Lights, Camera, Community Heart Health

Documentary film chronicles one rural health system's journey toward a vision for population health, and its recipe is deceptively simple—but not cheap.

Building a culture of wellness through focus on specific health measurement pays off, an ongoing project in Minnesota shows. The conundrum is, who pays for it when the benefits are so disparate?

The Heart of New Ulm tells the story so far of a rural health system in Minnesota that began a 10-year project in 2008 to see if it could demonstrate the impact of targeted population strategies around heart health.

Among the results so far:

• A 7% improvement in hypertension
• Reduced smoking and heart attack rates
• Improved physical activity and nutrition

Allina Health's New Ulm (MN) Medical Center and Toby Freier, its president and CEO, launched the Heart of New Ulm Project based on the premise that changing individual behavior through simple interventions can have an exponential impact on the health of a population.

The project is a collaboration of the medical center, the Minneapolis Heart Institute Foundation, and the community of New Ulm, MN, which has a population of approximately 13,500 and is located about 90 miles southwest of Minneapolis.

Measuring ROI
The film details the project's progress in improving the health of an entire community. With modern data analytics capability, it's possible to measure the impact of such programs, Freier says, making return on investment much clearer.

He hopes the project can serve as a national model for other systems that have questions about the ROI in population health.

The documentary, which chronicles the first seven years of the journey, was created by Health Catalyst, a Salt Lake City-based data warehousing and analytics company that provides those services to New Ulm Medical Center's parent, Allina Health.

The project was initially championed by renowned cardiologist Kevin Graham, MD. Graham pioneered a Level 1-heart attack protocol that improved outcomes in transfers from rural areas to tertiary centers.

The goal was to get to zero heart attacks in the community, which Freier acknowledges is unrealistic, but "we needed a bold goal to get robust innovation," he says.

"Eight years in, we've learned you can't just tweak the medical system. You have to be pretty bold."

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That work includes interventions, screenings, and measurement of outcomes over time. New Ulm's highly integrated health system made the town an ideal candidate for the project, according to Freier's recollection of Graham's thinking (Graham suffered a debilitating stroke in 2010).

Most people in New Ulm receive care through the medical center, which has documented that care in a single EMR for the past 11 years. "That provided us the opportunity to use innovative surveillance tools with which we actually monitor their health on a regular basis," Freier says.

Screening Participants
Researchers invited all adults age 40-79 within the city's ZIP Code to participate in screening. Of the 7,855 people invited, 5,198 were screened. The health system collected participants' blood and noted risk factors such as diabetes, obesity, and hypertension to create a full medical baseline in the EHR.

Of the group screened, 3,400 individuals were enrolled in the Move to Improve community challenge program, a free eight-week challenge to help them increase their activity level and improve their food choices to help reduce their overall risk for heart attacks.

The goal was to get the group to commit to at least 150 minutes of physical activity each week. Community resources, including restaurants and employer work sites, were enlisted to help promote healthier lifestyles.

Follow-up screenings, including additional blood draws, have been done twice since the initial screening.

The results so far show a general improvement on blood pressure (from 79% of participants at their target blood pressure in 2008 to 84% of participants now). The number of patients with LDL cholesterol levels at their goal for the project improved from 68% to 72%.

Participants' mean triglyceride levels decreased eight points, while the number of patients at goal for triglycerides increased from 66% to 70%, according to the Minnesota Heart Institute Foundation.

The bulk of the improvements occurred in people who were not at goal at baseline, and the cost of care is now 14% below the benchmark of the Allina Health System.

Those apparently modest improvements in statistics represent years of extended life, says Freier. Through that lens, investment of $1 million a year seems like a bargain. But it's never that simple.

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"Most other healthcare systems look at that investment and say that's a nonstarter," says Freier. "I wouldn't expect others to spend that. This was groundbreaking research about how to build this."

Instead, other health systems could fund interventions that the New Ulm project identified as worthwhile. Other systems might be able to do the bulk of monitoring and interventions for as little as $200,000 annually, Freier says.

For New Ulm Medical Center, it also helps that nearly 50% of its revenue is in value-based reimbursement arrangements.

"Sustainability of initiatives like this will take more than direct funding of the healthcare system," Freier says. "What can cities, public health, and schools bring to the table? ROI isn't solely on the back of the healthcare system. It should be a community investment.

"Too often we feel we need to be in control as a healthcare provider, but it has been a great learning experience and has given us so much appreciation for our community leaders," he says. "This could be a national model for population health."