Pediatrician and Founder of Pathways to Population Health Nathan Fleming joins us to share the keys to collaboration between nonprofits and healthcare systems. Nathan shares the philosophy that makes Pathways to Population health successful and the role of nonprofits, governments, and healthcare organization role in making a healthy community
(2:45) an intro to Pathways to Population Health
(5:30) The Milwaukee model for cross sector collaborations
(7:40) Setting up relationships between nonprofits and healthcare providers
(11:00) Tips for creating equitable collaborations between a large and small organization
(15:20) Data sharing’s role in collaboration
(18:50) P2P’ s culture of health
(21:40) What Nathan learned from Harvard Professor Paul Farmer
(26:42) Nathan’s greatest lesson learned from starting nonprofits.
Pathways to Population Health (the organization): www.pathwaystopopulationhealth.org
Learn how your local tax-exempt hospital uses its community benefit dollars: www.CommunityBenefitinsight.org
Network for Public Health Law: https://www.networkforphl.org/
Nathan’s twitter: https://twitter.com/nathanflemingMD?lang=en
Pathways to Population Health
Dolph Goldenburg: Welcome to the Successful Nonprofits™ Podcast. I’m your host Dolph Goldenburg. We’re joined today by Dr. Nathan Fleming to discuss his approach to cross-sector collaboration. Nathan is a pediatrician, holds an NPH, has started three nonprofits and authored the book Pathways to Population Health. His organization by the same name pathways to population health has used cross-sector collaboration to dramatically improve the health outcomes and communities across Wisconsin, and everyone here knows how much I love the idea of a big bold goal. When you look at your strategic plan and they have a big bold goal, I believe, of investing over a billion dollars to healthy communities in Wisconsin, I believe that his approach to cross-sector collaboration will help inform the work of any nonprofit regardless of the industry. So, let’s cue the music and welcome Dr. Nathan Fleming.
Thanks for joining us, Dr. Fleming.
Nathan Fleming, MD: Really glad to be here. Thank you so much for making the opportunity.
Dolph Goldenburg: Can I call you Nathan?
Nathan Fleming, MD: Yes, please.
Dolph Goldenburg: Great. Thank you, Nathan, so before we jump into the cross-sector collaboration that I know we’re going to be talking about today, can you share a little bit about your organization Pathways to Population Health?
Nathan Fleming, MD: Yeah, I’d love to. Pathways to Population Health is a capacity building nonprofit. We’re really committed to seeing cross sexual collaborations to improve health outcomes for families. The reality is that health care alone is not enough to improve the health at a local level. We really need to see investments from every stakeholder. Typically, we think of that as being public health, but it also means charities, foundations, churches, businesses. Everyone needs to recognize that they have a stake in creating a healthy community.
Dolph Goldenburg: What are some of the specific projects that pathways to population health are taking on?
Nathan Fleming, MD: We really do three things. The first one is the community coaching. An example would be in lacrosse, Pathways to Population Health helped the United Way to health systems. The county health department put together a community pathways hub. This allows them to pull resources and pay for better outcomes for particular families and struggling neighborhoods. The way it works is that you braid the financing to distribute risk, and then you really prioritize, what are the most pressing needs in the community? who’s doing it for the least cost? You must focus on how to make sure that the financial incentives match up with the existing work. By taking this approach, we were able to gather over $600,000 at a community pathways hub to pay for better outcomes for over a thousand families.
Dolph Goldenburg: Wow.
Nathan Fleming, MD: The second thing that we do is workshops. We bring together stakeholders from the Chamber of Commerce, critical access hospitals and local public health departments to talk about current sources of waste and the biggest pain points when you make your budget every year. What we tend to see is that there are areas of synergy between healthcare, public health and business where when you combine resources, they’re much more successful when they are thinking about their corporate benefit and how to serve families. Then the third thing we create here at Pathways to Population Health are equity reports where we look at what are the health disparities in your community, who’s currently working to address them and creating roadmaps for communities to gather resources and align community efforts.
