Mikelle Moore: This is Mikelle Moore. I'm Senior Vice President of Community Health for Intermountain. And in a little bit of a role reversal here, I'm participating in an interview with Dell Medical School's rethink storytellers platform with Dr. Karen DeSalvo. And I'm going to introduce Karen, and then she's going to interview me. Karen?

Karen DeSalvo: Thanks so much for making time to talk with me as part of this Dell Med's rethink storytelling platform. I think the Dell Med community is going to be very interested in and excited about not only the work that Intermountain's doing, but your career and trajectory and the way that you're approaching this really important work around social determinants of health. As you know Mikelle, we got to know each other as part of The National Alliance to impact the Social Determinants of Health, which is some work that I started following at public service, and then my time in academic medicine including my work in New Orleans after Katrina, which is probably when I got inspired to understand and be able to better address the social determinants of health. And so as part of this conversation today Mikelle, I want you to share audience more about our Intermountain is thinking about addressing the social determinants of health as one of the critical components to keeping health for everybody. And then I really want to make sure we have some time for you to talk about your personal and professional journey.

Mikelle Moore: Absolutely. It's really been an interesting journey in terms of Intermountain's transition to thinking about the social determinants of health. You're right, we've had a long history of focusing on continuous improvement, quality improvement as a part of our clinical practice as an organization. And one of the first things we began working on when I came into the community benefit role as we had called it at that time at Intermountain was to really look at the things we were doing to improve health in the community, and how we could do that more in partnership with the clinical part of our system. So we invited all of our clinical programs we call them. We have a cardiovascular clinical program, a women and newborn, a behavioral health, and so on. We invited all of them to work with us really to understand the health needs in the community, and to design interventions that were evidence based best practices clinically, and could be applied to the most vulnerable populations in our community through our partners and friends that we had made in the community, so to speak.

Mikelle Moore: And as we did that work and brought the continuous improvement approach to our community health improvement work, it really transformed way we thought about community based work altogether within Intermountain. And we began focusing on prevention of high blood pressure, prevention of diabetes and prediabetes. As well as depression, suicide, and prescription opioid misuse. And as we began working in each of those spaces, it became really clear that the clinical influence that we were having was just one piece of the puzzle that we needed to solve for some of the most vulnerable people we were serving. When we were talking with people about their prediabetic condition and the courses that we were making available to them to improve their outcomes, they were facing much, much more significant issues than just knowing how to manage their prediabetic condition. They didn't have access to healthy food, didn't have time in their life to prepare healthy food. Maybe they didn't even have a living situation where they could appropriately store healthy food, lack of refrigeration and so on. And so it really kind of all came to a head in a way that was very visible to our clinical leadership in the system. So while those who'd worked in the community health space had public health backgrounds or were influenced by public health, really kind of inviting our clinical teams to see these barriers is what enabled a transformation in our approach. I think

Karen DeSalvo: It's interesting to hear you talk about that journey from having the community facing part of your organization, the pretty in tune with the needs of community and how sometimes there needs to be some better bridging with the clinical world. And certainly clinicians often do have a sense that there's much more to the story about what's preventing health and wellness, or even recovery for our patients. I think one of the interesting approaches that you all have taken that is so powerful is using data and doing hot-spotting and data mapping. I wonder if you could just share a bit about how that feeds into the way you all help build evidence and awareness, not only for your own organization but for the community.

Mikelle Moore: I think it's interesting. We've actually done hot-spotting from two different points of view that are now coming together in our most recent work, which is really fun for me. We've spotted for several years around clinical conditions and the way that they present in our systems. So for example, we have used geographic data commingled with clinical data to help us see in a map sense or in a geographic sense where people live who are using the emergency department for conditions that could be treated in an ambulatory setting. We're using that same type of geo mapping data to look at where people live who have behavioral health conditions, substance use diagnoses. To help us think about how we can orient services more effectively. At the same time, about three years ago in our community health work, we began doing hot spotting around deprivation.

Mikelle Moore: We created what we call an area deprivation index that uses census tracked information that reflects quality of housing, income levels, education levels, and other similar points, and creates a relative deprivation from one census track to another. And as we were doing that work in our community work and then doing this other work clinically, we began to think what if we overlay these? And of course, it's as you would expect, the clinical prevalence of use of the emergency department or prevalence of disease overlays with the disparities we see in income and education, quality of housing and so on. And so it's really helped us to understand the relationships or show people the relationships in these issues. And it's helped us fine tune our application of some of our work. We have used that area deprivation data to help us fine tune to whom do we offer care management resources or nurse visitation programs. Because we've demonstrated it can be a predictor of a risk, and also a predictor of uptake or response to being offered a service. So it's really become now a part of the way we're applying resources.

