CASE STUDY AUGUST 2017 Health Care Improvement in Akron, Ohio: Moving from Collaboration to Coordination Martha Hostetter Sarah Klein Douglas McCarthy Consulting Writer and Editor Consulting Writer and Editor Senior Research Director AKRON The Commonwealth Fund The Commonwealth Fund The Commonwealth Fund PROFILE The Northeast Ohio region centered on the city of Akron and HEALTH SYSTEM PERFORMANCE Summit County as well as parts of nearby counties stands Improved on out, along with Stockton, Calif., for having improved on more OF19 33 indicators tracked over time — performance measures (19 of 33) than any other region on most among all regions the Commonwealth Fund’s Scorecard on Local Health System HEALTH SYSTEM RANK Performance, 2016 Edition. The region has made notable progress 127 224 expanding access to care. Health systems also have strengthened OF vs. OF primary care and improved care transitions, which may explain 306 306 regions in 2016 regions in 2012 reductions in potentially avoidable hospitalizations and DEMOGRAPHICS (2014) unplanned readmissions. Collaboration across health and social service sectors is a hallmark of the region, exemplified by use of 692,411 residents in Summit and parts of surrounding counties a shared set of measures assessing residents’ quality of life. But to address deep-seated problems, such as the high black infant 82% white (vs. 62% nationally) $57,476 median mortality rate, leaders say the region also will need to make 11% black household income (vs. $58,489 nationally) (vs. 12% nationally) specific commitments and potentially reallocate resources to see improvement. 5% other non-Hispanic 33% (vs. 8% nationally) living on incomes below 200% of the 2% Hispanic federal poverty level (vs. 17% nationally) (vs. 34% nationally) KEY TAKEAWAYS Data: D. C. Radley, D. McCarthy, and S. L. Hayes, Rising to the Challenge: C ollaboration across health and Akron’s health systems have A Scorecard on Local Health System Performance, 2016 Edition (The social services is a hallmark strengthened primary care and Commonwealth Fund, July 2016); and American Community Survey, 2014 1-year estimates, www.factfinder.census.gov. of Akron — evident in the use improved care transitions. of shared measures to assess residents’ quality of life. Health Care Improvement in Akron, Ohio: Moving from Collaboration to Coordination 2 BACKGROUND downtown also has reinforced neighborhood boundaries With just under 200,000 residents, the Northeastern Ohio and in some cases created pockets of poverty and isolation. city of Akron in Summit County is often described as a big Despite these divisions, leaders say residents have shown small town. Civic and business leaders say they see familiar a willingness to help one another. “What we have here is faces as they move between workplaces or committees and a rich mix of individuals and businesses and government prize residents’ warmth and lack of pretension, which some that come together to solve community problems,” says attribute to the city’s blue-collar roots. Once known as the Donna Skoda, health commissioner of Summit County “Rubber Capitol of the World,” Akron had a thriving rubber Public Health. industry for much of the 20th century. In 1950 it produced This case study is part of a series exploring the factors one of every three tires on American roads, but during the that may contribute to improved regional health system late twentieth century it lost many manufacturing jobs and performance. It describes initiatives led by the public with them roughly a third of its population.1 Since then, health department, local government, and other partners “meds and eds” have anchored the economy, with Summa to promote healthy behaviors and build a healthier Health, Akron General, and the Akron Children’s health environment, as well as those led by health systems and systems and the University of Akron all major employers. In other providers to improve services, particularly for those recent years the region has had some success in repurposing most at risk. Akron’s progress is noteworthy; while its its industrial equipment and workforce into polymer and poverty rate is not as high as other regions examined in other advanced manufacturing, thus staking its future on our series, it nonetheless faces pressing health problems the strongest parts of its past.2 common to other “rust belt” cities, including high rates of Akron’s residential neighborhoods still have strong ethnic obesity and other chronic conditions, a persistently high identities (including the rubber company–built Firestone infant mortality rate among African Americans, and an Park and Goodyear Heights). A highway running through epidemic of opioid addiction.3 A park alongside the Ohio and Erie Canal (below) and the historic Civic Theater (far left) anchor Akron’s downtown. James Hardy, pictured below, is Akron’s deputy mayor