Dolph Goldenburg: I hear United Way – which I know I’m in a lot of communities – is involved with health, but I also hear Chamber of Commerce which is often not involved with health and health disparity issues. So how do you identify those organizations that you need to be doing cross-sector collaboration with?
Nathan Fleming, MD: For me, the most important piece is the people when it comes to the Chamber of Commerce. They are going to be the convener for most of the small businesses and the manufacturing and the banking and within the community. These are going to be the leaders who can drive change when they talk to an elected official and matters. So, it’s important for them to understand the cost of the current system on business and in particular the competitive cost. If you don’t have employees that are ready and able to work, whether that’s because their children are sick because the educational system hasn’t prepared them to work or because of their own health issues. This leads to higher healthcare premiums and absenteeism – that term business owners hate where you hire someone and eight months later find out that they’re just not able to do the job you wanted them to do.
Dolph Goldenburg: What are some of the other cross-sector collaborations that you have developed?
Nathan Fleming, MD: So, one of the things that I’m really interested in is, particularly here in Milwaukee, how local health departments can partner with patient-centered medical homes to provide referrals for unmet social needs. So, what this looks like is that patient-centered medical homes are really that primary care provider, who’s the home base for a family and we recognize that when you’re dealing with a family, it’s not just the one child; I’m a pediatrician. It’s whether or not the parents have a living wage job, whether or not they’re in safe, affordable housing, whether or not they’re in a neighborhood that has high crime or access to transportation so we can screen those patients in clinic, but we don’t need to be the person within healthcare that’s actually addressing those services.
It’s much better if you’re working with the local health department, identifying resources through 2-1-1 call center and then using the United Way organizations to really come around and support those families. Now in Wisconsin, we’re looking at – in southeast Wisconsin – our 38 patient-centered medical homes within the children’s hospital and the resources that are available in each neighborhood where the clinic is at. If you just look at Milwaukee, it’s not as useful as if you go to a very granular going zip code by Zip Code, neighborhood by neighborhood to put together the local collaborations on health. If you’re looking at Milwaukee and you’re going zip code to zip code, about how many collaborations do you think you have in that city? There’s a global umbrella of [inaudible] Milwaukee, which is led by the group of local health departments.
Within that umbrella, there are 12 different cross-sector collaborations that are happening on a local level because the reality is that not every business is going to have a footprint in a neighborhood. Not every healthcare provider is going to be serving all families across Milwaukee. Finding out who are the most effective nonprofits working in that neighborhood to help families is a very cost-effective intervention for both public health and healthcare. After you identify those most effective nonprofits, you know, how do you approach them? How do you set up the relationship? The first thing to do is to frame health equity as being something that is not owned by any individual, but thinking of it more as a public utility. It’s something that we all benefit from, and in some ways, we all pay the cost of when it’s ineffective. The first thing to do is to capture the cost.
I look at what is the cost per person to provide health care in that community. How much are we spending on public health and what is the potential lost too disconnected youth? For those people in between 18 and 30 who aren’t currently involved in the workforce or in school, what’s the cost in terms of healthcare premiums for an insurer to buy in to an insurance plan in that community and what’s the cost to a household in terms of health care expenses in a given year? With this, you can get the sense from healthcare, public health, business, and then for the families themselves, the current waste. What we tend to see is it costs about $10,000 a year to provide healthcare, but we spend less than $100 on public health. The return on investment for every $1 put into public health is at least 3:1, and in some communities we’ve seen as much as 5:1. You spend the money upfront and then you decrease the monthly expenses that businesses, healthcare and public health or having to provide support for those families.
Dolph Goldenburg: I get the business case for that, but most of the listeners of this podcast are in that nonprofit sector. What’s part of the nonprofit sector case for that?
