Jennifer Lundblad, President and CEO of Stratis Health: Co-Designing Healthcare Quality Improvement

Van Ton-Quinlivan

Welcome to WorkforceRx with Futuro Health where future -focused leaders in education, workforce development, and healthcare, exploring new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health.

Medicare is the federal health insurance program that provides coverage for people 65 and older, as well as some younger people with certain disabilities or conditions. It covers nearly 20 % of the U .S. population and accounts for about 14 % of total federal spending, which is why there are a host of state and federal efforts focused on lowering costs and improving quality in the program.

We’re going to focus on one of those efforts today and take a look at what’s involved in improving healthcare quality in general with Jennifer Lundblad, the president and CEO of Stratis Health, a nonprofit that works with clinicians, organizations, and communities in Minnesota and beyond towards that end.

Jennifer has an extensive background in leadership, organization development, and program management in both nonprofit and education settings, and is a frequent speaker on topics related to health quality and organizational change. She serves as a member of the Policy Research Institute Health Panel in addition to several other local and national task forces and advisory groups.

Thanks very much for joining us today, Jennifer.

Jennifer Lundblad

Delighted to be with you here today, Van. Thank you.

Van Ton-Quinlivan

Well, let’s set the table with hearing about what Stratis Health does to drive and support quality improvement and who you engage with in order to do that.

Jennifer Lundblad

Great, I’d love to set that table for you, Van. So Stratis Health, as you said, is a nonprofit organization. Our mission is to lead collaboration and innovation to improve health. So what does that mean we do? You might think of us as designing and implementing improvement initiatives that improve the health of people and communities and improve health care delivery efficiency and value. So we work across the full continuum of health care with hospitals, clinics, nursing homes, home health and we work in communities with public health, with community -based organizations, and with other partners.

So some of our work is about translating and accelerating the adoption of research into practice, which is just terribly slow in this country. Other of our work is about testing new models of care delivery, and other of our work is about facilitating and convening groups so that they can together solve problems and work towards shared goals. So it’s exciting work. It’s challenging and it’s hard work all at the same time.

Van Ton-Quinlivan

Well, that sounds like a very complex set of stakeholders and a very big scope, so we’re excited to learn more. So Jennifer, Stratis Health, as you mentioned, has been long involved in improving health and care for Medicare recipients. In fact, we met because of your involvement in a federal network called the QIN-QIOs. Could you share more about what that network of organizations does and who it serves and its focus?

Jennifer Lundblad

Yeah, absolutely. Stratis Health does work for a variety of customers and a variety of funders, but our most long -standing body of work is serving what’s known as a Medicare Quality Innovation Network-Quality Improvement Organization or QIN -QIO. What that program is all about is that Medicare engages with organizations like Stratis Health around the country to assure and improve the quality of care for Medicare beneficiaries.

These organizations, like Stratis Health, work across the states that we’re designated to serve with all of the providers in health care that support and care for older adults, and with the state agencies and other organizations such as payers that are active in those communities and states. There is a designated QIN -QIO for every state in the country and most of us operate in regional consortium.

Stratis Health serves along with our partners in Superior Health Quality Alliance currently in Minnesota, Michigan, and Wisconsin. And as a result of that work, we and our peers who do this work across the country are sort of the boots on the ground, the in-the-field quality improvers throughout the country. So we touch every corner and every part of each of the states we work in. We’re trusted by those organizations because we’re local, we’ve had long -standing relationships, and we’re really valued for that external change agent expertise that we bring.

Van Ton-Quinlivan

So Jennifer, for the listeners who are less well versed about the healthcare ecosystem, you talk about “boots on the ground” quality improvers. What are some examples of initiatives or efforts so that our listeners can better understand?

Jennifer Lundblad

When you think about the Medicare program and you think about older adults, we generally work across five broad categories in that QIN -QIO program, all aligned with national strategies and goals so that it rolls up to have big impact across the country. Those areas are in nursing home quality, helping to care for some of our most vulnerable community members; care transitions and care coordination, because our health system really kind of falls down on the job in many instances, particularly in older adult transitions through their care needs; patient safety; chronic disease and prevention, and behavioral health, including the appropriate prescribing of opioids.

Within those five categories, we deploy a whole range of strategies. If you think about the range of healthcare provider types and the broad geographies we’re serving, we have to draw on every tool in our toolbox and match those methods and tools with what the needs are at hand.  I’ll give you an example of some the work we’re doing in Minnesota as part of Superior Health Quality Alliance. Our work is always data driven and always collaborative. One of the ways we try to drive that improvement is through community coalitions. We are a convening force that brings together organizations across the care delivery continuum as well as local partners like the Area Agency on Aging or local public health or maybe the local economic development organization or local government.

