50 states of population health

From Alabama to Wyoming, we asked a healthcare leader in the most populous city in every state to name the most pressing health concern facing their patients. Then we asked what they were doing about it. 

The COVID-19 pandemic — along with all of its ramifications for treating other diseases — continued to dominate hospital agendas. Mental health, obesity and substance use disorders were also cited frequently across the country. Social isolation augmented by the pandemic and social determinants of health like food insecurity were concerns for health systems, too. Many hospitals noted that equitable access to healthcare is among their main priorities and methods of treating their patients. 

The following compilation provides a sweeping look at population health — in leaders' own words.

Note: Responses have been lightly edited for length and clarity.


Tracy Doughty. President and COO of Huntsville Hospital.

Question: What is the most pressing health concern facing your patients?

Tracy Doughty: The most pressing issue we are facing would be "How do we effectively staff the hospital moving forward?"  There is a labor shortage in skilled and unskilled workers in our region. The Huntsville metro region has seen record growth over the last five years, and it continues to flourish. There have been many new industries that moved or expanded into our area. These include, but are not limited to: Amazon, Orbital, Blue Origin, Toyota, Mazda, FBI, Polaris, Kohler, Dynetics and Northrop Grumman. Wages are also rising rapidly. Several local companies have raised their base pay, and we have lost workers as a result. In addition, local MD practices, other hospitals in the region, urgent care centers and freestanding imaging centers are seeing increased volumes. This prompts them to recruit our clinical staff away. 

Q: How are you addressing it? 

TD: We are addressing the staffing challenges in multiple ways. We are evaluating pay increases in many areas. As a 24/7 healthcare provider, our organization has placed an emphasis on nights and weekend shifts. These shifts tend to be harder to fill for various reasons. We are reviewing best practices from other healthcare entities and ones from outside of our sector. We are exploring partnering with a school of higher education to create a "Huntsville Hospital"-branded licensed practical nurse school. We also have an healthcare ambassador program that promotes healthcare professions in elementary, middle and high schools. We plan to relaunch this program and make sure area students are aware of all the fields they can consider in a hospital setting.

In addition, we have also noticed that worker expectations are evolving. A single career with set workdays isn't the norm. Many workers have alternative means to supplement their income. Workers of today are searching for more flexibility to promote work/life balance (remote work, alternative schedules), vertical and horizontal career paths and organizational values (community, environmental, diversity and inclusion, etc.).

As we bring in new staff members, we must work hard to keep the current staff that we have.  Our current employees are experts and have a tremendous amount of institutional knowledge.  We have an entire program around this topic. Our retention strategies include, but are not limited to, an RN residency program, career ladders for clinical and nonclinical roles, flexibility, including different work schedules (remote work, create flex schedules), internal workforce development (diversity and inclusion initiative), leadership development/ raining, staff reengagement plans, fun/team-building opportunities, a "Bring Back the Prestige" campaign (with an emphasis on why we choose to work in healthcare) and the continuation of well-being initiatives while exploring new opportunities.


Michael Bernstein, MD. CMO of Providence Alaska (Anchorage).

Question: What is the most pressing health concern facing your patients?  

Dr. Michael Bernstein: Social determinants of health and the impact of disparities on health inequity are a significant area of concern in our state. Housing instability is a particular concern in Anchorage, where in any given year, approximately 8,000 individuals experience homelessness. The high cost of healthcare in Alaska is another top population health issue here.

Q: How are you addressing it? 

MB: Providence is one of the key drivers investing in systems change to end homelessness, including our investment in a permanent supportive housing project and data system that supports evidence-based community strategies to end homelessness. We also partner with other providers in the delivery of a medical respite program and clinical services in local shelters.

Providence is committed to leading the transformation of our healthcare system through the adoption of value-based care models that improve outcomes while addressing the rising costs of care. One recent action we've taken to advance in this area is to create a clinically integrated network — the Alaska Health Alliance with Providence — to support healthcare provider collaboration around clinical quality improvement and sharing of data to coordinate and streamline care for patients.


Steve Purves. President and CEO of Valleywise Health (Phoenix) 

Question: What is the most pressing health concern facing your patients?

Steve Purves: The most pressing health concern facing our patient population is equitable access to healthcare, not just in midst of the pandemic, but also with a declining economy and rising inflation, social determinants of health, such as food and transportation insecurity, have been exacerbated. Patients are putting off healthcare to reprioritize making ends meet. Vulnerable communities were disproportionately affected during the pandemic — first with access to the vaccines and then with access to accurate information about COVID-19 and vaccine safety. 

Q: How are you addressing it? 

SP: Valleywise Health has responded by dramatically expanding access to healthcare to our communities through telehealth and by opening new community health centers in medically underserved areas across Maricopa County. In addition, Valleywise Health provides comprehensive resources and benefits that other systems are unable to offer, such as sliding fee scales, FQHC [Federally Qualified Health Center] family resource centers that offer food programs for families and educational programs for adults and children, extended hours in our primary care clinics, same-day and urgent appointments, specialized programs, such as clinics for refugee women and families and the state's largest primary care clinic for patients with HIV/AIDS. In addition, we have developed partnerships with local community organizations and schools to offer our healthcare resources and outreach through educational campaigns about mask and vaccine safety and efficacy throughout the pandemic. 


Troy Wells. President and CEO of Baptist Health (Little Rock).

Question: What is the most pressing health concern facing your patients? 

Troy Wells: Life expectancy in Arkansas is less than the national average, and that statistic is attributable to more than just traditional healthcare (or lack thereof). The most pressing health concern for our patients today is the ability to achieve equitable health outcomes. Each patient is different and has distinct challenges to be addressed or needs to be met in order to reach a quality of life that is equitable to others. Social determinants of health influence nearly 80 percent of the differences we see in patient outcomes today. Even the best medical care will extend or improve patients' lives less than that of the benefits of addressing factors such as access to nutritious foods, safe housing, language barriers, educational or career opportunities, and a supportive community. Without confronting social determinants, we can't begin to effectively address other pressing concerns such as chronic disease or mental health. Recognizing that, the challenge then becomes changing our approach to care; instead of treating every patient equally, we now must treat patients fairly by addressing the specific circumstances that are impacting their health. 

Q: How are you addressing it? 

TW: Health equity is at the forefront of the strategic work Baptist Health is and will be doing over the coming years. As we are evaluating the communities we serve, specific plans are being developed to address identified needs and social determinants that are impacting the ability for patients to achieve equitable outcomes. In the western region of our system, we recently opened La Clínica del Pueblo, a primary care clinic that aims to help eliminate language barriers for Spanish-speaking residents in that region. Next year, we will be opening a clinic in partnership with Goodwill Industries on their southwest Little Rock campus. This will be a comprehensive clinic that will leverage community partnerships to focus on low-income and uninsured populations. It will offer primary care, dental care, behavioral health and social services such as financial counseling and job training all under one roof. Across our organization, our Food Rx program addresses food insecurities by providing bags of healthy foods to patients and families. This program simultaneously gives us the ability to address those with chronic diseases such as diabetes or hypertension through diet-specific bags. While this is just the beginning, we are confident that this work will help us start to move the needle on achieving more equitable healthcare outcomes for our communities.


Cynthia Litt-Deculus. Chief Population Health Officer and Vice President for Population Health at Cedars-Sinai (Los Angeles).

Caroline Goldzweig, MD. CMO of the Cedars-Sinai Medical Network (Los Angeles).

Question: What is the most pressing health concern facing your patients?  

Cynthia Litt-Deculus and Dr. Caroline Goldzweig: We are seeing significant resurgence of demand for primary care services — preventive screening and management of chronic illness — after nearly two years of care postponement. Not only are there pent up medical needs, but our patients continue to have questions and concerns about how to respond to the ever-changing COVID-19 news cycle. The conversations they are seeking — and deserve to have with their providers — require more than the typical 20-minute follow-up appointment and additional communication. This demand, coupled with a universal healthcare staffing shortage, is challenging to navigate while also balancing the well-being of our staff so they don't become burned out. 

Q: How are you addressing it? 

CL and CG: To balance all of these demands while continuing to provide high-quality care to those in our community who need it, Cedars-Sinai is taking a multipronged approach. We're partnering with a temporary personnel agency to support a more agile staffing replacement and resource model. At the same time, we're actively recruiting additional primary care providers and advanced practice practitioners and allied health staff to support a team-based approach to care. To increase available appointments, we're offering on-demand and scheduled video visits using advanced practice practitioners while also expanding clinic hours. To help address health concerns that could lead to hospitalization if left unattended too long, we're using analytics to identify high-risk patients and prioritize their appointments. Understanding that our providers are working hard to meet all of these increased demands, we're providing them with health and wellness resources.


Amy Scanlan, MD. Medical Director of UCHealth Coordinated Care Colorado (Aurora).

Question: What is the most pressing health concern facing your patients? 

Dr. Amy Scanlan: The COVID-19 pandemic has been one of the most pressing health crises of our time, not only in the morbidity and mortality it has caused, but also in the weaknesses it has exposed in our population's overall general health. One area in particular exposed as needing more attention is mental health. Rates of anxiety and depression skyrocketed as patients faced loss, grief and isolation. Lack of access to mental health services worsened all of the physical consequences of the pandemic. As we go forward, healthcare must address the lack of access to good behavioral health services.

Q: How are you addressing it? 

AS: Access to behavioral health services leads to better physical health and lower overall health care costs. UCHealth is investing $150 million over five years to improve patients' access to care and remove the stigma associated with behavioral health by embedding services in our primary care clinics. These efforts will help us to identify behavioral health concerns early and increase our ability to affect better patient outcomes. UCHealth's initiative integrates behavioral healthcare with our primary care services, expands virtual behavioral health services, builds a new inpatient behavioral health unit, and invests in the Center for Dependency, Addiction and Rehabilitation, which is UCHealth's residential and outpatient treatment center.


Anne Diamond. President of Bridgeport Hospital.

Question: What is the most pressing health concern facing your patients?

Anne Diamond: Access to care.

Q: How are you addressing it? 

AD: Even before the COVID-19 pandemic reached Connecticut in early 2020, Bridgeport Hospital was exploring ways to improve care for its patients. COVID-19 has only magnified the challenges facing patients. The hospital recognized there was a growing number of people living with complex care needs characterized by multimorbidity, mental health challenges and social vulnerability. These patients often experience increased emergency room use and hospitalizations. They also often have gaps in care resulting in delays in preventive services.

It was clear that these patients required integration of health and social care beyond traditional medical services to address their health needs and social determinants. With this, the Complex Care Management Team was developed. This team provides care to patients who meet criteria for the program and are receiving primary care services at the Bridgeport Hospital Primary Care Center. The team consists of a nurse care coordinator, social worker, pharmacist, patient navigator, medical advanced practice registered nurse and a psychiatric APRN. This Complex Care Team model provides consistency of care, more intensive follow-up and management while recognizing that patients are equal partners and a vital part of their care team. 

