How UW Health's population health chief is moving the needle to address social determinants of health

As the senior vice president and chief population health officer at Madison-based UW Health, Jonathan Jaffery, MD, works in collaboration with community partners to improve care.

Dr. Jaffery, who is also a board-certified nephrologist, brings a unique perspective to his role. After earning his medical degree from the Ohio State University College of Medicine in Columbus, he went on to complete a fellowship at the Burlington-based University of Vermont.

Below, Dr. Jaffery discusses the importance of social determinants of health and his population health strategy.

Editor's note: Reponses have been lightly edited for clarity and length.

Question: Social determinants of health have been a big topic of discussion in the past decade. What has UW Health done to move the needle when it comes to SDOH?

Dr. Jonathan Jaffery: The Population Health Institute, part of the University of Wisconsin School of Medicine and Public Health, created the County Health Rankings Population Health Model that is now used across the world to demonstrate that non-medical determinants contribute most of the impact on health for individuals and populations. As the academic medical center affiliated with the University of Wisconsin — Madison, UW Health has been dedicated to this notion of population health for many years.

Perhaps the most exciting work we’re doing to address the social determinants of health is as part of the Dane County Health Council. This is a group that has been in existence for many years, but more recently we helped redefine the membership and goals to address population health and the SDOH. The members include all the large health systems in the county, as well as the Madison Metropolitan School District, Public Health Madison – Dane County and the Dane County United Way. We now do a county-wide joint Community Health Needs Assessment and have chosen a shared community priority – addressing low-birth weight and infant mortality disparities for African American families.

We’ve publicly stated we consider racism a public health problem, are launching SDOH screening across all the health systems, and are pooling resources to create a community wide closed-loop referral system so that patients identified with needs based on the screening are connected to community-based organizations that can help address those needs.

Q: How has UW Health's population health strategy evolved? What are you doing today that is different from other healthcare organizations? 

JJ: Population health means a lot of different things at different institutions, including organizing and leading ACOs, developing and implementing population health care model programs, or community health improvement activities. The Office of Population Health at UW Health leads all three activities and leverages the synergies between all three. We have created a multiyear population health care model roadmap that encompasses dozens of different care model programs, and continuously re-evaluates how to best sequence program development, business planning, implementation, optimization, expansion and evaluation. We have a set of care model program core standards that allow for consistency across programs.

In addition to the long-term comprehensive approach to care model development and implementation, we’ve been very deliberate about who within the organization is accountable for different aspects of individual care model programs, making sure that population health and clinical operations are fully aligned so that as population health programs are launched, operations is ready to take on the day to day activities necessary to make them successful. This has been mainly through integration of population health and primary care, although specialist and inpatient care is also involved as necessary.

These factors have been key to our continued success, not only in creating high-quality affordable care for our large capitated populations but also in the Medicare population, where we’ve been successful in achieving shared savings in both the Medicare Shared Saving Program and the Next Gen ACO program, even as an academic medical center starting with total cost of care that is among the lowest across the country. 

Q: As a physician, how does your view of population health differ? What is your main priority, and has it changed? 

JJ: Being a practicing physician always helps ground me in how our work impacts our community and helps maintain that balance between creating a new model of care for high-quality affordable health care for our populations and the needs of individual patients, who may struggle to navigate a complex and expensive healthcare system, often at a time of personal distress. And of course, it helps me relate to our front-line providers who have to navigate the myriad of new expectations as they continue to provide care for our patients every day.

I think of this transformation as less “how do we start to think more like an insurance company” and more how do we take advantage of new revenue models to create a system that allows providers, especially primary care providers, to deliver the kind of care that they went to medical school for in the first place – a team-based model that brings mental health, social work, pharmacy and so on into their practices in a sustainable way, and lets them focus on the most fulfilling and impactful work for which they’re uniquely trained.

Q: Looking ahead, what initiatives do you have planned in 2020? 

JJ: In 2019 we launched a Home-Based Primary Care Program, bringing primary care teams to populations of mostly frail elderly who have high health care needs but also difficulty getting their needed ambulatory care. In 2020 we plan to continue the expansion and optimization of this program, as well as more systematic incorporation of palliative care into our ambulatory practices and expanding advance care planning across our primary care populations.

Longer term we envision continued expansion of home-based care, including for example hospital at home services. Providing the services that allow people to maintain their independence as close to home as possible is not only what people want, but also happens to be more affordable for individuals and the system overall. Increasing value-based insurance arrangements that move away from the perverse incentives of the fee-for-service model and make investments in these types of care models sustainable for delivery systems is another key component to our long-term success.

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