We bring them together, share with them the data that we have access to as part of the Medicare program, and help them discern where are those areas where there is the biggest problem, where there’s a shared need and a shared goal. We help them use that data to develop action plans and then help each of the members of that community coalition determine how their work can contribute to and interlock with the others to make change.

We might bring in guest faculty or subject matter experts. We bring the facilitation to allow those community coalitions to take action that’s going to best improve the health and care for adults in their community. Again, data and collaboration really underlie all the kinds of strategies we deploy to help improve quality of care delivery.

Van Ton-Quinlivan

Well, I want to invite you to have a bragging moment. Is there a particular outcome or set of progress that you’re really proud of?

Jennifer Lundblad

We again are so proud to serve in this capacity for Medicare and for all of our other funders and clients. I’m gonna share maybe two moments if you’ll allow me. One is some work that we’re doing around the opioid crisis and opioid prescribing. There is such stigma associated with addiction. It’s not a moral failing, it’s a chronic disease, yet we don’t treat it that way. If someone who has diabetes, were to have their insulin withheld, we would think that’s appalling. Yet we don’t have that same reaction when someone who has opioid disorder has medication for it — which is the gold standard of care for someone with OUD — withheld from them. So we’re trying to overcome stigma.

One of my proud moments as part of Superior Health Quality Alliance and our Stratis Health work is what we call our “Shine a Light on Stigma” campaign. We have had hundreds of clinicians and community members sign on to this campaign, pledge to treat their patients with OUD with respect and dignity, and to adopt those evidence -based best practices and the gold standards of care around medications for opioid use disorder. That makes a big difference for people and for communities.

Van Ton-Quinlivan

And what was your second?

Jennifer Lundblad

The second example is also related to opioids, but drills down to a very specific instance. We — not through our QIO work for Medicare, but through other projects that we do — are working quite frequently with county jails throughout the country to help them better respond to people who end up in jail who have substance use or opioid use disorder. So we work with them to redesign their workflow. We work with them to engage with the local community care teams so that when someone is discharged from jail, they can go immediately into community care. And importantly, we’re helping both law enforcement and correctional care to, again, overcome that stigma and get people who are incarcerated the right treatment at the right time.

I would just cite a very specific example for you. We worked with a county jail on all of those things about workflow and process and we got them to reduce the time from intake to initiation of appropriate medications from forty-nine days to twelve days. That’s a 75 % reduction. We still have further to go, but those kind of changes make a difference in people’s lives. We know that overdoses, overdose deaths, and recidivism are some of the biggest problems. They disproportionately affect people of color who are incarcerated. It’s great when we can see a result that we know that our hard work and our partnership with those jails and those caregivers is making a difference in people’s lives.

Van Ton-Quinlivan

Thank you for sharing those two very impactful projects with us. So, let’s for a moment transition to workforce issues. What are you hearing, Jennifer, from your collaborators and partners? And are you sensing a difference in workforce needs between rural and urban communities or from state to state?

Jennifer Lundblad

There are a couple of things that are top of mind when it comes to workforce right now. One is burnout. The workforce that we have in healthcare today is experiencing such burnout. They’ve lost that sense of well -being and joy and reward in work, which is the very reason why most people go into healthcare. That was certainly true before the pandemic and has now been exacerbated by all that was experienced by frontline caregivers during the pandemic.

The other is the workforce themselves. We have a shortage. We had a shortage before the pandemic and then many people left healthcare during the pandemic and so there are certainly not enough primary care physicians, nurses and nursing assistants out there to care for the patients that are in healthcare facilities and organizations across the country.

I would say it’s both a pipeline issue — we need to increase that pipeline of training for those professions — and it’s a need to redesign work. Pipeline alone isn’t going to solve those problems. We need to change how we consider our care teams, how they work together, how we support them, how we use technology, how we train them, and how we engage them.

So in answer to your question about kind of rural and urban or state differences, I do think there are differences or at least the workforce issues manifest themselves differently depending on where you are. Rural-urban is one example. There was for a time — and I think it’s a bit better now based on the work we do with rural hospitals across the country — but there was a time when rural facilities needed to use traveling nurses in order to keep their doors open. If you’re a small rural hospital and you don’t have the right nursing staff levels, you can’t keep your doors open, so hospitals had to rely on traveling nurses, which is

really expensive, first of all, and those nurses are really clinically skilled, but they don’t have the same commitment to care that someone who’s local and part of that community does.

