Design Research and Healthcare Reform - Mayo Clinic Proceedings

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Meaningful health reform in the United States must improve the health of the population while lowering costs. In an effort to provide a framework for doing so, the Institute of Health Care Improvement created the triple aim, which encompasses the goals of (1) improv- ing individual health and experience with the health care system, (2) improving population health, and (3) decreasing the rate of per capita health care costs. Current reform efforts have focused on the development of Patient-Centered Medical Homes (an innovative team-based model of care that facilitates a partnership between the patient's personal physician coordinating care throughout a pa- tient's lifetime to maximize health outcomes), but these relatively narrow efforts are focused on office practice and payment methods and are not generally oriented toward community needs. We sought to apply design research in assessing a community opportunity to apply the triple aim as a strategy to transform health care delivery.

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Design Research and Healthcare Reform - Mayo Clinic Proceedings

  1. 1. SPECIAL ARTICLE USING DESIGN RESEARCH TO GUIDE HEALTH REFORM Health Reform: A Community Experience Using Design Research as a GuideM A. S , RN, MA; D L. W , MD; C N. C , MA; L G. L , MA;A C. R , MBA; D C. A , MD; C P. H , MD; J K. B , RN, MS; K H. S , MA; B R. S , MHA; N F. L R , MDMeaningful health reform in the United States must improve the ture of an of ce practice or an integrated delivery system.health of the population while lowering costs. In an effort to providea framework for doing so, the Institute of Health Care Improvement In our view, this does not represent a true patient-centeredcreated the triple aim, which encompasses the goals of (1) improv- approach and does not truly assess and respond to the needsing individual health and experience with the health care system, of individual patients, families, and communities.(2) improving population health, and (3) decreasing the rate of percapita health care costs. Current reform efforts have focused on At the Mayo Clinic Center for Innovation, our experiencethe development of Patient-Centered Medical Homes (an innovative is that design research methods are more likely to be help-team-based model of care that facilitates a partnership between ful in creating new delivery systems that will achieve thethe patients personal physician coordinating care throughout a pa-tients lifetime to maximize health outcomes), but these relatively triple aim. Design research is based on qualitative research:narrow efforts are focused on office practice and payment methods smaller, targeted sample sizes are explored, and andand are not generally oriented toward community needs. We sought questions are investigated. It canto apply design research in assessing a community opportunity toapply the triple aim as a strategy to transform health care delivery. provide a deeper understanding of the For editorialMixed methodology provides greater insight into the unexpressed emotional, cultural, and aesthetic con- comment,health needs of individuals and into the creation of delivery systems text of a product, providing an important see page 930more likely to achieve the triple aim. In a small, midwestern town,a mixed methods approach was used to assess community health methodology for assessing the “experi-needs to facilitate design and implementation of care delivery ence” goal of the triple aim.4 This method can help a healthsystems. The research findings suggest that health system design care organization tailor health services to the true needs ofconcepts should focus on the creation of health, not health care;foster simplicity; create nurturing relationships; eliminate user fear; the community it serves. An effective design concept mustand contain costs. These observations can be helpful to health care be created from observational, design research before proto-professionals who are developing new methods of care delivery and typing and implementation. This article describes the appli-policymakers and payers contemplating new payment systems toachieve the goals of the triple aim. cation of design research to a community and demonstrates how results can be used to create design concepts for a new Mayo Clin Proc. 2011;86(10):973-980 health care delivery system. This research method has the potential to help health care systems achieve goals of better AMC = Austin Medical Center; PCMH = Patient-Centered Medical Home design, especially when combined with health indices and disparities