for administration and chief of staff. commonwealthfund.org Case Study, August 2017 Health Care Improvement in Akron, Ohio: Moving from Collaboration to Coordination 3 Exhibit 1. Akron, Ohio, Hospital Referral Region Local Scorecard Performance Ranking Summary Change in Performancea (of 306 Local Areas) Quintile Rank Average of HRRs Akron in the U.S. 2012* 2016 2012* 2016 Count Percent Count Percent OVERALL 4 3 224 137 Indicators Access & with trends 33 33 3 2 138 66 Affordability Prevention & Area rate improved 19 58% 11 33% 4 3 218 142 Treatment Area rate Avoidable Hospital worsened 0 0% 3   9% 5 4 250 208 Use  & Cost Little or no change Healthy Lives 4 3 231 143 in area rate 14 42% 19 58% * Rankings from the 2012 edition of the Scorecard have been revised to match methodology and measure definitions used in the 2016 edition. a I mproved or worsened denotes a change of at least one-half (0.5) of a standard deviation (a statistical measure of variation) larger than the indicator’s distribution among all HRRs over the two time points. Little or no change denotes no change in rate or a change of less than one-half of a standard deviation. For complete results, visit the Health System Data Center. Data: D. C. Radley, D. McCarthy, and S. L. Hayes, Rising to the Challenge: A Scorecard on Local Health System Performance, 2016 Edition (The Commonwealth Fund, July 2016). HEALTH SYSTEM PERFORMANCE IN AKRON said they actually sought out services, and more received Akron is one of 306 hospital referral regions, or regional recommended vaccinations. markets for health care, in the United States. The area Akron also has made progress in reducing unplanned includes the city of Akron and surrounding Summit County hospital readmissions after years of effort to promote safe as well as parts of nearby counties. On the Commonwealth transitions between hospitals and community settings, led Fund’s Scorecard on Local Health System Performance, 2016 by Direction Home of Akron and Canton, the Area Agency Edition, the region, along with Stockton, Calif., stands out on Aging (AAA). Since 1998, the AAA has embedded field for having improved on more performance measures (19 coaches (either social workers or nurses) in local hospitals. of 33) than any other region (Exhibit 1). In comparing the The coaches talk with seniors soon after they’re admitted performance of U.S. hospital referral regions, the Scorecard about their needs for rehabilitative services and other found wide variation on indicators of health care access, supports after discharge, such as home-delivered meals quality, avoidable hospital use, costs, and outcomes. or transportation. The coaches focus in particular on addressing the “social determinants that may have caused EXPANDING ACCESS AND IMPROVING CARE people to go the hospital in the first place,” says Abigail Morgan, senior vice president of planning and quality The Akron region has made significant progress expanding improvement at Direction Home of Akron and Canton. access to care, thanks to efforts by local health systems to enroll residents in Ohio’s expanded Medicaid program The AAA was one of the first groups selected by the Centers or in subsidized coverage through the federal health for Medicare and Medicaid Services to lead a Community- insurance marketplace. The Scorecard found that from Based Care Transitions program, an Affordable Care 2012 to 2014, the uninsured rate among working-age adults Act demonstration designed to encourage hospitals and dropped from 16 percent to 10 percent, compared with community organizations to work together to reduce national figures of 21 percent and 16 percent, respectively. readmissions among Medicare fee-for-service beneficiaries Perhaps as a result of expanded coverage, more adults through better discharge planning and other efforts. commonwealthfund.org Case Study, August 2017 Health Care Improvement in Akron, Ohio: Moving from Collaboration to Coordination 4 For example, Summa Health, which serves 22,000 beneficiaries through a Medicare Shared Savings We have purposefully worked accountable care organization (ACO) and another 68,000 to develop relationships with through other value-based contracts, has given grants all regional hospitals, even and other support to its primary care clinics to help them having their folks on our expand access to care and build teams that can proactively manage care for their sickest patients. Forty-seven of the board so we can understand health system’s 85 affiliated clinics have earned the highest each other. level of medical home recognition from the National Committee for Quality Assurance. Nearly all (94 percent) Susan Sigmon had earned incentive payments for use of electronic health Senior Vice President, Managed Long-Term Care records by 2015, and most employ nurse care managers to Direction Home of Akron and Canton help patients manage their chronic conditions.6 Summa also funds an after-hours nurse triage line, so patients have options other than the emergency department when problems occur. These and other changes have been Together, the 10 participating hospitals reduced 30-day associated with fewer unplanned hospitalizations among hospital readmissions from 19.6 percent in 2010 to 11.7 Medicare ACO beneficiaries, as well as improvement on percent in September 2016 (compared with a national rate measures of primary and preventive care.7 The ACO has of 15.6 percent for the period July 2014 through June 2015). 