Nathan Fleming, MD: I really think it’s the ability to be flexible when you get together businesses, health care, public health in a nonprofit, there’s a huge disparity in terms of purchasing power and those organizations to budget for a healthcare organization sometimes in billions of dollars and spreads over multiple counties. The budget for a county health department might be 12 or $15,000,000, but a lot of that’s going to be allocated based on state and federal requirements, so even though both of those have money, they’re so big that for a particular issue, it’s really hard for them to mobilize workforce. Whereas for the nonprofits, they really tend to have budgets that are orders of magnitude smaller, but their ability to have hands-on impact to really touch a family and to improve outcomes is so much higher.
So most of that return on investment comes when public health hospitals and businesses put a small amount of seed money into the nonprofit sector. Then the nonprofit sector is much more efficient in terms of the type of workforce they apply, the ability to hire new people, to address priorities and the local knowledge. All of those things come together to make it more cost effective to use these nongovernmental, non-hospital agencies to improve health for families.
Dolph Goldenburg: I think you raised an interesting point about the disparity in the sizes of the organization. If you are a $2,000,000 nonprofit organization working with a $20,000,000 health department and a $2,000,000,000 healthcare system, how do you show up at that table as an equal partner?
Nathan Fleming, MD: I think one of the first things is it helps to do your research. It really helps me to know how much these hospitals are spending and community benefit dollars, and thankfully, that’s publicly available. You can go to their form 990 or particular resources like www.communitybenefitinsight.org that I use to find out how much did they spend last year on their community benefit dollars and where did that money go. The second thing that I go to is I really think about the most recent budget from the county health department. It’s public knowledge. You can go and you can also see not only what they spent last year, but what are their strategic priorities for this year, and if you can match up the core service that your nonprofit provides with some of the most expensive cost to healthcare organizations and to public health agencies, it really gives you a place to be at the table.
They want to help you. They want to see their community partnerships thrive and if you really can engage two groups, it’s much easier to go to businesses and say, “Here’s this cross-sector collaboration that already exists. Will you help us make it sustainable?” Then make the business case for a manufacturer or for a small employer to come along and participate.
Dolph Goldenburg: For small nonprofits, in order for them to come to the table as an equal partner, they’re able to show what value they bring and essentially saying, “Hey, look, by partnering with us by giving us 10 bucks, we save you $150.”
Nathan Fleming, MD: Exactly. Nonprofits sometimes speak a very different language than a healthcare organization or even a public health department. Nonprofits are going to have clients.
Healthcare organizations are going to have patients, and the population health department is going to have beneficiaries, and when you start to think about those different things, the way you frame the issue matters, and so when you’re talking to a hospital system they’re interested in, they’re attributable patients, which aren’t necessarily going to be all the people within the community.
One of the things that you can do though is you can connect the benefits of a community-wide effort for their specific attributed population or for a public health department. They’re interested in some potential sub-segments of the population. What portion of your clients are elderly? What portion of your clients are living below the federal poverty line? What portion of your clients are women and children? This helps them get a sense of within the target populations that they might be interested in reaching how you can leverage your existing resources as a nonprofit to connect with their needs as big organizations.
Dolph Goldenburg: One of the other things that I think is different for most nonprofits versus most healthcare organizations, quite frankly. It’s also really data tracking. Healthcare organizations are probably further along in that journey of tracking health outcome data, whereas, a lot of nonprofits, especially smaller ones, are maybe not quite so strong and tracking their outcomes, whether their outcome is hunger or healthcare outcome or whatever.
Nathan Fleming, MD: I think it’s true, but I think one of the things that hospitals are really good at tracking are their reimbursed services; they’re not as good at following up on life outcomes for a particular patient and that’s just because the way in which we pay for healthcare hasn’t really rewarded that over the last 20 years. So, hospitals themselves are trying to figure out how do we do population health? What outcomes matter? What’s the connection between unmet social needs and healthcare expenses?