The Complex Care Team has enrolled nearly 100 patients to date. Nineteen patients have graduated from the program, all with an A1C count of less than 8, and are at goal for diabetes control. The patients currently enrolled are showing consistent improvement in their A1Cs. Of all patients enrolled, 72 percent have blood pressure control, and 86 percent completed their breast cancer screenings. They have a pneumonia vaccination rate of 88 percent and a depression screening rate of 100 percent. Emergency room visits pre- and postenrollment have decreased from 266 to 115, and hospitalizations decreased from 128 to 75. All patients in this program receive a social determinants of health screening pre- and postenrollment as well. The team has been able to address, and in many cases eliminate, barriers related to patients' housing, transportation, food insecurity and financial needs.

The Complex Care Team was also fortunate to be able to pilot a medically tailored meals program to a select group of enrolled patients. Funding for the pilot came from the Bridgeport Hospital Foundation and consisted of a two-month trial that provided lunch and dinner seven days a week. This program provided additional support to patients struggling with food insecurities while also providing education on food choices for these meals with the assistance of a nutritionist.


Christine Donohue-Henry, MD. Chief Population Health Officer at ChristianaCare (Newark).

Question: What is the most pressing health concern facing your patients? 

Dr. Christine Donohue-Henry: At ChristianaCare, we're heavily focused on identifying and eliminating health disparities. The pandemic has helped to highlight the extent to which Black, Hispanic/Latino and other underserved populations are less likely to have access to quality healthcare, health insurance, and linguistically and culturally sensitive healthcare.

Q: How are you addressing it?

CD: Onthe clinical side, our efforts focus on achieving health equity through identifying our neighboring communities in Wilmington with the greatest need and ensuring that they have ease of access to resources. In many ways, that means that we proactively go into the community to deliver those resources, which can range from the availability of our school-based health centers to community events where we offer vaccinations to protect people from COVID-19.

It also means training our workforce to ensure that they are aware of their own biases and are providing care of the highest quality to patients no matter their race. Our Institute for Research on Equity and Community, known as iREACH, whose caregivers represent diverse group of experts in epidemiology, biostatistics, program evaluation, and data management, partner closely with our organization's population health, community health, health equity and virtual health programs to work on the toughest clinical challenges.

On the workforce side, it is important that the diversity of our workforce reflects the diversity of our community. We continue to train our leadership on hiring in a way that safeguards from implicit bias, and we invest resources in cultural sensitivity and diversification training to make ChristianaCare a more inclusive place to work. We also are partnering with historically Black colleges and universities in our area to identify talent and increase the diversification of our clinical caregivers.


Russ Armistead. CEO of UF Health Jacksonville.

Question: What is the most pressing health concern facing your patients?  

Russ Armistead: Health issues made potentially more severe because some patients may be delaying care because of concerns about COVID, a possible loss of health insurance related to employment, and other issues, including mental health.

Q: How are you addressing it? 

RA: We continue to urge patients to seek preventive and, more urgently, emergency care despite the pandemic. We are also working to accommodate as many patients as possible, in our hospitals and clinics, over the coming months to help them meet their healthcare needs.


Jennifer Farlow, BSN, RN. Director of Population Health at Piedmont Healthcare (Atlanta).

Question: What is the most pressing health concern facing your patients?

Jennifer Farlow: In light of the COVID-19 pandemic, Piedmont, similar to many other health systems across the country, saw a decrease in preventive screenings and patients hesitant to attend routine follow-up appointments with their physicians. For those living with chronic conditions, this was concerning as it led to potential downstream impacts of lower adherence in addressing gaps in care and also the potential increase of risks for acute, costly and sometimes even catastrophic events such as heart attack or stroke. 

In turn, we responded to the healthcare needs and rapidly made revolutionary changes in how we deliver medicine and meeting patients where they are: in their homes. Piedmont has launched a telehealth program that has sustained and grown throughout the last few years. 

Furthermore, we're exploring other technology solutions to create greater efficiencies in our work and our ability to expand our reach to vulnerable patients by using various email campaigns, self-scheduling initiatives and e-check-in functionality. Our multidisciplinary population health team is also proactively targeting patients who are both rising in risk and who are high risk to ensure they are receiving appropriate and timely medical care and empowering them to be engaged with their health. We're also exploring predictive analytics tools to further refine our identification process to ensure we're reaching the right patients early, allowing for timely interventions and, in turn, better patient outcomes. 

Furthermore, we have physician-led task forces to focus attention on chronic conditions such as diabetes or hypertension to align quality metrics to provider performance and ensure evidence-based measure adherence across the network. Another pressing health concern has been the increasing behavioral health and substance abuse needs. 

Q: How are you addressing it?

JF: Our primary care providers focus on PHQ-2 depression screenings at every encounter and actively seek connecting patient needs with the strained network of community resources. In addition, social determinants of health is an area of focus as SDOH can have negative impacts on patient outcomes. We've implemented an SDOH screening tool within our EHR across all settings of care, and [we are] looking into vendors who can supplement community resources and other tools to address these barriers to care. Because of this global growing need in the community, we are finding that resources can be limited or that it has resulted in lengthy wait times. Consequently, we are working to expand our access to various referral sources. We've even partnered with various payers to leverage their resources to offer to patients as well.  


Whitney Limm, MD. Executive Vice President of Clinical Integration and Chief Physician Executive at the Queen's Health Systems (Honolulu).

Question: What is the most pressing health concern facing your patients?

Dr. Whitney Limm: Hawaii's most pressing healthcare issues include a growing geriatric population, substandard health outcomes among Native Hawaiian/Pacific Islander populations, worsening poverty in the face of the COVID-19 pandemic, and inefficiencies affecting care access and delivery. The confluence of these factors has led the Queen's Health Systems to focus its efforts on the state's most vulnerable populations. True to Queen Emma's mission, the healthcare system proudly cares for all of the people of Hawaii, regardless of circumstance.

Q: How are you addressing it? 

WL: One of the system's primary vehicles to support the health and well-being of Hawaii's population is Queen's Clinically Integrated Physician Network, a clinically integrated network that represents more than 1,200 providers and their patients across the state. QCIPN addresses Hawaii's most pressing healthcare issues across four core care domains — access, quality, efficiency and equity. Specifically, QCIPN improves access to high-quality, patient-centric care with a strong focus on primary care across the state's islands, addresses social determinants of health that reside beyond clinic and hospital walls, reduces care fragmentation through effective care coordination and navigation, prevents unwanted and unnecessary care for its population, promotes equity through culturally sensitive care, and alleviates administrative burden to its providers. Some of the system's notable efforts include: providing home-based primary care for frail and elderly patients who may have trouble accessing the clinic setting; improving access to virtual care through ensuring providers and patients are equipped with the tools and comfort to engage in telehealth; connecting high-risk patients who frequently visit the emergency room to community health navigators who address their social and health needs; and reducing unnecessary readmissions through ensuring that those who are discharged from the hospital have safe and smooth transitions to home. QCIPN's services facilitate our patients receiving the right care in the right place at the right time.


Frank Johnson, MD. CMO of St. Luke's Health System (Boise, Elmore and McCall).

Question: What is the most pressing health concern facing your patients?

Frank Johnson: "How can I afford the healthcare I and my family need?" When insurance premiums, out-of-pocket deductibles and copays outpace the annual discretionary income for most Idahoans, we have a problem. Concerns over affordability place additional barriers to access, which is already a challenge due in part to Boise's relative isolation from other major cities and Idaho's low ratio of physicians to population. Our patients assume great quality in the care they receive — and at St. Luke's Health System I'm proud to say we deliver on that expectation — but when our neighbors delay needed care through either circumstance or choice, it increases the burden of illness and disability for families, our communities and our healthcare resources.

Q: How are you addressing it?

 FJ: At St. Luke's Health System, we are working to address affordability by aggressively increasing value-based care contracting through St. Luke's Health Partners clinically and financially integrated network; establishing a standardized, uniform reimbursement rate across all payer partners and locations within the St. Luke's Health Partners network; contracting with Idaho Medicaid as a VCO (through St. Luke's Health Partners network); expanding the use of telemedicine services to the critical access hospitals and rural clinics within our health system; and aligning system population health, affordability and access goals with provider compensation. 

Additionally, we are engaging in partnerships around community health to address the social factors that lead to increased costs for Idaho families and investing in our people to build the competencies and engagement needed to achieve success.

None of these are new or profound ideas, but in spite of the headwinds we all face that threaten our ability to deliver on our promises, I'm grateful that we at St. Luke's have seen early success. In many cases we have been able to maintain, or even reduce, insurance premiums and to reduce the overall cost of medications for our patients. 


Tom Jackiewicz. President of University of Chicago Medical Center and COO of UChicago Medicine.

Question: What is the most pressing health concern facing your patients?

Tom Jackiewicz: Health inequity is a major concern of ours. Chicago's South Side is a storied collection of vibrant, resilient, culturally rich and diverse neighborhoods. Against this backdrop also lies one of the nation's largest underserved communities, where its residents are disproportionately afflicted by chronic diseases and other complicated public health concerns and where convenient access to quality care has been a challenge.

As an academic health system on the South Side, the University of Chicago Medicine recognizes that many of our patients face a variety of health disparities, the roots of which are born from systemic racism, poverty and generations of health inequity. As the COVID-19 pandemic has made clear, patients of color are far more likely to be on the losing side of the economic divide. That leads to poorer health outcomes and increased rates of chronic illnesses. Without targeted interventions to address the social determinants of health — and substantial work to address intentional violence — our patients remain at continual risk from the public health crisis. 

Q: How are you addressing it?

TJ: UChicago Medicine is committed to ensuring our patients have the best clinical outcomes, regardless of race, sex, geography, socioeconomic status or sexual orientation. Knowing we can't move this needle alone, we're working with community hospitals, safety-nets, federally qualified health centers and others in the region to add more clinicians to the South Side and expand access to quality healthcare in our region. Additionally, we're creating targeted clinical programs — such as sickle cell treatment — that are designed to help patients before they need urgent or emergent medical care. Meanwhile, our violence intervention and recovery programs provide intensive wraparound services to victims of violence to promote comprehensive recovery and reduce risks of re-injury.

Beyond our community-based work, we're also addressing health equity internally. We place an equity lens over our organizational quality measures, which allows us to view data by sex, ethnicity, ZIP code and even payer type. And we're driving equity, inclusion and diversity through our workforce development efforts as we strive to ensure our students, trainees, faculty and staff are diverse and reflective of the communities we serve.