4 earned shared savings from Medicare for three years in a row — the only one of Ohio’s 11 ACOs to achieve this.8 Area hospitals also are leading efforts to promote safe care transitions. Akron General, for instance, has reduced Summa’s shift to population health management began a readmissions among patients recovering from total joint decade ago, when it started building its shared electronic replacements by more closely collaborating with skilled health record, and is still ongoing, says Mark Terpylak, D.O., nursing facilities and allowing community providers to use president of NewHealth Collaborative, Summa’s ACO. “This a HIPAA-compliant platform to securely text pictures of is a long runway: there are a lot of bricks to be laid, a lot of patients’ incisions to surgeons, who can help ensure they’re culture change that has to occur,” he says. healing well. Hospital staff also have begun notifying primary care providers when their patients are discharged COLLABORATION ACROSS SECTORS TO so that they can follow up with them by phone or in person. REACH VULNERABLE POPULATIONS Akron’s ability to convene community leaders from across Building Medical Homes sectors is partly a function of its small size and the sense Despite this success in reducing readmissions, Scorecard of accountability this engenders. The region also has been data suggest Akron has work to do to reduce the number blessed with leaders who’ve worked to unite people, of people hospitalized in the first place. The region has including the recently deceased County Executive Russ relatively high rates of admissions among Medicare Pry, who brought county agencies and city government beneficiaries for conditions that can often be managed in together to tackle shared problems. ambulatory care settings, though there was some progress from 2012 to 2014. To strengthen the capacity of primary One example of the way the community has rallied around care providers to manage patients’ conditions, Akron’s a cause is its work to reduce infant mortality. Starting in health systems have been promoting patient-centered 2006, several public agencies “put every extra penny we medical homes. 5 ever had in this county to buy cribs,” says Skoda. commonwealthfund.org Case Study, August 2017 Health Care Improvement in Akron, Ohio: Moving from Collaboration to Coordination 5 Summit County now has very few infant deaths from cosleeping, SUMMIT COUNTY BY THE NUMBERS though infant mortality rates are Recognizing that many factors impact health, Summit County still high among African Americans, expanded its Community Health Assessment to encompass prompting further efforts as nearly 200 indicators in 2016, including: described below. Several partners launched another collaborative effort to find creative approaches to help bring people 43% of renters and out of poverty. Prompted by a local minister who saw the day-to-day 19% of homeowners spend more than 30 percent of their income on housing struggles of the working poor, the partners secured United Way and of women with a high-risk state funding to offer free “Getting Ahead” workshops, which provide 60% pregnancy are on progesterone or a progesterone drug, which may help prevent preterm birth training in financial literacy and other life skills. The program has thus far been delivered to some 12% 250 residents, including low-wage workers seeking guidance on how to of the population lives in a food desert earn promotions and develop their careers. The public health department has been a leader in these and other cross-sector efforts to help 28% of residents feel unsafe at night vulnerable populations — a shift from its past role of offering services to one resident at a time. “We failed miserably with efforts like nutritional counseling,” says Skoda. “That 20 14% of Summit County is public green space minutes of counseling doesn’t do a bit of good if people can’t buy fruits and vegetables.” Instead, in recent years the public health department has partnered with local government, 65% of preschoolers were ready for kindergarten schools, and others to create urban gardens and food hubs to bring more 18% healthy eating options into urban of residents do not have neighborhoods. The partners also Internet access helped to create walking and biking paths to encourage exercise