So as a healthcare organization, they’re going to track things like readmission rates, unnecessary visits to the ER, and the cost to provide care to someone with a chronic disease over a period of time. A nonprofit’s going to be much more interested in what was our reach within the population, how effective was our service, how many resources were we actually able to get to a particular family, and if we were advocating for a change, what percentage of our clients have adopted that change. Once you start to think in that model thinking about reach, efficacy, adoption, then you can really start to get at some meaningful nonprofit outcomes that will appeal to both healthcare executives as well as directors of public health departments,
Dolph Goldenburg: Nathan, [inaudible] how do the nonprofits and the healthcare organizations actually partnering, collect and analyzing that data?
Nathan Fleming, MD: One of the things that you’ll find are healthcare organizations would love to take data from nonprofits, but it tends to be very difficult to get the healthcare organization to share data, particularly protected patient information. One of the things that I found useful was to bring someone with expertise in negotiating information, sharing agreements to the table. Most hospitals will have some sort of information sharing agreement, and it can usually be a place to start. I’ve used the network for public health law. They’ve been very helpful to provide free legal consultation to small nonprofits. We’re looking to do these collaborations, and they don’t just say hospitals should do it. It’s because it’s the right thing. They tend to make the argument, “Here’s the way in which your three competing organizations serving similar populations have made it work. Here’s an outline for what information sharing might look like, and here’s the way in which the community is going to be able to protect that data.”
If you share it with them, it can really help to address some of the concerns that risk management or a medical or a legal department might have.
Dolph Goldenburg: That’s really cool. And we will get that organization’s URL and make sure we put it in the show notes.
Nathan Fleming, MD: Thank you.
Dolph Goldenburg: While we’re talking about resources, because I love that idea of bringing in someone who’s an expert at information sharing to kind of really mediate between the nonprofit and the healthcare organization. While we’re talking about organizations that might be able to assist with that, a lot of large cities – New York does Atlanta, Boston, Chicago – I’ll have a Pro Bono partnership program or nonprofit in our community where almost any nonprofit can go to seek free legal counsel, and it’s pretty much for whatever you need. If you need someone to help you who’s an expert in information sharing and help you negotiate that, they can do that.
Nathan Fleming, MD: Exactly, and I think one of the problems sometimes that nonprofits get into is that once a healthcare organization starts talking about risk management or lawyers, they get scared because that’s outside their expertise. It feels very formal. It feels very rigid, and sometimes it seems like it’s more work than it’s worth. I would encourage organizations to not hold those conversations at an arm’s length, but to embrace them, to dive in and really at the beginning, clarify what’s the value of sharing resources. What is the value we hope to get out this collaboration? If you can keep the conversation focused on values, it will really help both sides come together and troubleshoot some of the technical difficulties.
Dolph Goldenburg: Let me ask you another collaboration question. Ah, once upon a time I ran a housing organization that was co-located inside the public health care facility. One of the things that I would notice is that our culture within our office, even though we were an independent organization, would often mirror the culture or morale of the healthcare system as a whole. When morale is really high in that facility among the hospital’s employees, it was high among ours. When morale is really low among their employees, it was lower among ours.
How do you maintain your own independent culture that’s really independent from the larger organization that you’re partnering with?
Nathan Fleming, MD: So, for me, within Pathways to Population Health, we’ve really embraced this idea of a culture of health. It was first advocated through the Robert Wood Johnson Foundation. A culture of health really seeks to do is enhance individual and community wellbeing, reduce the toxic stress to families, reduce healthcare costs, but ultimately measurably improve population health by building healthier cross section collaborations. And so for me, what I look to are those leaders who taught me what a culture of health means. I was lucky enough to be mentored by Jeff Thompson. He was the CEO of Gunderson Health Systems for 15 years, and he really thought ahead about how a healthcare organization creates shared value, At pathways to population health, when we’re talking about our culture, we really focus on what is the way that we’re going to create shared value for every stakeholder that we’re connecting with and a community.
