Editor’s Note: Freya Spielberg, MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterprise dedicated to improving the health of Individuals living in low-income housing in Washington, DC.  Previously, as an Associate Professor at George Washington University, and at the University of Texas Dell Medical School, and School of Public Health, she developed a curriculum in Community Oriented Quality Improvement, to train the next generation of healthcare providers how to integrate population health into primary care to achieve the quintuple aim of better health outcomes, better patient experience, better provider experience, lower health care costs, and decreased health disparities. We spoke with her about her ongoing work in low-income communities to improve access to primary care and its impact on patient safety.

Kendall Hall: Could you just tell us a little bit about yourself and describe your current role, please?

Freya Spielberg: Absolutely, so my name is Freya Spielberg, and I am a family medicine physician, a researcher, and an educator, and for most of my career I’ve combined all three of those components. In my research, I've worked on identifying new strategies to deliver services to address health disparities. As an educator, I've developed a new curriculum, Community-Oriented Quality Improvement, to teach medical students, health providers, and MPH [Master of Public Health] students how to improve health outcomes among underserved populations. In my current roles, I am an Associate Professor at the Dell Medical School at The University of Texas at Austin as well as the CEO [Chief Executive Officer] of a social enterprise called Urgent Wellness, which I created to implement some of the more innovative models in low-income housing projects to address health disparities and improve health outcomes. I am also the Medical Director for Primary Care of Bluebonnet Trails, where I've been integrating primary care into mental health care. Bluebonnet Trails is a large safety net mental healthcare organization, and in the past year I've had some experience seeing the benefit of bringing primary care to people who are receiving mental healthcare services, but who do not have access to primary care. Finally, in June I'll be starting a new job as the Chair of Family Medicine at a large FQHC [Federally Qualified Health Center] teaching consortium in Phoenix, including District Medical Group, Valleywise Health, and Creighton Medical School.

KH: Can you describe how your work in the community setting intersects with patient safety?

FS: I think about patient safety very broadly. Health disparities that result from limited education, low health literacy, poor access to care, and social determinants [of health] create barriers to care that result in poor health outcomes that I would say are patient safety issues. A narrow view of patient safety is if you, for example, give the wrong medicines to someone and they have a bad reaction. But I think if the goal is really to achieve the quintuple aim of improving health outcomes, improving patient experience, improving provider experience, lowering healthcare costs, and addressing health disparities, what we need to do is to think more broadly about patient safety and fix the healthcare system. If we address those barriers to patient care that result in health disparities, we will improve the health of populations that currently have poor health outcomes.

The way I engage in community health comes from a model of care called Community-Oriented Primary Care. Prior to my role here, I'd been the Director of Community-Oriented Primary Care at George Washington University and evolved a curriculum that teaches a methodology that starts with understanding what the specific patient barriers to care are. That's critical in any setting where you're trying to address patient safety issues. In Community-Oriented Primary Care and Community-Oriented Quality Improvement (COQI), what we do is start with qualitative interviews of patients to understand what their real barriers are. What's leading to poor outcomes? What are their preferences? What's going to be acceptable? And then we look at assets in the community. There are always many, many social programs, social services, and individual resources that can be tapped into and that could improve health outcomes in the community, but we have to understand what is out there. Then, of course, we have to understand what the best practices are in the literature and make sure that we are designing an intervention that is evidence-based to address those barriers and key causes of morbidity and mortality identified by the patients and the stakeholders. Then we implement, evaluate, and determine the return on investment and the impact on the quintuple aim. If effective, we scale up and provide training. If ineffective, we start over and redesign the next COQI test of change improvement cycle.  

KH: What would you say are some your biggest lessons learned from that engagement? What are the pressing interventions?

FS: What you find is that we need to design new models of care. The new model of care that I designed initially with Urgent Wellness was really to address some of the main barriers to care: health literacy, access, and social determinants [of health]. In that model, we placed a wellness program inside a low-income public housing community, partnered with the public housing authority to turn an apartment into a clinic, and started by going door to door and doing holistic assessments of health needs, mental health needs, substance use, social service needs, etc. We assessed what community preferences would be for different types of services to address some of the barriers. With that data, we decided the most impactful model would be to have community health workers develop long-term relationships with individuals, to provide education, early screening, and the link to needed health and social services.