and use of nearby Cuyahoga National Park. Data: Summit County Community Health Assessment, 2016. commonwealthfund.org Case Study, August 2017 Health Care Improvement in Akron, Ohio: Moving from Collaboration to Coordination 6 As Akron works to dismantle 30 acres of highway and And for the most recent community health assessment, redevelop the Ohio and Erie Canal towpath that runs partners added several measures assessing residents’ through economically and racially diverse neighborhoods, social and economic well-being and examining how the a new vision of the downtown area is taking shape. built environment affects health — expanding from 29 To capitalize on this opportunity, the public health indicators in 2011 to nearly 200 measures in 2016. Some department is pushing city and county planners to new measures target identified problems. For example, in consider the health impacts of their transportation and response to evidence that prematurity contributes to infant development plans through adoption of a “Health in All mortality in the region, a measure was added to track the Policies” charter. number of women with high-risk pregnancies who receive progesterone, which can prevent preterm birth. Using Data to Improve To inform this and other work, Summit County Public One of the threads running through such efforts is leaders’ Health invested in the Explorys analytics platform, which willingness to be guided by data. This approach dates back enables it to gather and aggregate clinical data from area to at least 2003, when the former Summit County Executive health systems in near–real time. convinced leaders from the health, housing, transit, aging, and other social service agencies to pool their efforts to Summit County’s Alcohol, Drug Addiction, and Mental improve residents’ quality of life, relying on a shared set Health Services (ADM) Board, which funds some 25 of indicators to measure progress. All parties to this cross- behavioral health agencies, also has used data to improve sector effort, now known as Summit 2020, must explain services. In response to the region’s spiraling opioid abuse how their funds are being used to make progress on 17 epidemic, ADM Board leaders created a dashboard to track indicators, which focus on morbidity and mortality as well opiate dispensing, wait times for addiction treatment, as socioeconomic factors such as educational attainment, overdoses, and other key measures. This dashboard has affordability of housing, and instances of violence, abuse, or enabled the board to be nimble in its responses. For example, neglect that can have an outsize impact on health. when data showed that many overdose victims had never been in treatment, the ADM Board provided funding for a staff member from a local detox center to be on call 24/7, so that when an overdose victim arrives at a local emergency department the staffer can rush over to try instill hope and Prior to having the engage him or her in treatment. It also helped to create an ambulatory detox center for teens — one of the only software, if we wanted such facilities in the nation — in response to evidence that obesity rates, we either addicts were increasingly younger and may do better in treatment settings with their peers. had to use a survey or driver’s license data. And Engaging Residents Akron’s leaders also are working to engage residents how honest are people on in health improvement efforts. Akron’s mayor, Daniel their driver’s license? Horrigan, has been using his office to rally people around the issue of health equity — an unusual topic for a mayor to Cory Kendrick champion.9 His initial focus is on securing a communitywide Director of Population Health commitment to reduce the infant mortality rate among Summit County Public Health African American babies, which in 2015 was 14 per 1,000, compared with 5.7 per 1,000 among Hispanics and whites.10 commonwealthfund.org Case Study, August 2017 Health Care Improvement in Akron, Ohio: Moving from Collaboration to Coordination 7 While overall infant mortality rates have improved in recent years, black infant mortality rates remain the same PATHWAYS COMMUNITY HUB MODEL as they were 100 years ago. Black babies are also more Summit County is piloting the Pathways Community likely to be born prematurely, a leading cause of mortality: Hub among pregnant African American women. This in 2015, 19 percent were born before 37 weeks gestation, centralized referral and coordination system for compared with 12 percent of Hispanic and white babies.11 health and social services is part of a communitywide The Mayor’s Office and its partners have been engaging effort to reduce infant mortality rates. Instead of black residents and community leaders to brainstorm having each social service agency, hospital, or clinic solutions. “We have to create momentum on the demand assign their own case managers to