An Exploration of a Family-Centered Business Model, from Children’s Health System of Texas
Interview with Peter Roberts, President, Population Health and Insurance Services at Children’s Health; and Cheryl McCarver, VP & Executive Director Health & Wellness Alliance for Children Children’s Health.
Cheryl McCarver and Peter Roberts are eager to share a report from their four year journey with 200 local families, Children’s Health Dallas staff, and local community agencies to employ human-center design thinking strategy to co-create and prototype a new business model for health that focuses on the entire family in the context of their particular lives and community.
The report is open source, so Roberts and McCarver encourage others to share broadly, employ the tools, improve upon it and share again. “We have incorporated the learnings from the work into our Medicaid HMO and the Health and Wellness Alliance for Children, our community integrator here in Dallas, as a new business model,” says Roberts.
Link to the PDF version of the report HERE. Email Cheryl McCarver HERE to get a copy of the report in book form.
Interview by Tom Peterson
Stakeholder: What is the family-centered business model and why did you put it into this format? What is this project all about?
Peter Roberts: I was hired five years ago by Children’s Health in Dallas to build a Medicaid HMO. In the course of doing that, we decided to spend significant time actually interviewing, talking with, and getting to know families in the community. It was those initial discussions that made us realize that the job that families wanted done was not just to have health insurance, was not just to have medical care, but they wanted a better life. They were more interested in their well-being than they were in insurance and medical care. They actually led us to this concept of family health and well-being. Our hypothesis going in was – if you improved the well-being of a family, could you also improve both their health and their use of the medical system?
Stakeholder: One of your starting places was to reduce the inefficient use of the emergency department. Even though you had pediatric services throughout the area, people were still using the emergency department.
Roberts: I did direct observation work in the emergency room and was struck by the frequent and repeated use of the emergency room at all hours of the day or night. This was not just after-hours. Actually, 50 percent of our emergency room visits are made from 8 am – 5 pm, when you would think physician offices would be wide-open. I was struck by that and that we kept seeing the same families. So, rather than just say, “Well, I know what the answer is,” we decided to spend some time understanding why families used the emergency room for regular day-to-day medical care.
Stakeholder: You describe in the book a 15-week prototype program that you tested with 9 families. What were your goals for that and how did that work?
Cheryl McCarver: Our nine-week program was in a neighborhood in north Dallas where we leaned into organizations that we had relationships with and recruited families to be part of this experience. We had a hypothesis and a prototype that was developed with families in mind and we used this community to test this concept that if we met with families and talked about where they were and how they wanted to move forward in their goals.
We brought in care navigators, social workers who met with these families and set SMART goals based on what they felt was important to their well-being, which we believed would then impact the health of those children. Our goals there were to learn from them and to see if we could validate that if we helped families make their own self-identified goals, then that would help improve the well-being of the system in which that child lives as a whole. So, we focused on the entire family.
Stakeholder: Were these families of your already existing Children’s patients?
McCarver: Some might have been patients, but these were families that we had relationships with from prior interviewing and observations. New families were recruited as well.
Stakeholder: That’s a pretty intense approach for a healthcare system to take, including a lot of one-on-one meetings as well as group meetings.
Roberts: The original objective was to build a health insurance program. And as we thought about and assessed the enrollment of the children in a health insurance program, especially vulnerable children from vulnerable families, it became clear that if we focused only on the families and only on the medical determinants of health we were not going to move the needle. We were not going to impact their behaviors. We needed to embrace the entire family in the community. That’s what drove us to that real shift from the medical world into the community and from the individual child to the family. We call it Family Health and Well-Being.
Stakeholder: Was there anything that surprised you or that you learned that was especially interesting?
McCarver: One of the most intriguing observations for all of us was how the families built their own sense of support and community and started helping each other. This is one of the foundations that we’re learning across the country with building resilience and community among families. That certainly played out as families got to know each other and their kids played together. During each session they built a family inside their own family and a comradery that’s the key to strengthening family and community.
Roberts: That’s a good one — that families have more agency and power than we allow them to or enable. Number two was the constellation of social determinant challenges facing that family every single day. It was clear to us that we’ve got to help families in the way that they address that constellation and, as Cheryl said, we’ve got to help families strengthen their own sense of agency and control over their lives.
Stakeholder: You mentioned agency — that was one of your five elements of well-being: personal power. Can you talk about those and where they came from?
Roberts: Our collaborative team — which included Children’s Health staff, stakeholders from the community, community service agencies, and families themselves — were led by the Business Innovation Factory in a series of Design Studios. Then we took the material from the Design Studios and created these terms of balanced outlook, sense of self, personal power, connected knowledge, and system of support. Then we brought those terms back to our collaborative group to see if that described a belief-model that they had.
Second, we created a continuum for each of these elements of well-being. Then our observation was that the families that were stronger in these elements of well-being were actually thriving, as opposed to just struggling each day with those social determinants that were around them.
I watched a young woman, a single mom and pregnant, come to the realization that in order to move on she needed to go back and get her GED and her high school diploma. I watched another mom make the decision, and actually re-enroll in a community college despite the fact that she’s a single mom, raising a child, living on their own. You see that kind of personal power begin to emerge because they changed their perception of who they were and what they were capable of. As they connected the dots they realized that was going to be one of the most important steps to take, to take care of yourself first. It’s like when you’re on an airplane and they tell you to put on your own oxygen mask first.