One of the real assets of rural health care is that it is indeed local. If you are a physician or a nurse or otherwise in health professions in a rural community, when you leave that facility, you probably see your patients at the grocery store, your kids might play on sports teams or be in school activities together, you might be neighbors with them, and so when we do work that’s of high quality, we know those people are highly committed because they’re caring for their neighbors, their friends, their family members. When traveling staff come in, we can’t expect them to have that same level of commitment. So, it’s expensive and it has a long -term detrimental effect on quality and safety overall in terms of that commitment and intention.

But I would also say there’s really innovative things going on and that does, indeed, vary by state. My home state is in Minnesota and our state health department is recognizing that we have quite a number of people who have come to this country having been trained in other places in their health professions. And so our state health department has created a pathway for foreign trained physicians to accelerate through residency and get to being credentialed, licensed and being able to practice, which helps workforce. It helps having people of the same culture, community, or language being able to care for those patients. There are innovations that are happening state by state, and we should want to encourage more of those.

Van Ton-Quinlivan

In your collaboration, you’ve talked about making available evidence -based practices as part of the training and technical assistance to others. Are there other types of training that Stratis Health offers to the healthcare organizations that participate?

Jennifer Lundblad

Yeah, we think of training as one of our core competencies along with convening, facilitating, and providing technical assistance. With those core competencies, one of our underlying principles is that we are building capacity. We are teaching to fish, not fishing for them. So all of our training is designed to build capacity so that that can be sustainable when we step away. We’re the external change agent and we want that to be sustainable by those organizations that we’re working with.

We create bite -sized modules that can help, for instance, a new quality director who has previously been a nurse and he or she has taken on a new role. We have a whole curriculum that’s online that they’re able to use and draw upon as they build their quality improvement skills in addition to their clinical skills. We also are believers in the power of peers and so we create learning and action networks.

We use Project Echo as a peer -based and technology -supported tool so that we are not only helping to convey knowledge and best practice and emerging trends, but also giving those participants a network of peers and colleagues that they can call on for problem solving and help and assistance as they move and continue to do their roles and continue to improve their care.

Our training draws upon the kind of full complement of ways that we might both share knowledge, but help those participants to create and learn from each other in ways that are helpful through mentorships and other programs that we established to support quality.

Van Ton-Quinlivan

Jennifer, I’m curious, are you hearing much regarding value -based care and advancing those concepts within the quality improvement community?

Jennifer Lundblad

We absolutely are. There’s been a trend since the passage of the Affordable Care Act in 2010 to slowly but surely move from a volume -based or fee -for -service -based payment environment to one that is recognizing and rewarding for value. That’s the combination of quality and cost and experience that really helps put the health of a person at the center, not how many times they’re seen or what volume of procedures that they have.

We lead a national program called Rural Health Value, because it’s especially important to help bring rural hospitals and other provider organizations along in this journey. They are often paid in ways that are intended to support the rural safety net, but are in fact sometimes counter to value and value -based care and delivery. So, trying to bring forward the innovation that’s occurring, trying to study and learn from examples where rural is adopting and implementing value -based care and participating in value -based payment models is especially important to Stratis Health.

Van Ton-Quinlivan

Fascinating to learn about the infrastructure of healthcare, here. All right, switching topics a little bit…the Biden administration issued an executive order that defines new staffing ratios in long -term care facilities like nursing homes. Tell us why you think they did this and what do you foresee as difficulties that might be experienced on the ground in implementing it?

Jennifer Lundblad

Well, the instinct certainly makes sense. Staff in nursing homes care for our most vulnerable populations who aren’t able to live at home and independently and we know how important it is to have the right nurses and care teams and nursing assistants there in nursing homes. That’s why I believe the Biden administration moved forward with this piece of policy and regulation.

I think it’s in direct response to what we saw happen during the pandemic. Nursing homes were the initial epicenter of the pandemic. When you’re in congregate living and you have people who have the most vulnerable health conditions, of course it’s going to cause illness and death.  I think all of us watched that in horror in those early days of the pandemic.

But I think that it’s not just the staffing ratio that’s going to solve the crisis in long -term care. I think it’s really important that there are the right staff and the right mix of staff, but it’s not a one size fits all. We also have to consider things like social work, also have to consider things like infection control, we have to think about what a living wage means. Certified Nursing Assistants, who are part of that ratio, are often some of the lowest paid people in the health system and nursing homes are competing with Walmart or competing with local retail or other industries to get those staff. And so until we solve that larger issue of living wage and until we solve that larger economic development issue, a staffing ratio with a glide path is going to be challenging.