David Ingram, MD. Executive Vice President and CMO of Indiana University Health (Indianapolis).

Question: What is the most pressing health concern facing your patients?

Dr. David Ingram: The COVID-19 pandemic has only served to complicate Indiana's primary healthcare challenge: health outcomes that rank among the nation's worst. In multiple key health measures, Indiana ranks in the bottom fifth among the states, including poor performance for diabetes, obesity, tobacco use and COPD, according to America's Health Rankings. The pressing need for hospitals and other healthcare providers in Indiana remains to confront the chronic conditions so many of Indiana's residents face. That requires addressing the unhealthy behaviors, lifestyles and environmental and workplace factors that contribute to the state's undesirable health outcomes.

Q: How are you addressing it? 

DI: At Indiana University Health and many other health systems around the state, we continue to make inroads even in the throes of a two-year pandemic. To supplement the statewide anti-tobacco effort, IU Health organized a centralized tobacco treatment program that has seen a high engagement rate of patients referred to follow-up appointments with a tobacco treatment specialist. This successful virtual integrated care model will soon be expanded to broader non-medical needs of our patients. Using embedded and virtual medical social workers, our primary care providers will be able to refer eligible patients to social services in their communities for assistance with issues such as housing, transportation and access to healthy food.

We have used technology to connect primary care offices with a virtual integrated behavioral health team, staffed by providers who can address both acute and chronic behavioral health issues for patients. In addition, IU Health created a community impact investment fund, endowed with $100 million, to work with local service organizations around the state to address urgent human needs, such as affordable housing and educational attainment. So far the fund has awarded almost $12 million to dozens of organizations across the state.


Derek Novak. President of MercyOne's Population Health Services Organization (Des Moines).

Question: What is the most pressing health concern facing your patients?

Derek Novak: MercyOne has often found the most pressing health concern facing our patients is the need to prioritize social factors as they relate to their care. We are finding nearly 70 percent of Americans are experiencing a social challenge, which could negatively impact their health. Two of these major social factors shared by our patients in Iowa include food insecurity and social isolation (loneliness).

Throughout the pandemic, Iowa has seen a more than 50 percent increase in food insecurity, accompanied by nearly one in 10 of our patients reporting feelings of social isolation.

Q: How are you addressing it? 

DN: As part of our mission to transform the health of our communities, MercyOne, through the MercyOne Population Health Services Organization, helps navigate whole-person care for more than 1 in 10 Iowans under its value-based care agreements. In recent years, MercyOne has worked to expand its integrated care model to include Community Health Workers and build partnerships with community organizations.

MercyOne Community Health Workers are embedded within primary care clinics and function as members of the MercyOne''s Population Health Services Organization interdisciplinary care management team. They also facilitate universal screening for social determinants of health and partner with patients to identify and access resources within the community. As a result, MercyOne is not only able to address clinical care but also social factors impacting a patient''s health.


Don King. Senior Vice President at Ascension and Kansas Ministry Market Executive at Ascension Via Christi CEO (Wichita).

Question: What is the most pressing health concern facing your patients?

Don King: Ascension Via Christi, the largest provider of healthcare services in Kansas, operates seven hospitals and 75 other sites of care and employs nearly 6,400 associates. Across the state, our faith-based organization provided nearly $89 million in community benefits and care of persons living in poverty in fiscal year 2021.

The most pressing concern for our patients and for the caregivers in our hospitals, ERs, and outpatient and urgent care clinics is helping ensure patients' access to the right care at the right time and in the most appropriate setting for their needs. This is a longstanding challenge that has become even more vitally important during the nearly two years of the COVID-19 pandemic. The pandemic also has intensified the desperate need for behavioral health services, as evidenced by the alarming number of people seeking crisis care in our ERs.

Q: How are you addressing it? 

DK: We began preparing for our pandemic response before we saw the first cases, which helped position us to offer virtual care options for physician visits and consults. We also converted all of our childbirth and new parent education classes to virtual offerings, making sure expectant parents were not isolated and lacking in the education they needed to get off to a good start. Those classes, offered at no cost, now are supporting new parents from throughout the entire Ascension ministry nationwide.

We continue to work through the Sedgwick County Mental Health and Substance Abuse Coalition, in which we are a founding partner, to identify community solutions to the behavioral health challenges being felt statewide.

We also continue to work with rural Kansas communities to restore access to critically needed services after the sudden closures of their struggling community hospitals leaving entire counties without an ER. For example, we have opened 24/7 Emergency Departments in Fort Scott and Wellington, Kan., which are operated as departments of our hospitals in Pittsburgh and Wichita. This new model of care for our organization allows patients to receive timely care in an emergency in the most convenient place — their home community.

During the past two years, we have continued to provide high-quality care to thousands of patients battling COVID-19, a patient population that did not previously exist. We have done so despite the financial challenges of Kansas being one of only three states in the Midwest that has refused to expand Medicaid. We created capacity in our Wichita and Pittsburgh hospitals by being one of the few in the region to provide monoclonal antibody therapy, helping avoid the need for hospitalization. In Wichita alone, we have provided monoclonal antibody infusions to more than 1,000 COVID-19 patients at high risk for serious illness; only 25 later required admission to our hospitals.

In summary, we are listening to patients and caregivers to determine their preferences and identify any barriers to access. We are then using information gleaned from these conversations to adapt our service delivery models to best meet the needs of patients throughout the communities we serve. It is an enormous undertaking, but it is in keeping with our mission of delivering compassionate, personalized care to all, with special attention to persons living in poverty and those most vulnerable.


Russell F. Cox. President and CEO of Norton Healthcare (Louisville). 

Question: What is the most pressing health concern facing your patients? 

Russell Cox: COVID-19 aside, access to healthcare is a health concern facing too many people in today's society. When considering the mission of most healthcare systems to meet the healthcare needs of everyone within its community, we must take steps to ensure healthcare is not just a privilege for some, but a right for all. We are committed to doing what is necessary so that everyone has access to the healthcare they need.

We believe equity can be achieved only when every person has a fair opportunity to achieve their full health potential.

Q: How are you addressing it? 

RC: We have been working on increased access to healthcare, but in June 2020, I outlined imperatives for our organization in order to make true progress in addressing health and racial inequities. Much has been accomplished since the announcement. We recently celebrated the grand opening of our Institute for Health Equity in its permanent location in Louisville's West End, an area of the city with less access to healthcare resources due to multiple challenges, including transportation, housing, education, child care, food insecurity and employment. The purpose of the institute is to partner with others to identify and remove obstacles that prevent people from receiving the healthcare they deserve, as well as to eliminate disparities in care. 

We have expanded primary care services and access to testing and vaccinations in underserved areas and recently opened our first fully bilingual clinic for the Latinx community. With a $1.25 million grant from the Norton Healthcare Foundation, we purchased a second mobile prevention center to make it easier for community members who live in areas of our city that demonstrate a disproportionate share of health challenges to receive services such as mammograms, well-woman exams and colon cancer screenings. Additional permanent sites are planned in west and south Louisville to further expand access to care.


Greg Feirn. CEO of LCMC Health (New Orleans).

Question: What is the most pressing health concern facing your patients?

Greg Feirn: Patients want personal service — but not at the detriment of their health and safety.

Q: How are you addressing it? 

GF: LCMC Health is always looking to enhance the patient experience, both inside and outside hospital walls. Recent enhancements include:

  • $300 million expansion of Children's Hospital New Orleans to include one of the largest and most comprehensive freestanding behavioral health programs in the nation, leading the way in delivering healthier, happier experiences for Louisiana’s children and enhancing the quality of life for patients and families
  • The implementation of telehealth services and the nurse hotline to ensure convenient one-on-one virtual care and consultative services

Continuous expansion of healthcare beyond hospital walls to meet patients where they are, providing essential access to services, including drive-thru screenings, mass COVID-19 vaccinations sites and other off-site programming to offer convenient care for the community are all part of these enhancements.


Dora Anne Mills, MD. Chief Health Improvement Officer of MaineHealth (Portland).

Question: What is the most pressing health concern facing your patients?

Dr. Dora Anne Mills: Because MaineHealth's vision is "Working together so our communities are the healthiest in America," population health is at the core of who we are and what we do. Our community health needs assessment process has shown social determinants of health, mental health, addiction, other chronic diseases (e.g. cardiovascular disease, cancer and diabetes), tobacco, and obesity to be the major health issues facing our communities. However, in looking more closely at the data, we see these issues overlap a great deal. For instance, someone facing poverty and food insecurity is also more likely to be suffering from obesity and diabetes, given that foods with poor nutritional value (which are more likely to cause diabetes) are also more likely to be the most affordable foods. Another example is that when we help our communities become more walkable to address obesity, we also address a variety of aspects of mental health, since people are more likely to spend more time outside and socialize. 

Q: How are you addressing it? 

DAM: As a result of these insights, we're taking a multipronged approach and intentionally addressing several of these priorities in an integrated way. For instance, our chronic disease self-management classes for those living with low incomes also include food from our food pantry, cooking classes using SNAP-Ed, and a facilitator who builds peer support among the participants. Instead of offering the usual six weeks of classes, we're offering these weekly classes over several months in order to build a sense of community that is important for people living with multiple challenges who are addressing major changes. Given the pandemic, we are increasingly integrating aspects of emotional health, especially addressing isolation, in all that we do. For instance, our MOM Program (Maternal Opioid Misuse Program), for pregnant and postpartum people with substance use disorder, also uses groups that build peer support and a sense of community and addresses people's emotional health as well as the physical health challenges they're facing. We believe comprehensive and integrated strategies are key to addressing our top population health challenges. 


Scott Berkowitz, MD. Chief Population Health Officer and Vice President of Population Health at Johns Hopkins Medicine (Baltimore).

Question: What is the most pressing health concern facing your patients?

Dr. Scott Berkowitz: One of the most pressing concerns facing our patients, as well as those throughout Maryland and the U.S. today, is the rise in mental health needs, including, among others, mood and anxiety disorders, opiate and other substance use disorders, the effects of chronic stress and suicidality. In addition, there is an increased demand in behavioral health needs for children and adolescents. The COVID-19 pandemic has exacerbated underlying needs across the population, and recently, the U.S. surgeon general has issued an advisory related to mental health challenges among our youth. The rise in demand for mental health services has exceeded the ability of the system and safety net to keep pace, and has exacerbated underlying disparities in disadvantaged communities. Maryland has taken significant steps over the last few years through various state-sponsored initiatives to provide additional care; however, despite these efforts, behavioral health remains a significant need.  

Q: How are you addressing it? 