data for the community. From our perspective, emphasis on PCMHs is a neces-G rowth in health care spending exceeds that of the general economy and is unsustainable.1,2 Incessant in-creases in health care costs reduce availability of affordable sary component for coordinating care. Austin Medical Cen- ter (AMC) de nes care coordination as a clinical program that uses physician-led teams to provide patient-centered,health insurance and threaten access to care. Meaningful evidence-based, and proactive clinical and managementhealth reform in the United States must improve the health support for patients with multiple chronic conditions. Inof the population while creating sustainability by reducing December 2009, AMC, part of the Mayo Clinic Healthcosts. In an effort to provide a useful framework for achiev- System, implemented a care model based on the Minnesotaing long-term health care reform, the Institute of Health Department of Health guidelines for PCMHs.5Care Improvement created the , the goals of The city of Austin has approximately 23,000 resi-which are (1) to improve individual health and experiences dents, with another 15,000 persons living in small ad-with the health care system, (2) to improve populationhealth, and (3) to reduce per capita health care costs.3 From the Center for Innovation (M.A.S., C.N.C., L.G.L., K.H.S., B.R.S., N.F.L.) “Patient-Centered Medical Homes (PCMHs),” “Ad- and Division of Health Care Policy (D.L.W.), Mayo Clinic, Rochester, MN, and Austin Medical Center (A.C.R., D.C.A., C.P J.K.B.), Austin, MN. .H.,vanced Primary Care Practices” and “Accountable Care Address reprint requests and correspondence to Mary Severson, RN, MA,Organizations” have stirred considerable interest in the Mayo Clinic, Center for Innovation, 200 First Street SW, Rochester, MN,United States for their potential to minimize health care 55905 (severson.mary@mayo.edu).costs. However, most of these efforts are aimed at the struc- © 2011 Mayo Foundation for Medical Education and Research 973 For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings. a
  2. 2. USING DESIGN RESEARCH TO GUIDE HEALTH REFORMjoining communities. According to 2000 Census data, lifestyle and habits, and environmental analysis. Initialapproximately 9% of residents live in poverty; 93% are contact was made via email, followed by often multiplewhite; 6% are Hispanic/Latino; and the remainder are of face-to-face meetings. Because individual observationsother races. Of Austin households, approximately 35% could not readily be excluded, investigators did not useinclude members 65 years or older and 29% have mem- speci c selection criteria but made every effort to obtainbers younger than 18 years.6 a representative sample of the population by interacting Austin Medical Center is a fully integrated medical with all social classes and age groups and by choosingcenter incorporating 82 hospital beds, primary and spe- community sites likely to yield a heterogeneous andcialty clinics, outpatient chemical dependency services, representative community sample.home health care, and a hospice including a home oxygen Quantitative surveys were completed by participants inprogram. Physicians are both employed and contracted to the semistructured, individual, and dyad/triad interviews.work at AMC. The survey tool was created internally by the Mayo Clinic The goal of AMC is to transform the experience of pa- Rochester Survey Research Center and the Center for In-tients and/or their family members with the health care deliv- novation. The purpose of the survey tool was to determineery system to achieve better health for the individual patient a community baseline of demographic and health accessand the population as a whole, manage costs, and improve utilization issues.value over time. This research was seen as an important op-portunity to improve access to meet the health care needs RESULTSof the community, support AMCs continuous improvementpillars (quality, safety, service, operations, and nance), and COMMUNITY BASELINE SURVEYsupport AMC’s commitment to employees (healthy work- A total of 487 surveys were completed at multiple commu-force and satisfying professional environment). nity locations. Community leaders acted as facilitators, help- ing investigators to reach audiences. In-person distribution of surveys was found to be most effective for higher response METHODS rates. Of the respondents, 86% (n=420) spoke English andPrimary qualitative and quantitative research methods were 14% (n=67) spoke Spanish. Among English speakers, 64%conducted. The research goals were as follows: (1) to assess (n=269) were women and 36% (n=151) were men, whereasand measure community health care