at-risk women, side,” says James Hardy, Akron’s deputy mayor for the Pathways model channels services through administration and chief of staff. “We have to have the one case worker, typically someone’s first point community conversation about why this is important.” At of contact. That individual (a community health a 2016 Health Equity Summit, 100 participants — including worker, social worker, nurse, or other professional) representatives from city, county, and state government, visits women in their homes or other community health providers, health plans, public health, local and settings; assesses their health, social, and financial national nonprofits, the housing and transit authorities, needs; and follows standard protocols to connect NAACP, universities, a church-led dads’ group, and them to sources of help. They’re also tasked with several women who had been teenage mothers — came tracking what happens next — ensuring women together to discuss the causes of black infant mortality and make it to appointments, for example — and how they can work together to address them. Through monitoring outcomes. The Hub is led by a local discussion and real-time polling, the group identified nonprofit, Akron Summit Community Action. first steps, including direct outreach and a public health The Pathways Community Hub Model, used by campaign to educate pregnant women in high-risk several communities across the nation, was developed neighborhoods about good prenatal care. “The data during the late 1990s in Mansfield, Ohio — just 60 point to social factors that impact premature birth,” says miles southwest of Akron — by Sarah and Mark Horrigan. “Physicians alone can’t fix this; we need every Redding, two physicians who saw a need for greater sector to get behind this issue. But somebody has to take structure and collaboration among those working the lead.” to coordinate health and social services for their high-risk patients. The pilot effort of the model in Mansfield, which focused on women at risk of having poor birth outcomes, led to a countywide reduction in low-birthweight babies. Summit County hopes to roll out Pathways for those with chronic conditions, mental illnesses, the homeless, and others. For Health Commissioner Skoda, a clear benefit of this approach is that it encourages care coordinators to focus on the Dads, women who were teen moms, church leaders, community’s comprehensive needs — for job representatives from local and state government, health providers, and others came to Akron’s Health Equity Summit training, housing, or food, for example — not to brainstorm ways to reduce the high infant mortality rate just the crisis that may bring individuals to their among black babies. attention. Photos courtesy of City of Akron Mayor’s Office, Daniel Horrigan, Mayor. commonwealthfund.org Case Study, August 2017 Health Care Improvement in Akron, Ohio: Moving from Collaboration to Coordination 8 Moving from Collaboration to Coordination LESSONS To make further progress in improving residents’ health, Perseverance and humility can be important Akron’s leaders may need to more closely coordinate ingredients in the success of improvement efforts across sectors, leaders say. “Collaboration and efforts. Akron’s leaders have launched several different coordination are two different things,” says Hardy. efforts to improve residents’ health, and not all have Developing partnerships and good working relationships been successful. But leaders appear willing to learn from is a necessary foundation, he says, but coordination would unsuccessful efforts and persevere — traits that research entail specific commitments and if necessary reallocation has demonstrated are characteristic of organizations that of resources to address deep-seated problems that have succeed.12 multiple causes. This call for coordination — echoed by others — stems from recognition of mutual dependence; Counties can serve as a locus for change. Summit for example, Akron’s EMS handles drug overdoses but County’s public health department has served as a Summit County is charged with preventing them. And yet convener of health care providers, health plans, nonprofits, it can be challenging to coordinate efforts when money and others in efforts to improve residents’ health. It also and jobs are at stake. “We have to move beyond the, ‘Okay has used these partnerships to inject considerations of yes we’re willing to sit at the table’ to ‘What are the action health into discussions of the city’s built environment, steps that we can hold ourselves accountable to? What can education, transportation, and other issues. And county we measure to move that needle?’” says Terry Albanese, leaders have shown a willingness to use data to promote assistant to the mayor for education, health, and families. accountability and improve services. Akron’s troubled “Accountable Care