SB: The state of Maryland has taken steps to bolster investments in behavioral health within primary care practices for Medicare beneficiaries. Johns Hopkins Medicine has seized upon this opportunity to further develop care programs for patients with behavioral health needs.  Through the Maryland Primary Care Program, a component of the state of Maryland waiver, Johns Hopkins Medicine Alliance for Patients receives dollars to invest in improving patient care, and one area of focus has been integration of behavioral health services. Mental health teams consisting of licensed clinical social workers or professional counselors, with oversight from psychiatrists from Johns Hopkins University's department of psychiatry and behavioral sciences, deliver behavioral health services. In addition to providing ongoing education, liaison and curbside support to primary care teams, the mental health teams provide evaluation, care, pharmacological guidance and referral services for patients with anxiety, depression or substance abuse disorders, among other conditions. We recently surveyed our primary care providers, and one identified need was the ability to provide these behavioral health services to benefit all patients, irrespective of payer. We are optimistic that program expansion across payers will further this effort and are simultaneously working to develop alternative options to address this gap.  

In addition, through a Maryland health services cost review commission initiative, with a broad coalition of 17 hospitals (including three JHM hospitals), four local behavioral health authorities, and many behavioral health experts and community leaders, the Greater Baltimore Regional Integrated Crisis System partnership was established to promote response for acute mental health crises in Maryland. This effort will utilize a regional hotline, expanded mobile crisis teams, and faster access to community providers to reduce avoidable emergency department use and police involvement for people experiencing mental health crisis, while promoting further education around these efforts. This initiative is based on the national "crisis now" model and reinforces the notion that it "takes a village" to combat the growing local, state and national mental health crisis.   

Dr. Berkowitz wishes to acknowledge Scott Feeser, MD, Kostas Lyketsos, MD, and Nicki McCann from Johns Hopkins Medicine for their helpful input.   


Shelly Anderson. Executive Vice President and COO of Brigham and Women's Hospital (Boston). 

Question: What is the most pressing health concern facing your patients?

Shelly Anderson: The most pressing health concern at Brigham and Women's Hospital is the care that was deferred through the first two waves of the pandemic, seen in the increased acuity of patients requiring treatment/services for cardiovascular, cancer and orthopedic conditions.  Chronic disease management for cardiovascular conditions, diabetes and mental health continue to be a primary need and focus.

Q: How are you addressing it? 

SA: We are managing capacity in light of the increased acuity and staffing challenges with the sole purpose of meeting the demand due to deferred care in as timely a way as possible. From a mental health perspective, our integrated health system, Mass General Brigham, just initiated a new $50 million investment in a comprehensive community and mental health initiative in partnership with 20 community-based organizations that will expand our impact in local neighborhoods.


Kenneth Berkovitz, MD, FACC. Senior Vice President at Ascension and Ministry Market Executive at Ascension Michigan.

Question: What is the most pressing health concern facing your patients?

Dr. Kenneth Berkovitz: Ascension Michigan is continuing to manage the impact of the ongoing COVID-19 health crisis, not only in diagnosing and caring for those with COVID-19, but in the delay in seeking care by those suffering from non-COVID related diseases. 

According to recent national poll data, nearly one in five American households has delayed care for serious illnesses during the pandemic. This is due, in part, to fear of contracting COVID-19 in health facilities, as well as early lockdown mitigation strategies put in place to help control the spread of the virus. Delays in screenings and care have led to higher-acuity patients, requiring more intensive care across our health facilities, stressing our systems of care and often leading to outcomes that could have been improved with proper screening and/or chronic disease care management. 

Compounding these issues, access has become a concern as hospitals and ambulatory practices have needed to adjust workflows and capacity to accommodate and address increased acute patient care needs. 

All of these factors have amplified a delay in diagnosing, preventing and managing chronic disease and serious illness across the communities we are privileged to serve.

Q: How are you addressing it? 

KB: Ascension Michigan has been focused on utilizing our secure and robust virtual care platforms to safely care for patients via virtual visits and telemedicine monitoring technologies. We are fortunate we had an expansive virtual care platform in place before the start of the pandemic, and are grateful and optimistic about how it has been used extensively by our patients over the course of the last two years. 

People are becoming much more comfortable with receiving care virtually and are beginning to trust the comprehensiveness it can provide and the ease of use it offers. Virtual provider visits, virtual urgent care visits and telemedicine options in both our acute and home care settings will continue to be integral to how we provide care. 

As we expand the use of these virtual services across our patient populations — especially those managing chronic disease — we will be able to identify and diagnose potential health issues earlier, improving outcomes and avoiding the need for higher-acuity care.

In addition, we continue to stress the importance of not delaying care through multiple internal and external communication methods and channels, tasking our community members and nearly 23,000 statewide Ascension Michigan associates with checking on loved ones and ensuring they are getting the care they need when they need it.


Allina Health

Question: What is the most pressing health concern facing your patients?

Allina Health: Undeniably, the most pressing issue across Minnesota is the impact that the COVID-19 pandemic is having on the health of our communities, either directly from COVID-19 or indirectly through delayed care and preventive screenings and through increased incidences of mental illness, addiction and social isolation.  Across all of our communities, mental illness and substance use are pressing concerns highlighted in our community health needs assessment, and our communities see mental illness and substance use as highly interconnected with one another. Access to care is a key concern due to both limited availability of services and stigma associated with seeking care. Social isolation and social determinants of health are key contributors to mental illness and substance use concerns — both which have been further exacerbated by the pandemic.

Q: How are you addressing it? 

AH: To provide support around social isolation and other health-related social needs, Allina Health will be implementing a universal social determinants of health screening and intervention model across the organization in 2022. This social determinants of health model will build off of Allina Health's involvement in the Accountable Health Communities model (ending in April of 2022), CMS' cooperative agreement testing whether systematically identifying and addressing health-related social needs impacts healthcare quality, utilization and cost.

As the pandemic has increased the mental illness and addiction needs of our communities, it has also enabled us to accelerate and increase our mental health and addiction services by expanding the size and reach of partial-hospital and day treatment programs by 30 percent year over year and by growing our outpatient care services by 12 percent year over year. We now provide hybrid virtual care throughout the entire ambulatory continuum. Additionally, we have built a virtual addiction "front-door" program that spans the system and allows for access to specialized assessment/intervention/referral and medication-assisted treatment. We have deployed a virtual cognitive behavioral therapy platform prescribed by primary care and coached by our team to expand upstream access. In addition, we have deepened our investment in integrated primary care with 31 licensed clinical social workers, 80 psychologists and 15 psychiatrists embedded in primary care. Lastly, we have increased active treatment in 12 emergency departments, particularly focusing on enhanced suicide prevention and safety planning to focus on acute crises with 24/7 care.


Baptist Memorial Health Care (Jackson).

Question: What is the most pressing health concern facing your patients?

Baptist Memorial Health Care: Mississippi Baptist Medical Center conducts a community health needs assessment every three years to determine the most pressing health needs in the region. Through feedback from community partners and stakeholders, Baptist has prioritized the areas'' top health concerns into four primary areas: cancer, chronic disease, maternal and child health, and behavioral health. Our key initiatives are developed to strategically align with these needs and include improving access to high-quality healthcare and developing meaningful community partnerships. For example, in 2020 the hospital introduced a mobile mammography unit that provides affordable, convenient and lifesaving breast cancer screenings to Mississippi's rural communities. Baptist also provides healthcare to underserved and uninsured members of the community through subsidized services, such as emergency care, and free or reduced-cost preventive screenings that are essential for health but not adequately covered by federal and state funding. With the goal of reducing Mississippi''s shortage of medical professionals, Baptist provides clinical training opportunities for emerging healthcare professionals and encourages students to pursue medicine, nursing and other allied health careers.

Q: How are you addressing it? 

BMHC: Baptist collaborates with a number of community service organizations that have expertise in social needs, specialty services, faith leadership, advocacy and essential resources. Through these partnerships, low-income, uninsured and vulnerable community members receive free primary care, disease management support and prevention education, as well as access to nutritious foods, transportation and lodging — among other resources — when undergoing treatment. 


Daphne Bascom, MD, PhD. Vice President of Population Health at Saint Luke's Health System (Kansas City).

Question: What is the most pressing health concern facing your patients?

Dr. Daphne Bascom: There are two connected health concerns that are impacting patients at Saint Luke's Health System: a continued increase in the number of patients with chronic disease, especially cardiometabolic disease; and creation of partnerships and strategies to improve our community ecosystem to promote health.

Q: How are you addressing it? 

DB: Cardiometabolic diseases represent a spectrum of interrelated conditions, including hypertension, insulin resistance, obesity and hyperlipidemia that are a major cause of morbidity and mortality in Kansas City, in the U.S. and globally. Some of the major risk factors for developing cardiometabolic diseases include physical inactivity, smoking and an unhealthy diet. Primary prevention for cardiometabolic disease begins with our youth and in our community. Once the disease has become manifest, optimal management is key.

SLHS is focusing on primary and secondary prevention of cardiometabolic diseases. Under the leadership of Mikhail Kosiborod, MD, Melissa Magwire, MSN, RN, and the care teams at the Haverty Cardiometabolic Center, SLHS has become a leader in the management of patients with cardiometabolic disease. Dr. Kosiborod''s work has resulted in the launch of the national Cardiometabolic Center Alliance which provides members with training, protocols and materials to launch local centers of excellence related to cardiometabolic disease at their health systems. The team at the Haverty Cardiometabolic Center has developed patient-centric, team-based protocols that help patients better manage their conditions, improve quality of life and reduce the overall cost of care.

SLHS is also developing programs to address the primary prevention of cardiometabolic disease. We have partnered with community agencies such as the Boys and Girls Club of Greater Kansas City, Harvester's [food assistance program] and KC Care Health Center to implement community-based programs that focus on non-clinical factors that may reduce the risk of cardiometabolic disease:  access to nutritious and affordable food, safe places to be physically active, reducing or eliminating the use of tobacco and vaping products, and connecting with others to form a cohesive social network. 


Scott Ellner, DO. CEO of Billings Clinic

Question: What is the most pressing health concern facing your patients?

Dr. Scott Ellner: Timely access to mental health services is a significant issue and major challenge for many people in our region. Billings Clinic serves a huge geographic region that includes Montana, Wyoming and the western Dakotas. Much of that area is rural, with long distances between health care services, including mental health services. It’s often a very real challenge to bring mental health professionals into smaller communities and as a result, that leaves so many of these areas without services close to home. This is only exacerbated by the ongoing national shortage of mental health professionals, especially psychiatrists. But it’s not just an issue in rural areas. In Yellowstone County, which is the most populous in Montana and where our largest hospital is located, nearly 85 percent of those involved in a recent population health survey of community stakeholders identified mental health as a major problem in our area, while an estimated 1 in 5 residents identified their mental health state as poor or fair. Both Montana and Wyoming have tragically been at or near the top of national suicide rates for decades, with Montana’s 26.7 suicide deaths per 100,000 people nearly double the national average of 13.6.