One of the important care-seeking behaviors that we found is that both in Washington, DC, and in Austin low-income housing projects, about half of the individuals hadn’t accessed primary care in the past year, even though they had insurance. A similar number had been to the ER [emergency room] one or more times. When you go to the ER, or to urgent care, you don't get your preventive health or chronic disease management needs met, leading to poorer health and potential disparities. People don't know that they're not getting what they need; they think they've been to the doctor. That's a health literacy issue that needs to be addressed. We had community health workers work with medical providers to come up with a care plan that they went over with patients, noting that here are the healthcare services that would benefit you, here are health behaviors that, if you worked on changing them, would improve your health outcomes, here are social services that might help improve your life. They would review all the different needs and then they would negotiate with the patient on what they wanted to prioritize, so it was a very patient-driven model. Then they would work with the patient longitudinally. If they needed primary care, which we always encourage if they haven’t had it, the community health worker would work with them to help them figure out how to schedule the appointment, get the transportation there, find childcare, and overcome the barriers that get in the way of people having appointments. During COVID-19, developing telemedicine literacy was a huge focus, and ultimately resulted in better access to care, as it prevented the need for transportation, childcare, and even leaving work sites—the most common barriers to following through for primary care. 

In addition, community health workers supported individuals with behavior changes that would help them improve their health. For a behavior change, for example, if someone needed to increase their exercise and [people] were not walking because of safety concerns, the community health workers started neighborhood walking groups. They made options available to help improve access to what was needed to improve health. One of the most sought-after interventions to improve nutrition was cooking classes; however, COVID-19 made that difficult to implement. For chronic diseases like hypertension or diabetes, what we found was that a high percentage of people didn't know that they had these conditions because they hadn't been to the doctor. A big step was just educating people that, in fact, they have high blood pressure and how they can take of themselves, training them to do chronic disease management. As part of this education, the community health worker would give a patient a blood pressure monitor so they could take their own blood pressure at different times during the day and see for themselves that it is high. This helped them overcome personal health barriers, so they’d be ready to get treatment.

KH: What sorts of successes were you seeing with this model? Could you also please talk a little bit about your challenges? I imagine this could be quite difficult to get off the ground.

The goal of this model was to have frequent interactions until someone's chronic disease was controlled and to help individuals overcome barriers to control. For example, I had another patient with HIV and, all of a sudden, their viral loads spiked. If you just saw that in a clinic setting, often providers would say, oh, you're not adhering to medicines or we need to change the medicine. But when the community health workers dug into it, it turned out that that individual had housing instability, they'd been kicked out of their grandmother's home and all of their meds were at grandma's house so they didn't have access to them. The community health worker was able to go to grandma's house, get the meds, bring them to the patient, and get the patient back into care. That's the kind of thing that, if you don't have an on-the-ground community health worker working with the patients, it is difficult to address. I think that this model of care is just critical to improving health outcomes among low-income populations or populations that just have significant barriers to care.

One of the big challenges is, how do you pay for the community health workers? Right now, there's a lot of data in the literature showing the impact of community health workers, both on improving health outcomes and lowering healthcare costs. They’ve been used for transitions in care, for chronic disease management, substance use, mental health, all sorts of things. A lot of those projects are grant-funded, and so figuring out how to really integrate community health workers into the collaborative care team and figuring out how to pay for them are the challenges for scaling up this kind of model of care. In DC, Urgent Wellness works with a large Medicaid managed care organization, AmeriHealth, and we contracted with them so that we could get reimbursed for the community health worker activities. This was really the first time that we've had the ability to provide this kind of care outside of a grant. If we're not going to reimburse, it's just not going to happen. I do think that in ACO [accountable care organization] and pay-for-quality models of care, there's a greater likelihood that these kinds of programs will be integrated. However, it'll take a change in the culture because we’re so used to the idea that care is provided within the walls of the clinic.

KH: Who are the community health workers? Do they get better traction with the people in these communities if they are from the community?

FS: When you're picking community health workers, what we found is the most successful model is when we actually trained people from the community. We went into the low-income housing communities and looked for people with an interest in healthcare or even a CNA [certified nursing assistant]. We proactively recruited people that had gone through CNA training and who lived in the housing complex, put them through a community health worker training, and then we put them through a training of our particular model of care. Those people have just been so effective. Not only do they make the program more effective because they're members of the team, and anything that is designed they can give the community perspective on. They know what's going on. I can't tell you the vast array of design issues that you wouldn’t have even thought about that they are able to help guide. But then, they also live in the communities. It's convenient for them, so they don't disappear, and people begin to trust them. They become the first person that someone calls when they have an issue. There are just so many stories of people that didn't have food, that didn't have rent, that had disabilities that weren’t being addressed, where the community health worker was able to step in, understand, and bring resources to bear for it. Additionally, when patients come to the community health worker with a sore throat or a cold and they are used to going to the ER for care, the community health worker can help them find same-day outpatient care in clinic or telemedicine settings.   