Community” (ACC) State and federal policy and programs can play offers a cautionary tale of the difficulty of coordination, an important role supporting local health system particularly in a region with fiercely competitive health improvements. The Akron region leveraged the systems. Formed in 2011 among local health systems, state’s Medicaid expansion and use of the federal health universities, and the public health department with a insurance marketplace to dramatically expand access to mission to reduce chronic disease, the group claimed care. Providers also have participated in state and federal some progress in an early diabetes management program. efforts to improve care, gaining both financial support and But the partnership faltered after a few years following guidance for their efforts. the loss of a grant from the Centers for Disease Control and Prevention (CDC), lack of cooperation among the competitive health systems, and some participants’ desire to focus on potentially income-generating biotech rather than population health. Skoda says she and other community leaders learned something from this experience: “The legacy of the Accountable Care Community has been to sell the community on the CDC’s health impact pyramid — showing that you get the most bang for your buck in addressing socioeconomic factors and building environments that enable healthy decision-making.” commonwealthfund.org Case Study, August 2017 Health Care Improvement in Akron, Ohio: Moving from Collaboration to Coordination 9 NOTES National Committee for Quality Assurance within the 1 Ohio History Connection, Rubber Industry (Ohio next two years. History Central, n.d.). 7 Discharges from hospitals or skilled nursing facilities 2 A. van Agtmael and F. Bakker, The Smartest Places on among ACO members fell from 426 per 1,000 in 2013 Earth: Why Rustbelts Are the Emerging Hotspots of Global to 343 per 1,000 in 2015. Summa’s overall performance Innovation (Public Affairs, 2016). among Medicare ACOs rose from the 89th percentile in 2014 to the 95th percentile in 2015. See https:// 3 The percentage of Summit County adults saying they are www.summahealth.org/aco. CMS calculates quality in fair or poor health has gone from 13 percent in 2008 scores for ACOs participating in the Medicare Shared to 22 percent in 2013. (Summit 2020: A Quality of Life Savings Program as follows: The total points earned Project, Priority Indicators Update Report, 2015 (Summit for measures in each domain, including any quality County Public Health, 2015)). The Commonwealth improvement points, will be summed and divided by Fund’s Scorecard on Local Health System Performance, the total points available for that domain to produce a 2016 Edition, found that in 2013, 32 percent of adults in domain score of the percentage of points earned. The the hospital referral region were obese, compared with percentage score for each domain will be averaged 30 percent statewide and 28 percent nationally, with together to generate a final overall quality score for virtually no improvement from 2011–12 to 2013–14. each ACO that will be used to determine the amount of From 2006–15, the average infant mortality rate in savings it shares or, if applicable, the amount of losses it Summit County was 5.3 per 1,000 among white babies owes. See Centers for Medicare and Medicaid Services, compared with 11.5 among black babies. (Source: Medicare Shared Savings Program Quality Measure Summit County Public Health.) In 2015, there were 350 Benchmarks for the 2016 and 2017 Reporting Years (CMS, overdose deaths from heroin or other opioid drugs. Dec. 2016). (Source: Summit County Alcohol, Drug Addiction, and Mental Health Board.) By June 2016, there had been 358 8 For Ohio ACOs, see https://data.cms.gov/ACO/2015- overdoses. Medicare-Shared-Savings-Program-Accountable-C/ ay8x-m5k6. About a quarter of all Shared Savings ACOs 4 The Community-Based Care Transitions Program ended achieved savings in performance year two. See https:// in early February 2017. CMS will not extend the program www.cms.gov/Newsroom/MediaReleaseDatabase/Press- as the agency is shifting focus away from efforts built on releases/2015-Press-releases-items/2015-08-25.html. fee-for-service Medicare. 