utilization; (2) to ex- 45% (n=30) of the Spanish respondents were women andplore unmet community needs, beliefs, values, self-percep- 55% (n=37) were men (Table 1).tion, and cross cultural in uences; (3) to understand the con- Cultural Differences. Almost all the English speakerstext for the development of a PCMH in Austin, MN; (4) to were born in the United States, and more than half hadexamine key user populations and stakeholders of a PCMH; lived in Austin for more than 30 years (Table 1). Three-and (5) to identify the needs to be lled by the PCMH. fourths of Spanish respondents were born outside the Secondary research included a literature review and an United States, and almost 60% had lived in Austin for lessenvironmental scan to examine previous and current exam- than 10 years (Table 1).ples of PCMH efforts, trends in community-based care, and Income Disparity. The disparity between the incomehealth care trends to educate the collective team and stimu- of English and Spanish speakers was remarkable. Thelate thinking and dialogue. Some questions explored in the annual household income was greater than $50,000 forsecondary research are as follows: How are existing PCMH 30% of English speakers but less than $25,000 for 80%efforts constructed and how is a PCMH de ned? What are of Spanish speakers; no Spanish speakers had an incomethe design precedents in existing PCMHs? Who are the peo- greater than $50,000 (Table 1). More of the English-ple involved? What are the technologies/tools used? What speaking than of the Spanish-speaking respondentsare PCMH environments like? What are the technological, worked full-time (43% vs 29%), and fewer were unem-design, user, communication, and staf ng trends in PCMH ployed (40% vs 52%; Table 2).efforts? Preliminary observations focused on uncovering the Levels of Education. Disparities in education be-unmet needs and desires of the community regarding health tween English and Spanish speakers were also striking.care and assessing its health care–related behavior. Three-fourths of the Spanish-speaking population had an The qualitative process included embedding inves- eighth grade education, whereas virtually every English-tigators in Austin and neighboring towns for approxi- speaking resident had a twelfth grade or higher educationmately 16 weeks to gather information and conduct (Table 1).fieldwork. The investigators conducted in-depth, Relatively Low Self-Perception of Overall Health.semistructured community interviews, observations of Perception of health was also very different between974 For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings. a
  3. 3. USING DESIGN RESEARCH TO GUIDE HEALTH REFORM TABLE 1. Your Voice/Your Health Austin Survey Results (N=487) About you—demographics and overall health status English-speaking Spanish-speaking US native (n=420) (n=67) Yes 403 (96) 15 (23) No 17 (4) 51 (77) Sex (n=420) (n=67) Male 151 (36) 37 (55) Female 269 (64) 30 (45) Marital status (n=420) (n=67) Married 214 (51) 29 (43) Living with someone 40 (10) 15 (22) Separated 4 (1) 6 (9) Divorced 43 (10) 3 (4) Widowed 45 (11) 2 (3) Never married 73 (17) 12 (18) Residence in Austin (n=416) (n=65) <1 y 11 (3) 2 (3) 1-5 y 26 (6) 19 (29) 5-10 y 32 (8) 19 (29) >10 y 51 (12) 3 (5) >20 y 57 (14) 6 (9) >30 y 91 (22) 5 (8) Entire life 148 (36) 11 (17) Education (n=415) (n=64) Grade 8 or less 17 (4) 47 (73) High school or GED 136 (33) 12 (19) Some college 140 (34) 1 (2) College graduate 63 (15) 3 (5) Graduate school 45 (11) 1 (2) Other 13 (3) 0 Annual household income (n=393) (n=59) $0-$25,000 140 (36) 47 (80) $25,000-$50,000 133 (34) 12 (20) $50,000-$75,000 77 (20) 0 $75,000-$100,000 31 (8) 0 >$100,000 12 (3) 0 Overall health status (n=419) (n=66) Excellent 60 (14) 6 (9) Very good 194 (46) 5 (8) Good 119 (28) 29 (44) Fair 33 (8) 25 (38) Poor 13 (3) 1 (2) Data are provided as number (percentage) of respondents unless otherwise indicated. Percentages may not total 100% because of rounding.English- and Spanish-speaking respondents. Of English- Where Do People Seek Care When Feeling Ill? Bothspeaking respondents, 60% reported very good or excel- English and Spanish speakers most often sought care inlent health, compared with less than 20% of Spanish- Austin when it was needed. However, Spanish-speakingspeaking respondents (Table 1). residents were much more likely to seek hospital care than Gaps in Insurance Coverage. Insurance disparities English-speaking residents (Table 4).were as substantial as income, employment, and educa- Barriers to Access. Disparities in access betweention disparities. More than half of English speakers had English- and Spanish-speaking residents were relatedemployer-sponsored insurance vs only 7% of Spanish to lack of insurance and costs. Almost 80% of Spanish-speakers (Table 3). speaking residents reported not seeking care because of TABLE 2. Your Voice/Your Health Austin Survey Results: Work History English-speaking Spanish-speaking Work history (n=413) (n=66) Full-time 179 (43) 19 (29) Part-time 69 (17) 13 (20) Not working 165 (40) 34 (52) Data are provided as number (percentage) of respondents. Percentages may not total 100% because of rounding. 975 For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings. a