In a scaled-up model, I do think that having a physician medical director and a nurse or [someone at the] nurse practitioner level to supervise large numbers of community health workers is the other important piece of the model. You need someone to help when they have medical issues that come up, and to help guide continuous quality improvement. These community health workers should become critical components of the integrated collaborative care team to help provide seamless handoffs, and to decrease inappropriate costly ER visits.  

KH: I think that's the fascinating part of all of this is that you truly are re-envisioning healthcare. And what does patient safety mean, in that context?

FS: If you think about it, preventable hospitalization is a patient safety issue. Improve diabetes management, improve congestive heart failure management, and you decrease rates of avoidable hospitalizations.

KH: But in your model, the focal point is beyond those patients that are already getting care in the clinics.  

FS: Absolutely! The patients that are showing up to the ER, and ending up in the hospital, are those that aren’t getting care at the clinics because they're not plugged in. The other thing that we really, really, really need to do is redesign the technology and the processes for improving access to technology among people who experience poor health outcomes. There are two different aspects of that. One is, if you didn't have access to telehealth, your access to healthcare can be limited. This was particularly highlighted during COVID-19. It's totally possible to bring the technology to low-income communities and give them access, either by training them, providing the internet service, or providing the cell phone service.¹ A lot of states will actually provide cell phone service so people at least have access to a smartphone, but we have to be sure that they know how to use it. A community health worker can work with the individual to show them how to get into patient portal, how to set up appointments, and how to connect to telehealth. Sometimes it might just take one training session to get someone up to speed, but the other people who have other disabilities may just need that community health worker to be that person in between to help link them. So, re-envisioning what the CNA does, basically training them to work in the community and to help get the vital signs and get the health history and get someone ready for a telemedicine visit in their homes. That could have a huge impact. The other thing that's really important, is that what we've learned during the epidemic is that even if people don't have access to telemedicine, don't have access to a laptop, or can't navigate the system, they can use the telephone. Many patients actually prefer to use a telephone than a full telehealth system because it is easier to do privately when they are taking a break from work or child care. In fact, as COVID-19 immunization rates increase, it is critical that telephone care continues to be made available to individuals who have barriers to attending in-person visits. Some states are going back to the requirement that telemedicine is done with video, and this will result in greater health disparities for individuals who have telemedicine literacy issues, or who prefer the privacy of a telephone call. 

The other technological innovations that are necessary to really optimize medical care for the underserved, focus on the integration of data. Ideally, you would have a tool for the patient and the community health worker that pulls in data from all the different sources that the patient may have touched—the exchange of health information from the clinics, the hospitals, patient-reported outcomes, and from community health worker visit notes. When you have all that integrated data, the providers, the community health workers, and the patients can all be on the same page. But even more importantly, you can begin to build in decision support so that when a patient shows up at the ER, the community health worker is pinged and can help with transitions of care. Or when someone has diabetes that’s out of control with an elevated hemoglobin A1c, or when someone never got their colon cancer screening, the health worker can be pinged for their panel of patients and reach out to intervene.  That's where we need to get to, to be able to really address poor health outcomes.

KH: It sounds like the community health workers are acting as case managers essentially to help patients navigate the system as well as track their health. Is it kind of a hybrid?

FS: In part! The important piece is the integration of activities. Normally in a clinic setting, care coordinators would assist with linkage to care, CNAs would get the patient’s medical history and vital signs, and nurses or health educators would provide behavior change counseling and chronic disease management. In a sense, what is needed is a community health worker that can provide first-line assessment and linkage to all of those services. Once the individual is linked to primary care, the in-clinic staff can further implement the care plan, while the community health workers can support adherence to the care plan in the community setting. The community health worker would assess the patient’s vital signs but also help the patient learn to do their own vitals. For example, one goal is that since hypertension is such a huge issue in these populations, everybody should have a home blood pressure [monitor] and know how to use it. The community health workers can teach them how to do that, collect the information on their vitals if they don't put it into the portal themselves, or if home remote monitoring is not available. You need that person out in the community doing that education, doing the home screening, reinforcing any behavior change, helping to overcome the barriers to linking care. They can help make those care referral connections. They can do motivational interviewing to reinforce provider-directed behavior change agreed upon with the patient. So, it's kind of a hybrid position that's right in the middle of the whole collaborative care team.

KH: I hear you talking about patient activation and having that community health worker get the patient motivated and able to advocate. Is there any need to have a readiness assessment for the community at large? Is there a chance that it's the community that just can't support this model of care?

FS: That’s an interesting question. I think that that makes a lot of sense as a natural step in the process of trying to scale up. If you do the stakeholder interviews, you'd understand the community assets, right? You’d understand barriers to implementing different parts of the model, so that is really part of the COQI methodology. But I like highlighting the need for that as the first step before you try to implement these kinds of new programs. On the individual level, understanding needs, barriers, preferences so that you can start designing the program, but then understanding the community-level readiness for the intervention that has come from that process is a critical step as well.

