On the eastern shores of Lake Michigan, Muskegon, Michigan, has it all: recreation, festivals, a couple of Miss Americas, an Astronaut, actors, musicians, a U.S. ambassador, an NFL quarterback, a wealthy lumber baron, a TV evangelist and others who have achieved in broadcasting, science, technology, literature, and politics. However, the most densely populated city in Michigan (2010 Census, 38,000) has another side, not featured on the local Chamber of Commerce website: Muskegon fell to last in the state for public health. What happened after they hit bottom is when things got interesting.
I might never have heard of Muskegon had it not won one of only five slots for a ten-year cultivation program called the Way to Wellville, created by Esther Dyson. Together, the county is pulling together over a ten-year period to improve key health markers so it can figure out how this and other communities can support a healthier population.
About 18 years ago, Jeff Fortenbacher, now age 55, CEO, Access Health, returned to a suburb of Muskegon after attending college in Florida and spending time away. He got his masters in psychology, and set up shop not far from his father’s foundry, which manufactures metal castings for many different types of products.
Jeff practiced psychology for 10 years, gravitating towards and landing in management/administrative roles, such as his role at his local Health Department. He understands the importance of addressing the psycho-social determinants of illness or health. Muskegon is fertile ground to explore community instances of: alcoholism, depression, homelessness, hopelessness, mental health needs, smoking/tobacco/substance abuse, obesity. It was found to have the highest instance of smoking and obesity in the state.
Local Rotary Makes Community Health a Priority
When the town’s local Rotary made promoting a healthier community a top priority, “Then things started to happen,” Jeff says. “We, as a community started a program here called Access Health that was to provide a community health coverage program to lower income, working, uninsured people.”
Why so many uninsured — and under-insured — working citizens? These are the mom and pop businesses and local contractors and freelancers who work hard every day but don’t have sufficient health care coverage to protect their savings in the event of a catastrophic event. Our approach was to leverage the person’s access to our healthcare services to say you have to be an active participant in your health care.
“We gathered and disseminated data in cooperation with local businesses, the health system, and other community leaders, from religious institutions to local, environmentally conscious groups,” says Jeff. It would help when they donated their staff time to assist with local county contracts.
Jeff applied the lessons learned from his home-care company. He thought, in a sense I have a problem because the symptoms are there for a reason, a lot of times those symptoms are there because of behaviors and other things that need to be addressed.
“As part of that we started to initiate a lot of different education classes, business processes that reinforce multiple interactions with that individual on a yearly basis and also starting to gather the data and metrics around their healthcare and healthcare issues and the psycho-social issues that impact that.”
Under the Access Health model, each person has an individual health coach whom they meet with twice per year. There’s some preventive care and they meet with an exercise physiologist or a trainer. They set goals.
Jeff got help putting the pieces in place from local community participation. He says:
“We have offered a full coverage health coverage program for the last 18 years. For the majority of those years, it was $44 for employees. Then, $44 and through the DISH and the hospital support we’ve covered the other 40% of coverage.”
It is better than overcrowding the Emergency Department, today’s correct term for Emergency Room. Maybe they’re hoping people won’t be able to find it? Under the current system, the hospital is still a profit cetner, rewarded a high dollar value for donating community services. A healthy, fun routine for diabetes prevention instead of waiting and having to amputate? Yes, please.
How Jeff Got on Track
As soon as Jeff knew what he wanted to do for the community, he had no trouble getting support from community leaders, from schools to religious leaders, to the people themselves in the first town hall of its kind in the area. He bought a home-care company. He says: “That’s where I really got on track. As part of the home-care company, I would implement the behavioral health part of stuff.”
Jeff thrives in his medical/psychological practice and likes knowing he is significantly impacting the entire community as part of an effort to “put grains of sand in the engine” of this giant boat that’s been heading in the wrong direction. It takes time to turn it and initiatives to make community behavior healthier.”
He based his practice on asking for referrals of the most difficult patients — the ones always calling their doctors for visits, but were non-compliant. They waste time and money without getting a handle on the factors that have a negative impact on their health.
Jeff says: “If someone’s depressed, helpless, hopeless, isolated, all those things going on why are they going to take their medications as prescribed? They aren’t. They aren’t going to go to treatments either. So, I would go in and we work with them on multiple different things, whether it was financial health, social health, or physical health. Jeff’s multidisciplinary approach required that people agree to engage with their health care.
Jeff’s strategy, individual tracking software, and coaching team for each individual’s active engagement in healthcare reduced spending an average of $70,000-$80,000 in home care services down in to the $15,000-$20,000 range. They kept track of people by requiring several visits a year and telephone intervention and/or personal counseling visits to discuss recurring symptoms. The idea, was not to note that health markers were deteriorating, but to do something about it with a health coach.
His Biggest Mistake
Jeff’s engagement/accountability model was a great idea. Less than a great idea was building his entire caseload around cases with the toughest patients, who required hundreds of initial visits to get them on their est chance for a healthier, sustainable path.
Treating significant psycho/social issues to address did not improve when the healthcare rules changed. People needed time, often hundreds of visits, to scope out a plan with which an individual could live a happier, healthier life. The data collected could help Muskegon with better community practices and leadership fueled by requiring individuals to participate in and take responsibility for their health.
Among the local pilots that didn’t make it long past two years:
Stay Active Muskegon (SAM), which established the expectations of more movement and how to get its community’s people more active as a way to increase local health. It had not been tied to engaging people in healthy routines and holding them accountable for more movement.
Things really started taking off when the local Rotary stepped up healthcare as a priority.
We started the #1 in 21 initiative, Jeff explains. The goal was to be the number one healthiest county in Michigan by 2021. “Well you wouldn’t want to aim for #3, that wouldn’t be as interesting.”
The town kicked off the initiative with a series of billboards that put two objects representing health and unhealthy choices per board — a running shoe and a recliner chair; a cigarette upright next to an asparagus stalk. It was part of a campaign that illustrated how small changes add up to a healthy life. Access Health software feeds in data from individual Fitbits and other devices to maintain a patient overview and early warning system. That’s when a coach is alerted to start a discussion with the insured.
“Under the current fee-for-service system, people chase CPT Codes, which prescribe every procedure a doctor or hospital performs. The CMS is starting to say, we can’t continue doing this. We need a value-based system. We came up with a software system and a way to assign a health risk score to each individual in our system. As they move to a capitated system, which provides a set amount e.g., $300 per member per month to manage this population, healthcare campaigns need optimization. Preventive care, education, support, and accountability are helping Muskegon make small changes that could add up to a community with a healthy population.
Esther Dyson and the Way to Wellville team brought questions to the table to help ensure there was a defined structure around the program — goals, processes, expectations, metrics, and review.
It’s a big topic. Over the past year, year and a half, Esther and Welville have helped the 1 in 21 team to clarify its goals and how it hopes to achieve them. “How are we going to keep it focused? What is the existing capacity — such as Access Health, and what specific things will they do? Led by 1 in 21 coordinator, Jamie Helsen, 1 in 21 will be adding some structure to the program, defining specific metrics, and then looking no just at the leadership but also at bringing the community along to support them.
To date, because of some of the things they’ve done Muskegon has been designated as a States Innovation Model Community/grantee. Esther herself has been instrumental in saying ‘You guys need to do things to get more focused. You have ideas but not total understanding of what it takes to drive and make the changes.’ She reminds us we are dealing with years and years of embedded behaviors and changing direction of a huge ship of generations of culture.
The Wellville Five and the Way to Wellville team will be talking about their progress and learning from their mistakes as well as their successes over the next eight years. By the end, they hope that others will be following their lead in cultivating a healthy population.