When I was in medical school, I had another doctor who advised me, Alan Beck. She was fantastic. She ran a student-run, free clinic, five sites around San Diego County that was doing awesome work, and she really kept coming back to this concept of Social Tai-chi – the idea that you bend but don’t break; you’re flexible, but you keep clear to what your fundamental principles are. For her that meant providing free care to the neediest people in the community, and she would partner with anyone who wanted to do that, but she was very clear to vet her partners to make sure that big picture interests aligned and that those partners weren’t going to change the culture, the comradery and the sense of vision within the organization. When you think about fostering cross-sectoral collaboration, make sure that your partners aren’t going to change what makes you as a nonprofit distinct.
Dolph Goldenburg: I love that, and I also liked the fact that you mentioned Dr. Jeff Thompson. We had him on the podcast episode 42 to talk about his book, Living Values, Building People, Inspiring Communities. I just want to point out two things that he did that I would think were just super cool. One was they made his healthcare system made the strategic decision to take a portion of their reserves and essentially take it out of market investments in New York or in Tokyo and move it into community business investments to actually build the local community, the business community around them. I thought that was a bold move, but great way to improve health in your community by really improving the economic net that everyone else is under.
Nathan Fleming, MD: I totally agree with that. The other thing that I learned from one of my mentors, when I did my master’s in public health at Harvard, I was lucky enough to study under Paul Farmer and to take his course on global health delivery, and one of the first lessons that he taught from his time working in Africa, Haiti, and with policymakers in the US, is that as a leader of a nonprofit, one of the most effective things you can do is sometimes build a wall. He tells the story of how as a nonprofit who is seeking to partner with a government hospital in Haiti, they kept coming back to this strange requests from the public hospital. Could you just build a wall? When they really got down to it, what they meant was this underfunded public hospital didn’t have the resources to actually keep livestock from wandering into the facility.
What they really needed was a stone wall and it made the patient experience better in the hospital, but it also dignified the public facility. Although it wasn’t what they initially intended to do, Paul Farmers’ group was able to both mobilize money and volunteers and the local construction staff to put what amounted to a stone wall around the public hospital. But by doing that, it actually improved everything. You no longer had sheep and cows wandering through the halls. You had a specific space that was allocated for healthcare delivery, and you now had influence within the leadership who would recognize that you would listen to them and you would respond. And so, the Public Hospital actually invited the nonprofit partners in health to set up a clinic. To deliver better healthcare within that structure, so by building a wall, partners in health was actually able to leverage the entire public health system in this district in Haiti, so don’t overlook those small opportunities that might be. It didn’t recast partners in health very much, but it allowed them to leverage significant social capital.
Dolph Goldenburg: My Rotary Club built a school in Haiti, and I’ve been there and one of the things that you see when you’re there is almost all private property has a very substantial wall around it, but our school actually made the same request of ours and they were like, can you just help us figure out how to put a wall in? It keeps all of the livestock in, but it also clearly demarcates where people are supposed to be in where they’re not supposed to be. I think in Haiti I think that might be critically important.
Nathan Fleming, MD: The walls might look different here in the US. It might look like partnering on a, on a campaign to influence local stakeholders to engage with elected officials and it might not always see an intuitive to a small nonprofit I would help to partner with a big health system on an infrastructure project or a local housing project, but really the chance to be at the table to show your value and then through the process create shared values can be away. That leads the nonprofit to really pull above its weight at the policy level within a community.
Dolph Goldenburg: Right. It’s interesting you say that because one of the things in and the HIV housing sector, one of the things we would always say is housing is healthcare. You always want to partner with a health system around that.
Nathan Fleming, MD: I really think that the health systems need to help with nonprofits to understand that social medical integration. Because so much of housing nutrition, transportation, employment education happens across the street from what we typically think of as a hospital or clinic, the providers and then the executives may not clearly see the connection between someone having access to safe housing an ED visits for asthma, and it can be really helpful for the nonprofit to come with stories that are specific to the families that they serve. There are different ways that you can kind of coach people to do that, and there’s some real value to not only reporting the statistics but reporting the way in which your organization has helped to change the life course for a family and in doing so, highlighting those moments where there were synergy between what the nonprofit was doing, what the public health department was doing and what the hospital was doing. Because so often those organizations from a family perspective don’t appear to communicate, don’t appear to integrate services and sometimes may even seem to work at cross purposes.
