we need to be more specific about what we mean by engagement. And be prepared for what we wish for.

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Community Engagement – Harmonizing to the Same Tune #150

Danny van Leeuwen

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