9 According to James Hardy, Akron’s deputy mayor for 5 Ohio has long promoted the medical home model administration and chief of staff, none of the governors through its Medicaid program, and in August 2016 it or staff who attended the 2016 National Governors was selected to participate in the Centers for Medicare Association meeting had focused on health equity. and Medicaid Services Comprehensive Primary Care Plus Program, in which primary care practices that 10 Summit County Health Department, Office of Minority adopt elements of the medical home model become Health. eligible to receive enhanced reimbursement from 11 Summit County Health Department, Office of Minority Medicare, Medicaid, and participating commercial Health. health plans. See https://innovation.cms.gov/initiatives/ comprehensive-primary-care-plus. 12 See, for example, A. C. Edmondson, “Strategies for Learning from Failure,” Harvard Business Review, April 6 The remaining Summa clinics are developing their 2011 89(4):48–55; and R. Farson and R. Keyes, “The capacity to serve as patient-centered medical homes and Failure-Tolerant Leader,” Harvard Business Review, Aug. plan to submit applications for recognition from the 2002 80(8):64–71. commonwealthfund.org Case Study, August 2017 Health Care Improvement in Akron, Ohio: Moving from Collaboration to Coordination 10 ABOUT THE AUTHORS ACKNOWLEDGMENTS Martha Hostetter, M.F.A., is a writer, editor, and partner The authors would like to thank the following individuals in Pear Tree Communications. She was a member of the who generously shared information and insights for Commonwealth Fund’s communications department the case study: Terry Albanese, assistant to the mayor from June 2002 to April 2005, serving as the associate for education, health, and families, City of Akron; James editor and then creating the position of Web editor. She is Hardy, deputy mayor for administration and chief of staff, currently a consulting writer and editor for the Fund. Ms. City of Akron; Daniel Horrigan, mayor, City of Akron; Cory Hostetter has an M.F.A. from Yale University and a B.A. Kendrick, director of population health, Summit County from the University of Pennsylvania. Public Health; Abigail Morgan, senior vice president of planning and quality improvement, Direction Home of Sarah Klein is editor of Transforming Care, a quarterly Akron and Canton; Susan Sigmon, senior vice president, publication of the Commonwealth Fund that focuses managed long-term care, Direction Home of Akron and on innovative efforts to transform health care delivery. Canton; Donna Skoda, health commissioner, Summit She has written about health care for more than 15 years County Public Health; Douglas Smith, M.D., chief clinical as a reporter for publications including Crain’s Chicago officer, Alcohol, Drug Addiction, and Mental Health Business and American Medical News. Ms. Klein received a Services Board, Summit County; and Mark Terpylak, D.O., B.A. from Washington University in St. Louis and attended president, NewHealth Collaborative, Summa Health. the Graduate School of Journalism at the University of California at Berkeley. Editorial support was provided by Ann B. Gordon. Douglas McCarthy, M.B.A., is senior research director For more information about this brief, please contact: for the Commonwealth Fund. He oversees the Fund’s scorecard project, conducts case-study research on Martha Hostetter delivery system reforms and innovations, and serves as Consulting Writer and Editor a contributing editor to the Fund’s quarterly newsletter The Commonwealth Fund Transforming Care. His 30-year career has spanned mhcmwf.org research, policy, operations, and consulting roles for About the Commonwealth Fund government, corporate, academic, nonprofit, and The mission of the Commonwealth Fund is to promote a philanthropic organizations. He has authored and high performance health care system. The Fund carries coauthored reports and peer-reviewed articles on a range out this mandate by supporting independent research on of health care–related topics, including more than 50 case health care issues and making grants to improve health care studies of high-performing organizations and initiatives. practice and policy. Support for this research was provided Mr. McCarthy received his bachelor’s degree with honors by the Commonwealth Fund. The views presented here from Yale College and a master’s degree in health care are those of the authors and not necessarily those of the management from the University of Connecticut. He was a Commonwealth Fund or its directors, officers, or staff. public policy fellow at the Hubert H. Humphrey School of Vol. 27 Public Affairs at the University of Minnesota during 1996– 1997, and a leadership fellow of the Denver-based Regional Commonwealth Fund case studies examine health care Institute for Health and Environmental Leadership during organizations that have achieved high performance in a particular area, have undertaken promising innovations, 2013–2014. He serves on the board of Colorado’s Center for or exemplify attributes that can foster high performance. Improving Value in Health Care. It is hoped that other institutions will be able to draw lessons from these cases to inform their own efforts to become high performers. Please note that descriptions of products and services are based on publicly available information or data provided by the featured case study institution(s) and should not be construed as endorse- ment by the Commonwealth Fund. commonwealthfund.org Case Study, August 2017