Dolph Goldenburg: Well, Nathan, thank you so much for joining us today. I’m not going to let you go yet because I’ve got to ask you the Off-the-Map question and that is a question that is often tangentially related to what we’ve discussed today but allows listeners to get to know you just a little bit better. I
You have started three nonprofits. I would love for you to share with listeners what advice you have or what great lesson you learned in starting year three nonprofits. Take the cross-sector collaboration piece off the table. That might be the biggest thing you learned in your best piece of advice, but if we can take that off the table and then get your next piece of advice.
Nathan Fleming, MD: No, I think that’s a great, is a great question. It really is the question, right, because, how do you get that first client, that first donation? For me in particular, it’s finding a compelling story. My first nonprofit was actually building schools down in Guatemala and what really made it successful was when I was able to identify a local champion and make it so that the success of the nonprofit actually aligned with building the stature of this local leader and having a compelling story, which ultimately was Don Salamon Hernandez story about how his family had survived on earthquake. He had received a donation of money, and instead of building his own home and his own business, he ordered a brick. He built a brick factory to ultimately rebuild the infrastructure for the entire town.
Dolph Goldenburg: Wow.
Nathan Fleming, MD: Using those personal stories both locally and then to leverage with donors have been key because when you’re just starting out as much as you have a business plan, a theory of change, a logic model, what really matters is that both the clients you serve and the people who are going to donate to you believe in you as a person, see you as authentic, someone with integrity, but ultimately someone who can take very little and accomplish a ton. As you’re thinking about starting a nonprofit, focus on that story, the way in which you’re going to be able to meet a client’s needs in a new and dynamic way, but also that it’s going to be rooted in the history of the place where you’re going to work.
Dolph Goldenburg: I like that, a relevant story that really connects with people.
Nathan Fleming, MD: Exactly. The more local the example that can be, the more life-changing it can be, and as long as when you tell the story, people recognize it as something that matters to you and that you really believe in, t goes a long way. That to me has been more powerful than any business plan, any grant pitch for any amount of fundraising. They really want to know what I care about, what my values are and how I’m going to use the resources that they choose to share with me.
Dolph Goldenburg: Nathan, again, thank you so much for being on the podcast today. If listeners want to learn more about you or the work you’re doing, they can go to http://www.pathways2pophealth.org/, and from there I think they can also get a link to purchase your book. Is there any social media that you’d like to hang out on?
Nathan Fleming, MD: I tweet www.twitter.com/nathanflemingmd, and that’s my preferred social media. I’m also on LinkedIn, but I’m much more active on Twitter.
Dolph Goldenburg: All right, excellent. So, people can hit you up and at Nathan Fleming MD. That almost sounds like a television show by the way.
Nathan Fleming, MD: That’s a good pitch.
Dolph Goldenburg: Again, Nathan, thanks so much.
Nathan Fleming, MD: Thank you so much. I really appreciate it.
Dolph Goldenburg: Grateful thanks to Dr. Nathan Fleming for joining us today, and I really hope that his personal story of transforming healthcare and health outcomes in Wisconsin inspires you to find ways that you can go out and create cross-sector collaboration. Whether you’re housing organization, at workforce development organization, a legal services corporation, find some way to reach beyond the sector that you’re working in and really build the strength of the people you serve.
Now, as always, you can go to our show notes at www.successfulnonprofits.com, and from there you can get the link for Nathan’s organization, book, and Twitter. If you found this episode helpful, please share it with somebody and rate and review it on iTunes or your streaming app of choice. That is our show for this week. I hope you have gained some insight that will help your nonprofit thrive in a competitive environment.
(Disclaimer) I’m not an accountant or attorney, and neither I nor the Successful Nonprofits™ provide tax, legal or accounting advice. This material has been providing for informational purposes only and is not intended or should not be relied on for tax, legal or accounting advice. Always consult a qualified licensed professional about such matters.