  4. 4. USING DESIGN RESEARCH TO GUIDE HEALTH REFORM TABLE 3. Your Voice/Your Health Austin Survey Results: Insurance English-speaking Spanish-speaking (n= 420) (n= 67) Insurance Yes No Yes No Employer paid 221 (53) 199 (47) 5 (7) 62 (93) Government paid 174 (41) 246 (59) 10 (15) 57 (85) Pay for own insurance 40 (10) 380 (90) 2 (3) 65 (97) Data are provided as number (percentage) of respondents. Percentages may not total 100% because of rounding.lack of health insurance vs only 11% of English-speaking feeling that varies from person to person and depends on theresidents. Cost was cited as a barrier to care more often by individuals baseline of health and wellness.Spanish respondents (Table 4). The research observations in the community provided valuable information about the obstacles and barriers toDEFINITION OF HEALTH AND WELLNESS care and the means for successfully surmounting thoseThe communitys de nition of health is succinctly summa- hurdles. When acting as caregivers, individuals observedrized in a personal quotation from one respondent: “I want few incremental choices for help: they could either totallyto live a long and healthy life so that I can take care of my- relinquish control (typically with high nancial implica-self and do what I need to do every day without constraints tions) or had to do everything themselves. One participantbecause X count(s) on me.” Depending on the participant, stated: “Most of the time I just take care of things myself.“X” could be a spouse, child, parent, neighbor, or colleague. I’d rather not bother anyone.” Since systems were notFor this community, our research found that means perceived as exible, individuals often encountered dif -balance, health, and quality of life. Indeed, wellness was culty nding resources to help them adapt to their changingoften described as “quality of life” rather than “absence of needs and personal situations. Men, in particular, often didillness or disease.” A signi cant number of people think they not ask for help and had trouble setting up systems to pro-are “well” because illness is absent or has not affected their vide temporary relief for the caregiver. Another participantquality of life. For the young, in particular, wellness is a said “I never think about getting help until it is almost too TABLE 4. Your Voice/Your Health Austin Survey Results: Access to Care English-speaking Spanish-speaking Access to care No. of respondents 420 67 Austin 329 (81) 48 (80) Outside Austin 40 (10) 9 (15) Don’t know 4 (1) 1 (2) Both 32 (8) 2 (3) Yes No Yes No Type of access No. of respondents 420 67 Community clinic 107 (25) 313 (75) 10 (15) 57 (85) Walk-in clinic 183 (44) 237 (56) 39 (58) 28 (42) Emergency department visit 52 (12) 368 (88) 6 (9) 61 (91) Hospital 141 (34) 279 (66) 47 (70) 20 (30) Veterans Affairs/military facility 20 (5) 400 (95) 4 (6) 63 (94) Another community-based group 20 (5) 400 (95) 8 (12) 59 (88) Stay at home and someone comes to you 15 (4) 405 (96) 8 (12) 59 (88) Yes No Yes No Barriers to access No. of respondents 248 47 No health insurance 28 (11) 219 (88) 37 (79) 10 (21) Cost of care 72 (29) 175 (71) 31 (66) 16 (34) Other family member needs more care 12 (5) 235 (95) 0 47 (100) Other needs more urgent 10 (4) 237 (96) 0 47 (100) Transportation dif culties 13 (5) 234 (94) 1 (2) 46 (98) Could not obtain an appointment 37 (15) 210 (85) 0 47 (100) Could not get off work 15 (6) 232 (94) 0 47 (100) Data are provided as number (percentage) unless otherwise indicated. Percentages may not total 100% because of rounding.976 For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings. a