KH: I want to shift to talking about your work around bringing primary care into mental health, rather than having primary care integrate the mental health piece.

FS: I’ve just learned so much through my recent experiences as the Primary Care Medical Director for Bluebonnet Trails, an eight-county safety net mental health network. It has really changed my understanding around how we need to address health among people who have mental health needs. In my work in community clinic settings, we always had a behavioral health person integrated into the clinic. However, there was rarely enough staffing to be able to get everybody who needed mental healthcare services into behavioral healthcare. I thought that access to mental healthcare was the primary issue, not access to primary care. But then, when I started working in the mental health safety net clinic system, I realized that the vast majority of patients had not had primary care for some time. Almost all my patients have no insurance, and so getting them access to care is really, really challenging. I would have patients that had diabetes, COPD [chronic obstructive pulmonary disease], congestive heart failure, history of MI [myocardial infarction], and who hadn't had primary care and could only go to the emergency room. I strongly believe that to improve mental healthcare, you have to address primary healthcare needs. To improve primary health outcomes, you have to address mental healthcare needs. The best way to do that really is to integrate services—all mental healthcare should really integrate primary care and vice versa. What it comes down to is that people that have challenges and multiple social determinants of health have difficulty getting plugged into any kind of healthcare setting. You'll find that there are some people that get plugged into mental healthcare settings but won't go anywhere else. Similarly, some people get plugged into primary care settings but would never go to a mental healthcare organization. So you really need both of those models. Nationally, it'll be important to come up with payment models and programs that incentivize integrating primary care and mental healthcare, and vice versa. And then on the ground, we have our community health workers screen for depression, anxiety, and PTSD [post-traumatic stress disorder]. They just get that as part of their vital signs screens and if someone screens positive, we link them to a mental health provider. That's a direction that I think is really important.

KH: When you are talking about mental health, I assume you're including in that bucket patients with substance misuse?  

FS: Absolutely. We screen for substance use and assess readiness for treatment as part of the mental health assessment. I do think that the more convenient a program can be made for a patient who has a chaotic life, the more likely they will be to get services. The other interesting thing that I've learned recently was from overseeing a student who has been helping to assess an integrative pain treatment program. We know we can’t use opioids for chronic pain without the risk of creating addiction and overdose, so what do you do? Integrative pain management programs are what's needed. There's one that's being done in Austin at People’s Community Clinic that brings together groups of people with chronic pain and they have a variety of interventions, mental health and acupuncture, a variety of integrative therapies. But in the qualitative work, at least so far, it seems that it's really the support group that is having a big impact in being able to get that needed social support, understanding they're not alone, sharing ideas about new coping mechanisms for living with pain and anxiety and stress. It seems to really have an impact. So we're going to have to also think about how group visits could play an important part of chronic disease management and substance use treatment. I think, as we have more and more data that this is what works, we will need to figure out the financial models, logistically how you make this happen, and how to do it virtually, is going to be key for some populations. That's another exciting direction that we are moving in.

KH: What do you think comes next for population health and training the next generation of health providers and collaborative care teams?

FS: If you don't have a good infrastructure to do population health, you will not be able to address poor health outcomes because you won't know that you have them. A lot of clinics now have data visualization software, but really, I believe what's needed on the collaborative care team is an MPH-level trained person to support providers in the design and assessment of rigorous Community-Oriented Quality Improvement interventions. Providers have excellent ideas, but the MPH training can drive the Community-Oriented Quality Improvement methods further and faster for the team. Obviously, you need a data system that will allow individual providers to know how they’re doing with their patient population for all the reportable quality outcomes. That's critical and it needs to be talked about as part of regular routine meetings so that the team understands what's necessary, what has to be prioritized, what's needed to change, and so that they can see the impact of changes that they make. So that's one key thing. The healthcare team of the future will be a collaborative care team, in-clinic or virtual, that will include community health workers and an MPH-level population health expert, as well as healthcare providers, nurse educators, behavioral health counselors, clinical pharmacists, and care coordinators. And then training the providers, that's really key. Providers that get MPHs as part of their education have a good understanding usually of population health, but they may not learn the Community-Oriented Quality Improvement methods that focus on making sure you understand, first and foremost, what the patient's needs and preferences are, the stakeholders’ needs and preferences, and community assets. I think, you know, the vast majority of medical providers come through trainings that don't really have a rigorous population health program. One of the things that I'm going to be doing as we grow the Urgent Wellness model of care, is to partner with Medical Schools and Family Medicine residency programs to introduce training in Community-Oriented Quality Improvement to medical students and residents, so that they get those skills and methods to bring with them when they go out into the world.