McCarver: As we journeyed alongside our families, I recall the interaction between the parents and their children becoming strengthened. In one family, the son was trying to build healthier behavior and the mom became part of that. They applied naturally this whole-family component and the dynamic as they, together, decided on healthier behaviors and started experiencing that as a family.
We just gave this space, this opportunity space. It was cool watching families explore this thought process and how they accepted it and just continued. It was remarkable how the relationship strengthening between the adults and the children happened organically in this environment.
Roberts: When I was involved with, not only the families, but the health coaches and the patient navigators, I heard repeatedly that the hardest part for the coaches and navigators was that for the first time they found themselves having to, and forcing themselves, to let go.
There was a family whose car was towed away from their apartment parking lot and impounded. The family believed the landlord was in cahoots with the towing company, and they would find some small thing about the vehicle. In this case, it was an expiration of a tag on a license plate, and they used that as an excuse to drag the car away. Well, the first reaction of the health coach is, “Well, I’ve got to help you get your car out, so let me make some phone calls, let me get engaged.” And the mother said, “No, that’s not my highest priority right now. Therefore, I wish you would just step back and not engage in that particular issue.” The frustration of the health coach not being able to intervene and then watching that family struggle without transportation was probably the hardest thing she said she’s ever done in her career.
Stakeholder: There’s a lot in your model about building trust and focus on finding community partners that can transfer some of that trust to the process.
McCarver: When we first started we had our short list of partners in the target area where we were going to bring this financial coaching prototype. The first organization that we called was eager to assist our families and actually prioritized their approach to coaching families. They made their staff available to our families for coaching around credit and banking. That organization wouldn’t have thought about allowing our families priority-access without a longstanding relationship from the alliance and the rest of our team.
So it’s not only trust that is built with the families, it’s trust with our community-based organizations and recognizing their strength, capacity, and willingness to be there for these families. That’s priceless when you’re trying to help families work with systems that have made them jump through so many hoops to access these social resources.
Roberts: The recruitment process for the families was through trusted agents in the community. We had to establish trust with the community leaders and the agencies before they recruited the families. It was based on that trust that the families then were willing to sign up, listen, participate, and give us a chance.
Stakeholder: You describe measurements, including a high rate of families that achieved their goals. If I understood it right, 100 percent of the families overcame obstacles and made progress.
Roberts: For the prototype itself, we went to the literature and found a model called the Kirkpatrick Model, which basically relies upon the learner or the person in the experience to qualitatively provide feedback in terms of what did they remember from the experience, what did they learn, what behaviors did they change, those kinds of questions. We also used a self-developed well-being quotient and that quotient actually asked families to rate themselves using these five elements of well-being and give themselves rating both before and after the experience.
Stakeholder: And what did you find?
Roberts: In most cases, the families could point to specific behaviors that they changed in their family dynamics and could point to specific learnings they had within their family. Personal power, as Cheryl indicated, increased probably the greatest. Their own assessment of their personal power had some of the greatest increases in it. The sense of self, from more unstable to stable, also had significant improvements.
Stakeholder: What are your plans for the model itself and how will you share it?
Roberts: We have incorporated this model into our recently launched Medicaid HMO, which has approximately 10,000 members in it. The combination of our care management team under the HMO. The community integrator team under Cheryl and the Health Alliance are responsible for leading our families in the HMO through this process.
We just started in the new year with our home visits for each of our families that are enrolled in our HMO, so only a few families have set goals. After they set the goals, the navigators from the Health and Wellness Alliance connect those families with the social service agencies in the community to help meet the goals that are laid out.
Stakeholder: So you’re hoping to include all 10,000… did you say individuals or families?
Roberts: It’s 10,000 children, but actually each child is surrounded by a family.
Stakeholder: You are hoping ultimately to include all 10,000 children with this model?
Roberts: Yes, right now we’re having a blitz of home visits, as you can imagine, but as the HMO grows each year, we’ll be adding new families and we’ll start the process with each of those new families.
Stakeholder: You’ve made this program design available in PDF and book form – how do you imagine this being used by other health systems?
Roberts: My hope is that other health systems will take individual chapters and certain tools, metrics, and approaches that apply to them and improve them even more. Cheryl’s done some thinking about our community stakeholders – our Health and Wellness Alliance partners – and how they may be able to use this program or playbook in their work.
McCarver: This relationship-building around social services is an aspect of how we approach and link our families to their needs. But we are also learning that it’s really all about meeting those families where they are. It’s about supporting those social services and our care navigators in recognizing smaller goals that may not actually be the transfer of a service, but a conversation and support to help our family think more about what exists within that household that will help them be successful.
Roberts: This is our second playbook. The first focused on collective impact and our learnings from applying collective impact in a specific set of zip codes in a place-based initiative. Our hope is that people will use each playbook as open-source documents and literally rip out individual chapters and tools to test and use in their own journeys.
McCarver: It’s important to bring families alongside your journey as a hospital, as a community-based organization, or provider. No one can do it alone, and it will be a better product when the family is recognized as a key player in the co-design and creation of solutions. The old way of designing programs without the end-user in mind is most probably going to fail and not be as impactful. So, being courageous enough to respect the family, the end-user, at the beginning of our work, at the beginning of thinking about our work and planning will really be priceless as we move forward in this whole endeavor of helping folks be healthier, and live longer, and have a better quality of life.