Q: How are you addressing it? 

SE: Meeting the mental health needs of a large population over a huge geographic area takes a thoughtful, multifaceted, and often creative approach. We have to meet people where they are while also making sure we’ve got the support and resources within our system to take care of them when they need us. For those patients with the most acute needs, Billings Clinic operates a 44-bed inpatient adult and youth psychiatric unit, the only such care unit in Eastern Montana. We also offer outpatient behavioral health services and our psychiatry department includes psychiatrists, advanced practice providers, counselors, nurses and numerous support staff. But we know that people may not always be able to make it to us, and to help meet that need we also offer multiple telehealth services. This includes virtual patient visits, consultation with health care professionals at other facilities and Project ECHO, a collaborative virtual service that brings together clinicians from multiple organizations across Montana to improve mental health care through shared knowledge, expanded treatment options and peer support. To bolster mental health services and with the goal of attracting more psychiatrists to serve in rural areas, we have also created Montana’s first and only psychiatry residency program in collaboration with the University of Washington. The first class of residents arrived in Billings in the summer of 2021. It’s also worth noting that advocacy is incredibly important to lasting and effective solutions and to that end, and being active in both community-wide efforts and supporting policy and legislation that bolsters mental health services or resources will always be a top priority.


Stephen Mohring, MD. Medical Director of Population Health at Nebraska Medicine (Omaha).

Question: What is the most pressing health concern facing your patients? 

Dr. Stephen Mohring: The most significant issue facing our patient population is the obesity epidemic and the myriad complications that are related to it. Weight and inactivity not only are a principal cause of conditions such as diabetes and hypertension but are also the chief reasons for the disease-related complications of chronic heart, kidney and liver disease. Lack of diabetes control is a significant cause of morbidity related to vision problems, painful neuropathy and diabetic wounds leading to infections and amputation, as well. From a population perspective, lifestyle choices around proper nutrition and exercise carry the largest potential for benefit in both disease prevention and chronic complications. 

Q: How are you addressing it? 

SM: From a health system perspective, we have added layers of support — such as health maintenance alerts, physician dashboards, care gap lists, patient letters and messages — to try and make missing preventive services and disease screenings a "never event." We message the importance of a strong patient-PCP relationship and encourage regularly scheduled office visits. We discuss dietary choices and exercise habits during each visit and have nutrition counseling services available in each of our primary care clinics. These conversations may be the only opportunity we have to change a patient''s health journey before it's too late.  

The important thing to remember is that we didn't happen into this epidemic overnight; thus, it will take a multidisciplinary focused effort to stem the tide and improve health outcomes. 


Tony Slonim, MD, DrPH. President and CEO of Renown Health (Reno).

Question: What is the most pressing health concern facing your patients?

Dr. Tony Slonim: Renown Health is a not-for-profit healthcare network with an integrated provider-sponsored health plan serving a population in excess of 750,000 in a 17-county area in northern Nevada, the Lake Tahoe area and northeastern California, welcoming patients from 29 referring rural hospitals in a vast and isolated 80,000-square-mile catchment area.

For nearly a decade, Renown Health has been focused on providing value-based population health for our community. Value is a representation of clinical and service quality divided by cost. As clinical or service quality increases at a given level of cost, so too does value. Our employees' and physicians' efforts at driving quality have been extraordinary, yet despite everyone's best efforts, the pandemic, workforce expenses and supply chain issues have continued to cause healthcare costs to rise and made our efforts for providing access to value-based care for our community more difficult.  

Quality, patient engagement and affordability measures increase when the focus is on the value to the patient instead of the volume of procedures performed on the patient. This requires attention to upstream health so that chronic illnesses are avoided, alternative settings of care are used, and more efficient technologies are leveraged for the patient's benefit. With the current and prospective costs of labor and supplies, balancing the value equation has become even more difficult for our community, like so many others. 

Q: How are you addressing it?

TS: We are proud of our national reputation as an innovator and our ability to bring better systems of care to consumers across Nevada and the country. We are transforming contracts with insurance companies to value-based care arrangements, creating innovative medical home models, advancing remote patient monitoring technologies that enhance experiences, and collaborating with providers in a clinically integrated network and direct contracting entity models, so we are in a better position to address the threats to value based healthcare.

To address workforce shortage issues, we've leveraged digital technology and a new state-of-the-art team and facility, the Renown Transfer and Operations Center, to customize healthcare to the needs of every patient, delivering the right care, at the right time and place across the integrated delivery system. This system enables providers to provide care closer to home, in lower-cost ambulatory, outpatient surgical and skilled nursing settings instead of the hospital, and to deliver a sizeable portion of care to patients where they want to be: in their homes. The RTOC team is dramatically improving the efficiency of our entire health care system both inside and outside of the hospital walls.

New Hampshire

Dr. Keith Stahl, Associate Chief Medical Officer for Catholic Medical Center (Manchester).

Question: What is the most pressing health concern facing your patients?

Dr. Keith Stahl: Putting COVID-19 aside, substance use disorder continues to be the most pressing and growing population health concern among our patients and in our community.  The disorder also includes alcohol misuse.  When you look at hospitalizations, infections, heart valve replacements, homelessness, job loss, crime, and domestic violence, there is an all too common theme of the disorder playing a role. In addition, the prevalence of it puts a significant strain on healthcare and social service resources.  It 2017, it was estimated that the disorder cost the state nearly $3 billion. Between a third and half of clients in CMC's Health Care for the Homeless have either an ongoing or past history of substance use disorder. 

Q: How are you addressing it? 

KS: Our primary focus is on breaking down silos and barriers to care. So many different organizations touch the lives of these people. We continue to work on improving communication and collaboration between these agencies so that we don't duplicate resources and lose track of people in the process. I can step back and see improvement over the last 10 years.  That's not to say we're where we should be, but there is greater awareness and cooperation between organizations today than there was 10 or even five years ago. At CMC, we've also expanded our medication-assisted treatment and worked to break down the stigma against it so that more providers are comfortable administering it. CMC is also runs the local Health Care for the Homeless program, administers The Doorway (an intake and resource center for those seeing treatment for substance use disorder), and is the lead for our region's integrated delivery network (working to coordinate behavioral health services and increasing access to those services earlier in the healthcare continuum).

New Jersey

University Hospital (Newark)

Question: What is the most pressing health concern facing your patients?

University Hospital: Sixty-five percent of UH inpatients have at least one chronic condition such as diabetes, HIV, chronic heart failure, chronic obstructive pulmonary disease or hypertension. Additionally, obesity, substance abuse and problems related to housing and economic circumstances are among the top health concerns of our patient population. University Hospital serves some of the state's most diverse yet economically and medically challenged patients. Health conditions in Newark, which are higher than state percentages, include asthma, kidney disease and depression. Obesity and being overweight are problematic citywide, with the New Jersey Department of Health estimating that 38 percent of Black New Jersey residents are obese, 33 percent of Hispanic residents, 27 percent of white residents and 10 percent of Asian residents. The obesity rate in the city of Newark is approximately 39 percent.

University Hospital continues to lead the region in responding to the pandemic. COVID-19 has painted a bleak picture in Newark, compounding a pandemic on an already vulnerable community. As with most public health crises, underserved populations are at a higher risk for adverse medical, behavioral and social outcomes. Approximately 1,000 patients were admitted during the first wave, with 52 percent of those admitted being Black and 32 percent being Hispanic. Nearly 50 percent of those admissions had Medicaid, 23 percent Medicare, and 13 percent either self-pay or recipients of charity care. Newark's poor health outcomes impact Essex County's low ranking of being the least healthy county in New Jersey. With these factors combined, socioeconomic issues and health disparities mean that Newark residents live a harder life and face more challenges than the average resident of New Jersey. In fact, Newark has an average life expectancy at birth of 76.6, compared to an average of 79 across cities analyzed by city data. 

Patient population data for context: Fifty percent of inpatients reside in the seven ZIP codes of our core service area, while 80 percent live in the 27 ZIP code area known as our primary service area. Having the second-largest share among local hospitals, and being the only public hospital, approximately 13 percent of all inpatient cases in the PSA were treated at University Hospital. Forty-nine percent self-identify as Black or African American, 27 percent as racially diverse, 12 percent white and 11 percent Hispanic.

Q: How are you addressing it? 

UH: University Hospital, as a safety-net hospital, has undertaken several new initiatives to help close the health equity gap. The hospital launched a dedicated care recovery team to perform extensive outreach to reengage patients who missed important clinical and preventive screenings during the first and second waves of the pandemic. 

We painstakingly audited the medical records of over 200,000 patients to identify those who were lost to care or who had missed these important screenings. The goal is to close any gaps in care, with specific attention to patients with diabetes, COPD and CHF, patients who had experienced symptomatic COVID-19, and patients who had been recommended for various cancer screenings, among others. Following this patient audit, 2,701 patients were identified, and about 500 have been reached as part of this effort. 

UH also established the Department of Population Health to galvanize several efforts that respond to the community's clinical and social needs. The department endeavors to address social determinants of health by interfacing directly with patients and referring them to much-needed resources. This includes more intensive case management and therapeutic services to victims of crime (gunshot wounds, stabbings, domestic violence, human trafficking and physical assaults) through UH's Hospital-Based Violence Intervention Program, Trauma Recovery Center and Trauma Survivorship Clinic; engaging frequent users of the emergency department one-on-one through our community health worker/chaplain model; providing health screenings in the community through collaborative partnerships with community-based organizations; and connecting people to preventive care by removing barriers and stigma through an evidenced culturally competent-based approach.  

As part of ambulatory care, we provide access to the Weight Management Center of Rutgers New Jersey Medical School at UH, which provides a comprehensive approach to treat obesity and its complications. The center provides both medical and surgical weight loss interventions. 

Currently, the hospital offers pop-up programs and wellness events in the community to monitor health and connect residents to primary care. Efforts are underway to expand funding sources to grow these pop-ups into a "Prevention Army" for Newark and surrounding communities. The Prevention Army will work in the community to provide health screenings, monitoring and health education, and address social determinants of health (food, housing, income and transportation insecurity). Collectively, the team will bolster access, connectivity and continuity of care to stem the tide of those not seeking care because of fear, anxiety, or the inability to access or afford healthcare. 

Given the coronavirus crisis, our outpatient care teams launched an aggressive telehealth enterprise. Since the launch, we have provided close to 50,000 telehealth visits, averaging more than 1,000 e-health visits per month. Through an on-site vaccination clinic, as well as the support of community and corporate vaccination sites across the city of Newark and greater environs, University Hospital has administered about 55,300 COVID-19 vaccine doses. This has resulted in the full vaccination of more than 25,000 of our regional neighbors. UH partnered with the New Jersey Department of Health to coordinate vaccinations across the state through New Jersey's vaccination van fleet. With regional vans, vaccinations are brought directly into the community, especially in areas that have shown low rates of vaccination. In total, the vans have provided more than 6,040 shots in 21 communities across 140 days. 