A JAMA study just came out this week that indicated only 20% of nursing facilities across the country are currently at the staffing levels that are in the mandate so we’ve got a long ways to go. Again, instinct and directionally correct, but it has to be wrapped in a larger strategy that enables that workforce to be there, that enables the training and support and regulation to adopt and adapt to ways that will create the best care and the best environment both for those living in nursing homes and for those working there.

Van Ton-Quinlivan

Thanks for helping explain that policy to our listeners. Now, Jennifer, what are some recent and emerging changes and needs in the healthcare quality improvement field? We’d love a tutorial.

Jennifer Lundblad

Our work and our approaches have been traditionally grounded in quality improvement and patient safety theory and science, and they still are. Those are some really valuable methods like testing things out, the “plan, do, study, act” method, and using data and statistics to identify trends, patterns, and outliers. Those will always be part of how we do our work, but what I think is exciting as I think about what has emerged in terms of quality improvement approaches is both implementation science and co -design.

Implementation science is what will enable those of us who work in quality to do the replication and adaption and adoption much faster. It’s so frustrating to watch a pilot study or a demonstration study be effective and show promise and then see it languish. It doesn’t get spread rapidly. We don’t see the adoption and spread of those really exciting and promising practices and changes. So, implementation science — as it’s built on behavioral economics and network theory and the other underlying components of implementation science — gives us a different base to come from and different approaches that allow us in the quality space to accelerate the adoption of those promising practices and models. So, that’s exciting.

The other is co -design. It’s a little bit linked to implementation science, but co -design is a part of an improvement process that brings to the fore the voices and experiences of those who are traditionally not part of or not listened to during a quality improvement process. So it’s perhaps people with lived experience. It’s perhaps people who aren’t seen as directly a part of a process, but have actually a great deal of influence in how something can be designed better.

It’s like that old saying that if you want to understand how to get something done, ask the people who are most affected by it. We have a lot to learn from that in healthcare space and co -design is an emerging approach that will allow us to bake that into our methods so that we can design things in the right way from the start and then replicate and spread them more rapidly. Those are two exciting changes that we’re beginning to use at Stratis Health and see very much promise around.

Van Ton-Quinlivan

By the way, if one of our listeners is interested in having their family go into this field of healthcare quality improvement, how does one even do that?

Jennifer Lundblad

There are many paths to quality improvement. Our staff, for example, often come from having been in care delivery and wanting to have a greater impact. So, instead of working for a single organization or health system, they can come to an organization like Stratis Health and have a much broader impact working with more facilities.

There are public health avenues to quality improvement. There are health care, physician, and nurse avenues to quality improvement and there are behavioral sciences avenues to quality improvement through, for example, health education. So it is a field in and of itself, but it is also an overlay to many other parts of health professionals that are wanting and seeing the need to be able to address the continuous improvement and continually raising the bar for what quality and safety are all about.

Van Ton-Quinlivan

Thank you for that career tip for our listeners. Let’s end with a big picture question. What concerns you and what excites you about the future of care.

Jennifer Lundblad

The erosion of trust is what concerns me. I think we’re coming off a very challenging time related to the COVID -19 pandemic and all that that both illuminated and exacerbated and I think we’ve seen the trust between patients and their clinicians erode. I think we’ve seen the trust between clinicians and healthcare administration erode. I think we’ve seen the erosion of the trust in science. I think seen erosion in trust between urban and rural.

If you layer all those things on top, it’s a very concerning picture because in the work that we do around quality improvement, trust is our currency, right? We’re coming in to help and we need to be trusted and we need to be trustworthy. And when there are all these breakdowns over multiple levels related to trust, it’s really concerning as we look ahead and try to do the kind of work that’s so important ultimately for and communities.

The flip side of that, what am I excited about, is the long overdue recognition that a person’s health is so much more than the medical or clinical care that they get. We’ve known that for a long time, but that’s finally been elevated in such ways that it’s now central to so much of the work of healthcare and so much of the work of Stratis Health and other organizations like ours.

We’ve recognized that social needs and social care are part of the fabric of health. It’s now being measured differently by Medicare and by state organizations and by health plans. It’s tightly linked to commitments to improving health equity and addressing health disparities that we have at the local, state, and national level. And so we fully embrace the broader conception of health, even as we continue to use healthcare as our point of leverage for making those changes. That’s promising because that’s recognizing the full person that everyone is and the whole person care that we can deliver.

Van Ton-Quinlivan

There you have it. Thank you very much, Dr. Jennifer Lundblad, for being with us today.

Jennifer Lundblad

Thank you, Van.

Van Ton-Quinlivan

I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future -focused workforce in America.