  5. 5. USING DESIGN RESEARCH TO GUIDE HEALTH REFORMlate. I think it has something to do with the idea of being ing included in the conversation. Patients are often frus-carried off the eld…you know, like in football.” trated by not being able to digest information provided in Understanding what it means to be well can facilitate a physician’s appointment. As they become older, manyearly diagnosis and faster recuperation from an acute patients bring members of their family to their appoint-health problem. However, wellness is a vague concept. ment to take notes to ensure that they remember importantOur observations demonstrated intriguing social dynamics points. When given information or records for their ownfor identifying health and illness. Respondents commonly keeping, people feel empowered and are more motivated.de ned wellness relative to their typical baseline. Those These insights may lead to consideration of a new model,who had experienced illness had a much better under- in which people own their information and which wouldstanding of the meaning of wellness. They also gained a include open source data gathering, exchange, and sharedmuch greater ability to understand and articulate their con- access. This model includes the ability to view longi-cerns regarding their bodies and at times to make decisions tudinal deidenti ed data for future health planning forbased not on a physician’s advice but instead on what their individual patients and the community.bodies were telling them. Respondents sought out other Another example showed that many people feel isolatednetworks to understand what “normal” meant and how physically and psychologically. Any existing “community”they should be feeling. is lost once people become ill or become immobile in their homes. Lack of transportation or fear of the unknown canRESEARCH INSIGHTS prevent participation in new peer networks; the lack of activeThe ndings are useful for creating design objects for new engagement in live peer networks can lead to psychologicalhealth care delivery methods. The insights were framed into isolation and depression. Some turn to online social net-themes classi ed as , , and works, others to existing peer groups that are not set up to . The insights assist with health issues, and still others become withdrawn.stem from respondents feelings about their own health and These insights demonstrate the need for the following: (1)wellness; the obstacles and barriers to care; and the means virtual and community social networking, (2) availability ofthey have used to successfully surmount those hurdles. For support groups and awareness of that availability, (3) accessexample, trust and transparency were perceived to be lack- to reliable transportation across the community, and (4) pos-ing in health care professionals. If people do not trust an sible contact with a live person 24/7 online or via a hotline.institution or individual, they are likely to seek care only in Our ndings also showed that people often hesitate toextreme cases and default to their own judgment. begin certain exercise or nutrition programs because they Cost and time were identi ed as primary barriers to do not perceive themselves as totally committed in the waystaying healthy and well. One research participant stated, they would like. Caregivers may feel as if they have few“I wish I had more time and money for treatments and incremental choices for support: they can either totally relin-expensive creams but kids come rst….” Although most quish control (typically with high nancial implications) orpeople, primarily women, did not feel as if they had they must do everything themselves. Programs that are per-enough time to be healthy, others (some older, some who ceived to be in exible are often abandoned or never begun,had recovered from illness, empty nesters, and retirees) and resources that seem unable to adapt to changing needswere equally frustrated by not knowing how to manage and evolving situations go unused. Some caregivers, menthe time they had. Some people felt so overwhelmed that in particular, do not ask for help and have trouble setting upthey had trouble carving out time for their health and well- systems that allow them temporary relief. People need care-ness. In general, unless something forces a persons state giving systems that are inherently more exible and adjust-of health to the forefront, it remains a low priority. When able. This type of “step-up or step-down” program may bepeople transition to a life stage with more time, they often less intimidating initially and may also prevent drop off.do not know how to use it and end up doing nothing. Over- “Community” insights involve the speci c challengesall, they perceive that hospitals “cost too much.” Although a community—the hospital, clinics, health care profes-cost conscious about what they are spending, they are not sionals, and residents—faces in providing the appropri-comparing costs over time. They have not embraced the ate level and type of health and wellness services. Foridea of “spending more to get more.” example, people who do not have an established and Although people seem to want to own their health in- healthy relationship with a physician may not feel “caredformation, they perceive that it does not belong entirely to for” in the traditional health system and may believe thatthem. Many believe that physicians do not want to share health care professionals are not listening to them, spend-or are withholding information or that they do not think ing enough time explaining their options, or listening topatients would understand. Women, in particular, like be- how they feel about them. 977 For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings. a