New Mexico

Rohini McKee, MD. Chief Quality and Safety Officer at the University of New Mexico Hospital (Albuquerque). 

Question: What is the most pressing health concern facing your patients?

Dr. Rohini McKee: New Mexico is vast and mostly rural with one of the lowest number of beds per capita of any state in the country. This year, the SARS-CoV-2 pandemic and the associated increase of cases along with higher than usual non-COVID patient volumes have been our greatest challenges. This has led to crowded hospitals and a Crisis Standards of Care declaration by the state and our hospital.

Q: How are you addressing it? 

RM: From the beginning of the pandemic, the state response has been defined by close collaboration across the major health care institutions. A hub-and-spoke model was developed to distribute patient load and facilitate patient transfers. At the University of New Mexico Hospital, we pivoted quickly to address these challenges. We activated our emergency operations center in March 2020 and adapted its function to our patient volumes and community needs. We opened spaces usually reserved for ambulatory and urgent care to accommodate inpatients and adapted our outpatient clinics to provide follow-up care for COVID patients. Despite the financial implications, we hired hundreds of traveling nurses to care for our hospitalized patients. 

When needed, we delayed the more elective surgical procedures to make room for our COVID patients, adding to the financial burden that we, along with many other hospitals, have experienced. In partnership with the New Mexico Department of Health, we opened a vaccination site that delivered more than 100,000 vaccines. We made monoclonal antibodies available to patients in an effort to prevent hospitalizations. UNMH collaborated with Indian Health Services and our community hospital partners in the Northwest region of the state with weekly calls to share challenges faced, facilitate peer-to-peer learning and coordinate care.

Our clinical leaders across Albuquerque hold frequent joint press briefings to inform the public, encourage adherence to public health guidelines and promote vaccinations. Looking forward, we think about a world where we coexist with COVID, learning to adapt and use the tools at our disposal to keep ourselves safe. We will also use the lessons learned from this pandemic to strengthen our healthcare delivery systems and policies.

New York

Deepa Kumaraiah, MD. Senior Vice President of Service Lines and CMO of NYP Medical Groups at NewYork-Presbyterian Hospital.

Question: What is the most pressing health concern facing your patients?

Dr. Deepa Kumaraiah: At NewYork-Presbyterian, a pressing concern for our teams is ensuring that our patients continue to prioritize their everyday care, which means staying up to date on important, preventive care. We are here for our patients when they suffer from illness, but we are also here for their wellness needs. Since the onset of the global pandemic, many patients have delayed such services as primary care visits, cancer screenings,  colonoscopies, mammograms and more, which has resulted in an increase in diagnoses that may very well have been preventable. Navigating healthcare overall can also be an anxiety-inducing experience for our patients, particularly when the pandemic has disrupted so many of our normal social support structures. Fortunately, however, we are seeing a rebound in patient confidence to resume routine care through healthcare providers as we all adapt to living our lives in a new normal.

Q: How are you addressing it? 

DK: We are a physician-led organization at NewYork-Presbyterian, and quality of patient care is at the center of all of our decisions. Not only do patients expect personalized care, they also expect and deserve access to care that is convenient and in their communities. In addition to communicating the importance of preventive care through clinician communications, patient education and community outreach, we're making care more accessible through hybrid in-person and virtual healthcare solutions, including remote patient monitoring. With 10 campuses across New York City's five boroughs, Westchester and the Hudson Valley, combined with a telehealth program that was implemented long before COVID-19 impacted the state, we've made a conscious and concerted effort to make sure people know they have plenty of options to access care when, where and how they need it through a seamless system that prioritizes patients first. We are also acutely aware that virtual solutions may not be equally accessible to all of our patients and are continually working to ensure equitable access to care for all.

North Carolina

Jesse Cureton. Executive Vice President and Chief Consumer Officer of Novant Health (Charlotte).

Question: What is the most pressing health concern facing your patients and how are you addressing it?

Jesse Cureton: We have a tale of two cities in Charlotte: those who have access to quality healthcare, education, food, housing and transportation and those who do not. There are ZIP codes in our city where 1 in 4 live in poverty. Novant Health has demonstrated a long-standing commitment to improving access to quality, affordable healthcare for communities that need it most. We have been investing in community clinics, mobile health units and innovative wellness initiatives with the help of our community partners to ensure vital access to primary and preventive care services are available where and when our communities need us. 

We have identified priority ZIP codes in the communities we serve, and for years, we have been strategically placing clinics in our communities to address access and equity. These clinics offer comprehensive care, including behavioral health and social support services, to more directly address health equity gaps and social determinants of health such as housing, food, job and transportation insecurity, which we know have a significant impact on one's overall health and wellness. One of our most notable is our partnership with Michael Jordan and the two Novant Health Michael Jordan Family Medical Clinics in Charlotte that provide vital access to primary and preventive care in underserved communities. The clinics were carefully designed with input from the community throughout the planning and development process. We met with leaders of the community and held forums with community members on a monthly basis, receiving feedback on everything from the aesthetic features of the clinics to the services they felt they needed most. Team members working in the clinics were recruited from surrounding neighborhoods. So we listened, heard and understood the unique cultural and demographic needs, and decided to run the clinics, using a unique integrated services model designed to identify, treat and support social determinants of health.  Over five years, the Novant Health Michael Jordan Family Medical Clinics are projected to care for nearly 35,000 children and adults who do not currently have access to primary and preventive care or who use the emergency room for nonurgent medical needs. These clinics have the potential to decrease emergency room utilization by 68 percent and decrease hospitalization by 37 percent for the residents of these neighborhoods.  

North Dakota

Bryan Nermoe. President and CEO of Sanford Health Fargo. 

Question: What is the most pressing health concern facing your patients?

Bryan Nermoe: The challenges facing our patients in North Dakota and across the rural Midwest may not be new, but issues like barriers to access and health disparities have only been exacerbated during the pandemic. The continued strain from the pandemic is causing the worst healthcare workforce shortage in a generation, taking a disproportionate toll on the communities we serve across our rural footprint. Lack of reliable transportation, harsh winter weather or unpredictable circumstances at home and work due to the pandemic can also make it more difficult to access timely care. 

We have also seen the demand for behavioral health services skyrocket over the last two years. We've been working to expand access to behavioral healthcare through innovations such as telehealth and by integrating behavioral health providers into our primary care settings. In addition, we are collaborating in behavioral health research with our university partners in the state of North Dakota. This is especially important since 91 percent of the counties in North Dakota are designated as mental health shortage areas, making it harder for people to seek behavioral health care close to home.

Q: How are you addressing it?

BN: We are committed to providing patients in rural, underserved parts of our state and region 24/7 access to world-class, affordable and seamless care no matter where they live. In the fall of 2021, Sanford Health announced a transformational $350 million gift to establish a cutting-edge virtual care initiative. 

The Sanford Virtual Care Center will initially set up five rural satellite hubs to serve communities across our footprint through our network of hospitals and clinics, allowing patients to access healthcare using the most advanced technology as close to home as possible, with a particular focus on underserved rural areas. 

Sanford Health has invested in career academies across the upper Midwest, opening the door for more students to engage with health sciences. We are also leading initiatives with colleges, universities and government entities to create capacity in training more medical professionals.

Sanford Health recently launched an initiative to create eight new graduate medical residencies and fellowships in critical specialty areas. Recruitment and retention of healthcare professionals is an ongoing challenge in rural America. By doubling the opportunities for graduate medical education, Sanford Health will build a stronger workforce and bring highly sought-after clinical expertise, resources and subspecialties to our rural communities in North Dakota and beyond.

Our promise to those we have the privilege to serve is that their care won't be limited by their ZIP code. 


Aaron Clark, DO. Medical Director of Ohio State Health Accountable Care Organization and Clinical Associate Professor of Family Medicine at The Ohio State University Wexner Medical Center (Columbus).

Question: What is the most pressing health concern facing your patients?

Dr. Aaron Clark: There are many competing health concerns facing our patients, all exacerbated by the ongoing COVID-19 pandemic. In our communities, and in the population of patients we serve, we see ongoing health needs especially around mental health/addiction, as well as obesity, heart disease and infant mortality. Each population of patients experiences these health concerns differently, and we have a very heterogeneous patient population here at The Ohio State University Wexner Medical Center. Franklin County (where most of Ohio State University Wexner Medical Center clinics/hospitals are located) has a higher rate of poverty than our state average. We understand that poverty is a key driving factor in many health outcomes and concerns.

Q: How are you addressing it?

AC: One of every five adults in Franklin County has a diagnosis of depression. One in every eight report having used illicit drugs in the past month, and our rate of unintentional drug overdose deaths continues to rise dramatically. At The Ohio State University Wexner Medical Center, we have responded to this community need by embedding behavioral health clinicians into each of our primary care clinic locations. This allows direct, warm handoffs of patients from their physician or advanced practice provider to an on-site behavioral health clinician all in the familiar setting of the primary care clinic. We also have expanded our offering of addiction medicine services to our primary care environment. We now have a Primary Care Addiction Medicine clinic staffed by a physician who is dual board certified in family medicine and addiction medicine. We have also expanded the number of primary care, emergency medicine and inpatient providers who have Drug Addiction Treatment Act X-waivers to allow prescribing of medications for opioid use disorder.

For infant mortality, we have a Moms2B team which helps expectant moms have healthy babies. This is a community-based pregnancy program for low-income women in our communities. The Moms2B team consists of physicians, nurses, patient navigators, dieticians, lactation counselors and others all working together to promote the health and well-being of pregnant women and their children.

Unfortunately, food insecurity remains a large area of concern for many patients in our community, affecting nearly one in every five residents of Franklin County. This rate is higher than national averages. To address the needs for access to fresh, healthy foods, The Ohio State University Wexner Medical Center has partnered with the Mid-Ohio Food Collective, which is the largest food bank in Ohio. Together we participate in a Mid-Ohio Farmacy program, which enrolls patients from doctors' offices into the Farmacy program, giving them access to free, fresh foods for themselves and their families. We understand that food is medicine, and access to a healthy diet can help reduce the rates of obesity and heart disease, which are both very predominant in our communities.


Dale Bratzler, DO. Chief Quality Officer at OU Health (Oklahoma City).

Question: What is the most pressing health concern facing your patients?