  6. 6. USING DESIGN RESEARCH TO GUIDE HEALTH REFORM Such people may turn to alternative healers, nutrition- sages that speak to them at their particular life stage.ists, and trainers for a more holistic experience, enjoying One research participant stated, “It’s funny…when I usebeing treated as a “client.” To build and keep loyal cli- an anti-wrinkle cream, I’m thinking about what I’m go-entele, these providers are going outside their expertise ing to look like in the future. But when I take vitamins,to treat patients. Through various programs (formal and I’m not thinking about what I’m going to feel like in theinformal), they are mirroring womens language and ful- future from the inside.” When interacting with traditional lling their need for communication: they are ghting for health systems, people do not feel “cared for” unless theybusiness by spending additional time listening to, check- have established a nurturing relationship with a particularing in with, and “caring” for their clients. This re ects health care professional. Community health partnershipsa pressing need for dialogue between patient and health could build and/or improve relationships between patientscare professional. For many people, that is at the root of and health care professionals. They would allow people“feeling cared for.” To prioritize their own health, people to become familiar with the health care setting and healthneed to feel as if their health care professional considers care professionals outside a necessary visit. People needthem a high priority. Increasingly, they are looking to to have a strong connection to the institution where theynontraditional providers to meet this need. receive care; otherwise, they seek it elsewhere. Long-term A new service integration model is needed to effec- investment in community relationships will help make thetively coordinate existing services, including physical Austin community sustainable.fitness, senior services, mental health, and childcare. Peer-to-peer networks can comfort patients by al-Barriers to obtaining care were identified at a systemic lowing for freer, more relaxed communication than islevel and included difficulties navigating complex typical of most exchanges with health care profession-health care systems, lack of insurance or the ability to als. Such networks can help address social isolation,obtain insurance, lack of access (the ability to obtain of particular concern in the elderly population, whoseappointments when needed), hesitance to bother some- stoic attitude and hesitance to “bother someone” makeone, lack of education, lack of communication, and the them more vulnerable.necessity to stay within a given health care system forpurposes of insurance coverage. It appears that a “big DISCUSSIONpicture, connecting view” is missing for both patientsand health care professionals, leading to misunder- Zuvekas and Taliaferro7 described disparities in healthstanding and quality of care issues. Individual organiza- care access as experienced by racial/ethnic groups andtions do not have enough time or energy to “spread the the uninsured; health care treatment and outcomes arenews” about other relevant services or to help people in uenced by a person’s ability to access the health carenavigate the entire system. There is a need for one “or- system. Freeman et al8 illustrated signs of deteriorationganizational entity” that can handle service and staffing. in health care access for the nation’s poor, minorities, andThe hospital/clinics could be a much stronger partner uninsured. The access concept has been explored in previ-in health and wellness if seen as part of an integrated ously published research. Khan and Bhardwaj9 suggestedcommunity network with nonmedical entities, such as that potential access to health care relates to the avail-physical fitness, mental health, transportation services, ability of health care resources (facilities and personnel)and other resources. relative to their needs for services, whereas realized ac- When people delay seeking care, they can develop co- cess relates to the actual use of such resources to satisfymorbid conditions that complicate their treatment. By the those needs. Use is greatly in uenced by availability, astime some seek help, their condition has become chronic, well as the inherent characteristics of the service systemwith multiple factors and complexities. A design concept and those of potential users, which express themselvesfor consideration is to explore “gap” clinics focused on as either barriers or facilitators.9 In this community, ac-multiple comorbid conditions that would serve as con- cess to care is often considered dif cult because of theduits for linking patients to more holistic wellness and complexity of the system and the anxiety associated withprimary care. Creating “open” referral systems to other navigating this complex environment. The results of ourcommunity care providers is worth consideration. study suggest that the needs of the community can best In the insights classi ed as being at the “intersection be met by simplifying processes and reducing anxiety.between the individual and the community,” the unmet The integration and navigation of services and greaterneeds of the public collide with the challenges faced access in terms of physical access, cost, and visibilityby a community in providing care. People prefer to be constitute a near-term win—not the creation of addi-presented with options. People look for targeted mes- tional individual products and services. The point is to978 For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings. a
  7. 7. USING DESIGN RESEARCH TO GUIDE HEALTH REFORMcommunicate to individuals how to care for themselves a static relationship that de nes for what and for whomthroughout their lifetime in a manner appropriate to each an agent is responsible. It is expressed by accountablelife stage and speci c individual situation and to equip agent 1 (A1), agent 2 (A2), which means that agent 1 isthem to make long-term behavior changes and adhere to accountable to agent 2 for performing tasks of this type.personalized regimens. The agents themselves are implemented using a layered Plsek and Greenhalgh10 urge abandoning linear models architecture, called .12 In the agent-driven mod-and developing new conceptual frameworks. These frame- el, peer-to-peer networks and individuals drive the devel-works should incorporate a dynamic, emergent, creative, opment of service infrastructure and navigation. Similarand intuitive view of the world to replace traditional “re- to the open source model, the agent-driven model movesduce and resolve” approaches to clinical care and service from the ground up, relying on peer networks to sustainorganization.10 Decreasing complexity in this community the exchange of critical information.would mean developing both virtual and live aids to as- The “Living Labs” concept represents a user-centricsist system navigation at life’s crucial transitions. The research methodology for sensing, prototyping, validating,creation of health kiosks at community meeting points and re ning complex solutions in multiple and evolvingmay allow easy access to information and appointment real-life contexts.13 Currently, a disparate system of healthscheduling; this includes bilingual health care profes- care professionals treats different aspects of wellness, pre-sionals and navigation aids. This community would also vention, maintenance, and illness.bene t from physician-guided assistance in prioritizing Currently, the open source model in combination withconditions and how to treat them. Another concept worth the agent-driven model is most conducive to addressingexploring is the provision of health education from the patients unmet needs because they place the emphasis onprimary school level on up. Future health mapping could patients and their family members and friends. The openhelp patients understand the life stages that lie ahead and source model empowers patients and gives them a degreehow their current behavior affects health issues that could of control in their health care. It provides people with thearise at those stages. A navigator service and/or a 24-hour means and tools to take care of themselves.hotline would also be useful. This community may bene tfrom increased education and awareness of mental health CONCLUSIONand stress-reduction services. Redesigning the fragmented US mental health system Applying design research as an initial step in creatingrequires knowing how service sectors share responsibility a new community health care delivery system yieldedfor meeting health care needs.11 The complexity of the several new insights. First, such a community-focusedUS mental health care system diffuses responsibilities for system should adopt a whole-person orientation thatpatients over multiple service sectors, posing challenges