Dr. Dale Bratzler: That is a broad question, since there are so many different types of people in our care. I think one of the key challenges at the moment is access to care. I think we are all dealing with a shortage of primary care providers, and there are many barriers to being able to access care. As an institution that serves as the community safety-net hospital system, many of the patients we serve have limited ability to access care. Primary care practices are often booked and not able to take new patients; emergency rooms are crowded right now with many people dealing with significant health concerns, including COVID-19; and hospital resources are stretched in part due to nursing and other personnel shortages. Because of this limited access, we have grave concerns about the many patients who have not sought preventive health services or sought medical care at early stages of symptoms. We too are seeing more people present with heart attacks rather than chest pain, completed strokes beyond the window for early intervention, or malignancies that are more advanced.

Q: How are you addressing it? 

DB: In our ambulatory health settings, we are trying to expand access through additional hours in clinics, use of telemedicine to reach people that have difficulty with transportation, and expansion of the role of our advanced practice professionals (physician assistants and non-physician practitioners) to provide primary care. In our hospital setting, we are trying various ways to keep patients out of the emergency department through case management, use of urgent care or in-home urgent care, and some at-home monitoring of patients. We are aggressively focusing on hospital length of stay to get patients home or to post-acute care as soon as it is safe to help open inpatient beds.


Eric Herman, MD. Chief Primary Care and Population Health Officer of Oregon Health & Science University (Portland).

Question: What is the most pressing health concern facing your patients?

Dr. Eric Herman: Patients are experiencing profound challenges getting timely access to providers and services within the health system. This includes longer than normal wait times to see their trusted primary care providers and specialists and to complete scheduled procedures. This causes delays in the management of chronic diseases, behavioral health concerns and the evaluation of new problems and ultimately results in sicker patients with urgent needs who must go to emergency rooms and/or require hospitalization.

Q: How are you addressing it?

EH: We are doing everything possible to create as much access as we can for our patients.  Unfortunately, medical providers and nurses are so overwhelmed and short-staffed, it is difficult to ask anything more of them. Despite these challenges, they have heroically rallied to the cause and continue to work after hours and take extra shifts. In efforts to further support patients and our care teams, our system has set up highly efficient vaccination and testing sites, leveraged telehealth and other digital technologies, launched central call centers to answer the tremendous volume of questions and calls, and of course actively recruit for more  positions and temporary staff.


Tony Reed, MD. Executive Vice President and CMO of Temple University Health System (Philadelphia).

Question: What is the most pressing health concern facing your patients, and how are you addressing it?

Dr. Tony Reed: In terms of ongoing health concerns, Temple Health's vulnerable patient population is disproportionately affected by chronic conditions such as diabetes, kidney and heart disease, and obesity. We also have a tremendous volume of gun-related violence and the continuation of the opioid pandemic. Making these conditions infinitely worse, our patients suffer significant challenges of nearly every social determinant of health. Our immediate concern is, of course, COVID — for which care provided by our expert pulmonologists, primary care physicians and their teams yields a faster recovery time and a lower mortality rate than the national average when adjusted for the diversity of the population we serve. Temple Health's population health teams also continue to reach out daily to our community members and have delivered over 120,000 COVID vaccination and booster shots to date.

Rhode Island

Paari Gopalakrishnan, MD. Interim President and COO of Kent Hospital, a Care New England Hospital (Warwick).

Question: What is the most pressing health concern facing your patients?

Dr. Paari Gopalakrishnan: As a hospital president, my biggest pressing issue that will impact our patients especially this year and even over the next few years is the labor shortage. I don't see a quick end in sight for this problem. We are seeing these workforce shortages in many industries across the country, including healthcare. Nurses, techs and physicians are leaving the labor force. They aren't going to other hospitals; instead, they are leaving the healthcare industry, and the pipeline to get more workers into the industry just takes a while. As a result, a major problem is that I don't have enough staff to always care for all of the patients. 

When I think about healthcare and access to healthcare for our patients, the most pressing problem is making sure we have enough providers to care for our patients safely. In the past when a physician or nurse would resign, usually they had a place they were going. They had another job at a different hospital, system or state. Now, we are seeing people resign and they don't have another job. It's because of the stressors that really emerged amid the pandemic. The pandemic has really taken its toll on our entire country and our staff especially. Our staff for 24 months essentially have dealt with various COVID surges and changing protocols. So when it comes to my biggest worry, it is providing healthcare to our community in the next one to two years amid this staffing crunch. 

When it comes to diseases specifically, the most pressing, especially post-pandemic, is behavioral healthcare and substance abuse. Those are the two areas where we've seen a dramatic increase in the needs of our patients, and the resources to care for them in our community are not matched yet. A lot of patients dealing with substance abuse and mental health problems use our front door as an entry point into the system, which is great and we want to help them, but the reality is that the hospital stay is a short part of the disease process. The lack of resources after they leave our system is something impacting our entire country. 

Q: How are you addressing it? 

PG: When it comes to the staffing shortages, the first thing we are trying to do is understand why people are leaving the labor force, particularly in healthcare, and trying to address that. We are focused a lot on making sure our staff understand how valuable they are to our organization. We are trying to understand their pressure points and working to address those. Wellness and burnout are big areas of focus for us. We are working to make sure our staff is engaged and developing, while we are looking to improve and ease their day-to-day work. The second thing is being hypervigilant about recruiting top talent and then retaining them. The third thing is looking at reimagining how we deliver care in our area. We are also looking at innovative ways to care for our patients to address these staffing challenges. We are looking at things like "hospital-at-home" programs, where patients can be cared for at home versus the hospital. We are also looking at potentially getting paramedicine folks or other clinical folks who aren't typically in the hospital to help the care team in the hospital. We don't have the perfect solution, but these are the levers we are focused on right now. 

For behavioral healthcare, the reality is these patients need help outside of the four walls of our hospital. We are partnering with state and community organizations to look for better ways to meet the needs of these patients outside of the hospital and in the community. This is an area where collaboration with state agencies as well as other healthcare organizations is vital. I think to address this, it is going to take some real investment from the government and public agencies to increase the amount of services available for patients with these behavioral health needs. Organizations in our area are so passionate and so good at what they do, but again, it comes down to needing more help and resources to provide the care to these patients. 

South Carolina

Danielle Scheurer, MD. MUSC Health Chief Quality Officer and Professor of Medicine at the Medical University of South Carolina (Charleston).

Question: What is the most pressing health concern facing your patients?

Dr. Danielle Scheurer: I would say mental health challenges are the most pressing health concerns our patients face. Challenges include access, resources and the stigma around mental health.

Q: How are you addressing it? 

DS: •Expanding virtual care and crisis stabilization access and resources.

  • Expanding primary care-based mental health access and resources.
  • Improving Emergency Department and inpatient mental health care variation and length of stay (to improve care and outcomes and expand access).
  • Improving team member and patient access to well-being resources and education, to prevent crises and reduce stigmatization.

South Dakota

David Basel, MD. Vice President of Clinical Quality at Avera (Sioux Falls).

Question: What is the most pressing health concern facing your patients?

Dr. David Basel: Within the Avera footprint, Type 2 diabetes and obesity are our most pressing population health concerns. These conditions impact a significant portion of our population and can be challenging for patients to manage themselves.

Q: How are you addressing it? 

DB: At Avera, coordinated care is at the core of population health management. Our physician-directed approach brings together nurses, pharmacists, dietitians, social workers and more to help patients overcome barriers to better care. 

To additionally support these patients, Avera has initiated the Healthy Weight with Avera program, which includes an order for weight management services. Within two business days, patients receive a call from a health coach who helps identify the right weight management program for that patient's health history, location, amount of weight to be lost, time constraints, finances and more. Additionally, our Healthy Weight with Avera patient education offers information on the healthy habits that lead to better weight management.

In the coming months, we're looking to focus on the journey patients with diabetes make from diagnosis to management, to hone in on key points where additional support can improve patient outcomes.



Jeffrey Balser, MD, PhD. President and CEO of Vanderbilt University Medical Center (Nashville).

Question: What is the most pressing health concern facing your patients?

Dr. Jeffrey Balser: As we enter the third year of the COVID-19 pandemic, one of the more pressing population health issues continues to be the low COVID vaccination rate in our region. Not only does the rate trail many other parts of the U.S., but we are also seeing broader vaccine hesitancy as people delay or decline vaccines for other preventable diseases. There is a concerning dip in childhood immunization against diseases that were nearly eradicated in the U.S. These trends have the domino effect of leaving our population more vulnerable to serious illness, disrupting family economic circumstances and putting even more pressure on healthcare systems already reeling from unprecedented patient demand that outstrips existing capacity. As new COVID variants evolve and other preventable diseases spread, we are at risk for an escalating public health crisis that will impact our ability to care for patients with non-infectious illnesses such as trauma, heart disease and cancer.

Q: How are you addressing it? 

JB: From the beginning of the pandemic, Vanderbilt University Medical Center has been a vocal leader encouraging the public not to delay necessary medical care and to get the COVID vaccine. We've led media campaigns and education programs that help patients and community leaders understand public health concerns; we've made our physicians available as resources for the media, political leaders, community groups and employers; and we've provided educational materials in multiple languages and led outreach efforts in underserved communities. Our outreach has extended well beyond Nashville to the entire nation as we work to ensure that accurate and compelling health guidance is readily available and accessible.  Finally, as the largest private employer in Middle Tennessee with over 30,000 clinicians and staff, we've led by example through achieving COVID-19 vaccination compliance that exceeds 99 percent.


Mujtaba Ali-Khan, DO. CMO at HCA Healthcare Gulf Coast Division (Houston).

Question: What is the most pressing health concern facing your patients?

Dr. Mujtaba Ali-Khan: Without question, delayed care throughout the COVID-19 pandemic is the most pressing public health concern for our patients. Countless standard health check-ups and treatments were delayed in fear of contracting the coronavirus. Consequently, that caused chronic conditions to worsen for many, landing them in hospital critical care units. Our clinical teams have noted high volumes of heart-related and neurological issues that may have been prevented with proactive healthcare. In addition to delayed care, all healthcare systems are experiencing an unprecedented shortage of registered nurses (RNs). This shortage has taken a toll around the world.

Q: How are you addressing it? 

MA: When a patient enters an HCA Healthcare Gulf Coast Division facility for treatment of any nature, our team pays careful attention to provide a high-quality experience with no complications. HCA Healthcare Gulf Coast Division developed [the S3 excellence program] (sepsis, stroke and ST-elevation myocardial infarction) to mitigate harm through preventative and care management efforts. The program targets clinical workflows and algorithms, then applies data science to help accelerate positive outcomes.

Sepsis, for example, requires early recognition and prioritized assessments by the clinical team to optimize patients afflicted with this condition. The sepsis excellence branch of S3 arms our nursing teams with identification software and a standard checklist to execute critical actions in a time-sensitive manner. Similarly, workflow processes in stroke and STEMI ensure loved ones receive necessary medications or touch points while under hospital care. Continuously educating our nurses and new clinical teams adds a layer of quality control to keep the program running at a high level. HCA Healthcare Gulf Coast Division values patient care above all else, and the S3 excellence program is just one measure leading to a quality stay.  