seeks to reduce service isolation and increase accessi-for patients, health care professionals, and policymak- bility. Second, it is critical to evaluate community-wideers.11 Our examination of Austin shows various service perceived barriers to care, such as use of outside servicenetwork models that coexist and overlap. The existing network (transitory migration), community scal sustain-model shows a fragmented service network. From the ability, and visioning. Third, chronic social conditions,community perspective, the biggest service ow problems such as social and scal waste, the intersection betweencenter around the following: (1) overall network discon- individuals and community, and peer-to-peer health cannect and perception of disconnect, (2) transportation and be improved through experience and investment in one’smobility, (3) transparency of information, (4) visibility of own well-being. Fourth, enduring solutions will facilitateservices, (5) service integration, (6) facilitation and bilin- healthy behaviors, simplify processes, improve access,gual sources, and (7) burden of care issues. and reduce costs. A different service network model is the “open The triple aim offers a framework, but design researchsource” community service network model. This is a provides a more detailed understanding of the needs of“bottom up” approach to designing services with an the community based on actual observations that can beoverall emphasis on data transparency. People drive this used to guide health care professionals, policymakers, andmodel insomuch as the model is meant to ful ll their payers in developing new ways to deliver care. Currentneed for sharing, listening, transparency, access to infor- efforts at health care reform do not meet speci c patientmation, choice, and creativity. care needs. To better do so, future system design concepts “Agent-based systems” were developed to help man- should focus on creating nurturing relationships; creatingage the care process in real-world settings. They focus health, not health care; eliminating complexity for users;on task allocation and accountability. Accountability is and managing costs. 979 For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings. a
  8. 8. USING DESIGN RESEARCH TO GUIDE HEALTH REFORM 5. Minnesota Department of Health (MDH). Minnesota’s vision: a better state of health. Health Care Homes (aka Medical Homes). http://www.health.state. mn.us/healthreform/homes/index.html. Accessed June 24, 2011. 6. Austin, Minnesota census data and community pro le. AmericanTowns. Com Web site. http://www.americantowns.com/mn/austin-information. Accessed June 24, 2011. 7. Zuvekas SH, Taliaferro GS. Pathways to access: health insurance, the health care delivery system, and racial/ethnic disparities, 1996-1999. . 2003;22(2):139-153. 8. Freeman HE, Blendon RJ, Aiken LH, Sudman S, Mullinix CF, Corey CR. Americans report on their access to health care. . 1987;6(1):6-8.REFERENCES 9. Khan AA, Bhardwaj SM. Access to health care: A conceptual framework 1. Fenig EC. Despite the new mood, the economy not doing well. American and its relevance to Health Care Planning. . 1994;17(1):60-Thinker Web site. Published January 14, 2011. http://www.americanthinker.com/ 76.blog/2011/01/despite_the_new_mood_the_econo.html. Accessed June 24, 2011. 10. Plsek PE, Greenhalgh T. Complexity science: the challenge of complex- 2. Campbell KE. Report on healthcare spending shows government with 44% ity in health care. BMJ. 2001;323(7313):625-628.share. American Thinker Web site. Published January 7, 2011. http://www.ameri- 11. Wang PS, Demler O, Olfson M, Pincus HA, Wells KB, Kessler RC.canthinker.com/blog/2011/01/report_on_health_care_spending.html Accessed Changing pro les of service sectors used for mental health care in the UnitedJune 24, 2011. States. . 2006;163(7):1187-1198. 3. Institute for Healthcare Improvement. The IHI Aim: better care for 12. Huang J, Jennings NR, Fox J. An agent-based approach to health careindividuals, better health for populations, and lower per Capita costs. IHI.org Web management. . 1995;9(4):401-420.site. http://www.ihi.org/IHI/Programs/StrategicInitiatives/TripleAim.htm. Ac- 13. Eriksson M, Niitamo V-P, Kulkki S.cessed June 24, 2011. Lulea 4. Saffer D. University of technology. Sweden: December 15, 2005;1-13. http://www.vin- 2nd ed. Berkley, CA: New Riders; 2010. http://www.designingforinter- nova.se/upload/dokument/Verksamhet/TITA/Stateoftheart_LivingLabs_Eriks-action.com/designingforinteraction2_sample.pdf. Accessed June 24, 2011. son2005.pdf. Accessed June 27, 2011.980 For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings. a

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