In regard to the global nursing shortage, our team is taking active steps to support and replenish our nursing core. Clinical resources, staffing and recruitment teams have been continuously working to make sure we have the staff and resources to continue providing quality care. We have recently hired more than 2,000 nurses this year. This influx of additional nurse colleagues comes just as we opened our new HCA Healthcare Center for Clinical Advancement in July, designed to help standardize nurse training across our facilities. These nurses will all be trained on our COVID-19 protocols and will be able to assist us in combating this horrible virus.



Dan Liljenquist. Intermountain Healthcare Senior Vice President and Chief Strategy Officer (Salt Lake City).

Question: What is the most pressing health concern facing your patients?

Dan Liljenquist: The cost of healthcare in the United States is continuing to rise, and that's not sustainable for patients. For many Americans, healthcare is already unaffordable.

Q: How are you addressing it? 

DL: At Intermountain Healthcare, the growth of value-based care — where providers are paid on the basis of capitation and patient health outcomes — is helping make care more affordable. Value-based care improves quality of life and corrects misaligned incentives (e.g., paying providers on the basis of the volume of procedures they perform rather than outcomes). It can reduce healthcare costs by making care more accessible and keeping people healthy, which reduces the treatments and procedures needed. For example, over each of the past three years, Intermountain Healthcare's SelectHealth insurance plans, which focus on value-based care, have reduced premiums by 2 percent to 3 percent for those insured through the federal exchange.


David Clauss, MD. CMO of University of Vermont Health Network (Burlington). 

Question: What is the most pressing health concern facing your patients?

Dr. David Clauss: At the moment, our day-to-day operations are almost completely preoccupied with the pandemic, related capacity and workforce challenges, and unprecedented demand for inpatient services. However, behind the scenes we continue to work very hard to transform our care delivery system to address the health needs of the population, align with value-based payment and address determinants of health that have not traditionally been thought to be the domain of the healthcare system. These efforts are central to our strategic vision for our network.

Q: How are you addressing it?

DC: Because the pandemic forced care to be delayed for months, patients have been and continue to be sicker when they arrive at our hospitals, requiring more acute care and regularly pushing the limits of intensive care unit and emergency department capacity. These challenges have been exacerbated by local and national workforce issues. Many hospitals around the country have begrudgingly closed beds, limited services and/or refused patient transfers in the face of these challenges, including some hospitals serving Vermonters. The UVM Health Network has worked hard to do the opposite. From day one, our mission has been to keep our academic medical center open, and we have added bed capacity in innovative ways to meet growing community needs.
In terms of longer-term population health strategies, we remain firmly committed to increasing the percentage of our revenue that comes from value-based contracts. To prosper under those contracts and shift our focus to population health management, we are building out our care management and data analytics capabilities and aligning population-based quality metrics across all of our payer contracts.


Jordan Asher, MD. Executive Vice President and Chief Physician Executive at Sentara Healthcare (Norfolk).

Question: What is the most pressing health concern facing your patients?

Dr. Jordan Asher: At this time, vaccination rates are the largest concern for Sentara Healthcare. Like many hospitals across Virginia, we are starting to see another rise in the number of COVID-19 patients in our care, largely among unvaccinated individuals.

Q: How are you addressing it?

JA: We strongly encourage community members to get vaccinated against COVID-19 and to get a booster shot when eligible. COVID-19 vaccines have proved effective in preventing the spread of COVID-19 and severe illness, hospitalization and death due to the virus. Sentara Healthcare hosted the first COVID-19 vaccine clinic in Virginia less than 24 hours after receiving the first shipment of COVID-19 vaccines on Dec. 15, 2020. Sentara continues to offer the COVID-19 vaccine to patients by appointment and to community members through pop-up community vaccine clinics. As of December 2021, Sentara Healthcare has hosted more than 550 COVID-19 vaccine clinics and administered nearly 200,000 COVID-19 vaccines to healthcare workers, patients and community members throughout Virginia and Northeast North Carolina.
Sentara partners with numerous faith-based organizations, nonprofit organizations and community leaders to spread the word and to focus on vaccinating underserved community members. Our ongoing work with community and faith-based partners also has opened the door for opportunities to improve community health and wellness. Not only do these partnerships help to increase vaccination rates in our communities, but they also provide opportunities to better address other health disparities such as hypertension, diabetes and colon cancer.
Education is key. Sentara continues to participate in webinars and community discussions and provide educational resources for our patients and communities. Our VaxUp campaign is a recent effort to reach the vaccine-hesitant and to provide information and educational resources from trusted community voices and neighbors.
We also urge patients in our communities not to delay necessary care. Part of the high census issues we are seeing in our hospitals can be attributed to patients putting off procedures, surgeries and routine screenings for months due to COVID concerns until symptoms dictate a more urgent response. Patients should schedule their mammograms, colonoscopies, annual physicals and other routine screenings to avoid missing a potential health issue in its earliest stages. Sentara follows strict guidelines and has implemented extra safety measures to ensure patients are safe while receiving the care they need.
Sentara's behavioral health tactical operations committee has been working since June to address a growing demand for behavioral health services — including children and adolescents — in the wake of the state's closure of several psychiatric hospitals to new admissions over staffing and safety. Our operational improvements include developing a streamlined, standardized process for triage and agitation response, broader use of telepsych services, capital improvements to enhance patient and staff safety in our emergency departments, urgent recruitment of new clinicians and safety partners, and improved liaison with community services boards.


Charleen Tachibana, DNP, RN. Senior Vice President and Chief Quality, Safety and Patient Experience Officer at Virginia Mason Franciscan Health (Seattle).

Question: What is the most pressing health concern facing your patients?

Charleen Tachibana: One of the most important factors we are considering from a population health perspective is the impact of delayed preventive health appointments and screenings.Much routine care has been deferred as health care systems prioritized capacity for COVID-19 and other emergency care. The Virginia Mason Franciscan Health system is focused on making certain the community gets back on track as quickly as possible to support the best health outcomes for our patients. 

Q: How are you addressing it?

CT: There are a number of ways we can refocus on preventive care across the industry. This means instituting systems to quickly determine when patients are overdue for care and getting in touch with them directly. We also need to ensure our delivery modalities are conducive to reaching as many people as possible through a combination of technology, expanded hours, and community outreach and partnership.

The pandemic has identified myriad inequities in our national and global health care system — top among them the lack of access for traditionally underserved communities. It’s essential that we prioritize prevention and find ways to overcome barriers to ensure all patients have support for ongoing conditions and the opportunity to detect others before they progress.

West Virginia

Michelle Coon. President of CAMC Health Network (Charleston).

Question: What is the most pressing health concern facing your patients?

Michelle Coon: Since the onset of the COVID-19 pandemic, West Virginia has seen a decline in those receiving preventive services such as annual wellness visits, routine vaccinations and cancer screenings. Routine chronic disease management is also an area that has been impacted due to the hesitancy of people to seek nonurgent primary care. West Virginia's rural population is impacted by many social determinants of health, such as lack of transportation and food deserts, that create barriers to seeking out healthcare and maintaining a healthy lifestyle.  

Q: How are you addressing it? 

MC: Although the flexibilities granted by insurance payers for telehealth and telemedicine have helped increase access to care significantly, there are still services that are not accessible with those methods. Expansion of telehealth, including remote patient monitoring, was used to monitor patients with COVID and other chronic diseases such as chronic obstructive pulmonary disease and heart failure after discharge from the emergency room. Telephonic transitional and chronic care management by nurses was utilized to coordinate care for patients at risk due to medical history or disease burden. More recently the CAMC Health Network has partnered with our local Kanawha County Health Department to host drive-through health fairs with a focus on immunizations and preventive healthcare, including colorectal screening. Other strategies included collaborative partnerships with insurance payers to improve incentives to patients for completing screening and funding initiatives to address food deserts. The key to success in improving care to our patient population will be continued innovations that bring healthcare closer to the patient by partnering with community partners and improving broadband access for expansion of telehealth services.


Bob Rohloff, MD. Medical Director of Community Services and Health Management at Children's Hospital of Wisconsin (Milwaukee). 

Bridget Clementi. Vice President of Community Health at Children's Hospital of Wisconsin (Milwaukee).

Question: What is the most pressing health concern facing your patients?

Dr. Bob Rohloff and Bridget Clementi: By far, the most pressing health concern today is the disparity in health that exists across our community. The ZIP code in which one lives, a family's economic status, a patient's life experiences are far too connected to someone's health outcomes. As a community, we must do all that we can to ensure everyone, each and every community member, has the ability to reach their full mental and physical health. Everyone must have access and receive care that meets their holistic needs, and we need to put a greater focus on wellness, not sickness.

Q: How are you addressing it? 

BR and BC: Children's Wisconsin recognizes that advancing health equity will take an intentional commitment of time and resources. This is not a strategic priority but a moral imperative. We are working to improve our ability to collect and monitor health data to identify and improve care delivery for all, especially those most in need. We are measuring our performance using demographics like race, ethnicity, gender, financial class and ZIP codes. We are working to understand the causes of identified disparities in healthcare and seeking solutions. Patients across the organization are asked to provide additional information about their social needs so we can provide care that meets the needs of the whole child. Healthcare alone cannot meet all needs for families, so Children's Wisconsin works closely and collaboratively with community-based partners, assets and resources to support children and families with other factors that impact one's health, including stable housing, sustained access to nutritional food and safe neighborhoods where children can play, learn and live. As the only independent healthcare organization in Wisconsin devoted to the health of kids, we also advocate for policy change on behalf of children and families.


Tim Thornell. President and CEO of Cheyenne Regional Medical Center.  

Question: What is the most pressing health concern facing your patients?

Tim Thornell: From a population health perspective, one of the more pressing concerns facing our patient population is access to healthcare. Challenges to access are varied. It might be finding a certain physician specialist or getting an appointment when it's convenient or in a manner that's convenient. It might be as straightforward as lack of transportation, or, for the population we serve who are in a rural setting, distance to travel may be the challenge. 

Q: How are you addressing it? 

TT: We are addressing the access issues in a variety of ways. We are bringing in more specialists to decrease wait times for appointments as local demand increases: interventional cardiology, endocrinology and radiation oncology, just to name a few. Like so many others, we are using more telemedicine options, including SmartExam, which can be used asynchronously from a smartphone. Telemedicine can address both convenience and distance challenges. We have augmented remote patient monitoring capabilities for those who have a difficult time making frequent trips to the doctor. And we have started our own intra-facility transportation program to help patients get from one appointment to the next when same-day coordination is the challenge.


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