Karen DeSalvo: It's really exciting and innovative work. I hope that others will start to think more about the opportunity to have data to drive the not only thinking about how we're going to improve care, but just that you all are doing about thinking about improving total health. And I want to get you to share about the recently now Utah Alliance Effort, which is just so exciting and you're getting a lot of attention for as you should. Because it's building upon this history of really wanting to do better by the people you serve, including the community. And then leveraging data and the best of your organization to partner with communities. I think you're taking on some really exciting efforts. So tell us about the vision for the Utah Alliance work and then what you're going to be doing, and then a bit about what you might already be learning in that effort.

Mikelle Moore: It feels kind of funny to have you ask me this question because I think so much of what the Utah Alliance represents, I feel like has been influenced by your coaching and teaching me about these issues. So it's really a pleasure to talk with you about it. As I mentioned, we could really see that the social determinants are influencing health. This concept of social determinants in health has definitely become a buzzword. I don't believe for a minute that Intermountain is the leader in this space in terms of knowing exactly what to do and how to do this. And in fact we've been trying to learn as quickly as we can from people like you and others who have been doing this. But the thing that we observed as we began to learn from others was that there's a lot of good work going on. There's beginning to be an evidence base around programs that work. And yet it doesn't seem like many have figured out how to create an economic model for funding the social determinants of health.

Mikelle Moore: What dollars should we actually move if you will, from our healthcare pocket to our housing pocket, or transportation, or food? And how can we create something sustainable? So the vision of the Utah Alliance for the Determinants of Health is to really create a demonstration of how to make an economic model that can work and be sustained. Whether it's by a health plan, or a state, or a country, we hope we lend to the conversation for all. Because we think that ultimately, this isn't just about a health system acknowledging the link, or a community benefit team, or a community outreach team or whatever a health system might call it going to do good work that can matter. It's really about creating a sustainable economic model that can work. And that's our vision for creating the demonstration projects we've just announced and will begin in January.

Karen DeSalvo: I thank you for thinking about this on the front end as a way to create a business model. As a part of all this conversation, tell us who's involved in the alliance. What's that mean for Intermountain when it thinks about the fact that it needs to pull together a set of partners to get this work done on the ground?

Mikelle Moore: The alliance efforts really started as bringing together some of our state leaders from Department of Health, Human Services, the governor's office, as well as workforce services and other parts of government to understand given our aspirations to improve health for a specific population, ow might they want us to work together and what could we lend to the broader conversation in our state and also nationally? And that really helped shaped things. But we ultimately decided really in consultation with them that in order to do something that could be demonstrative for Utah, we needed to choose to communities where we could have geographic based influence on the determinants of health and measure very clearly health outcomes. So we have selected two zip codes in Ogden, which is in Weber county, and two zip codes in St. George, which is Washington County. Those zip codes were identified on the basis of some of the disparities that we've talked about, as well as what we could see in our own select health claims data for Medicaid members who are covered in what we call Select Health Community Care plan, where we were able to observe in those four zip codes in total a higher rate of use of the emergency department for ambulatory sensitive conditions, higher prevalence of behavioral health conditions, and some other disparities that we thought really lent themselves to working with community partners to try to improve outcomes.

Mikelle Moore: So in total, there are 8,000 Select Health Medicaid members in those four zip codes. We envision working with all of them in some ways in that some of our interventions we hope are felt at a community level or at a plan level. And yet we estimate based on input from both our community partners and our own data about these members, we anticipate that about half of them are at risk for one of the social determinants of health types of needs. And that of those, about 20 percent really need very specific and thoughtful comprehensive interventions with the alliance in order to improve health outcomes. So we've brought together partners in both St. George and Ogden. Given what we understand about the needs of the population, the first partner we identified needing was the behavioral health and substance use provider in each community.

Mikelle Moore: Here in Utah, Medicaid works through the local mental health authority to deliver those services to the Medicaid and the unfunded population. So bringing them in as our first partners was key. We're also working with the local health departments, county commissioners, mayors, those in public office. As well as different community based organizations who have an interest in addressing the social determinants of health like education, housing, food, income, etc. So United Way, food banks. And depending on the setting, shelters, universities, there's different partners in each community. But those are some of the common participants.

Karen DeSalvo: So perhaps you could talk a little more about [inaudible 00:14:42] working with governmental public health, and I'd love for people to hear more about is how deeply you've gone into community to work with them? I know from you, but also from talking to your team that you all are taking quite seriously this idea that you have to build this social determinants effort with community, not for them. To the point of actually [inaudible 00:15:02] to learn more about what would work for them. So those are two areas that I would just really love for people to hear more about the kind of great work that you all have been doing.

Mikelle Moore: You're right. We have a history of working with our public health colleagues to try to establish a comprehensive or shared understanding of the community's health needs. And to bring our relative resources and expertise to the table to address them. We started that effort about four or five years ago. Began with the requirement to do a health needs assessment in order to become an accredited health department. As a not for profit hospital system, we're required to do community health needs assessments by the ACA. And so what if we did those together? And those conversations were, it honestly took a while for us to get to an established partnership. But today, that partnership is statewide. We have all health departments, local mental health authorities, and all not for profit hospitals in our state working together to conduct a community health needs assessment that occurs in every community where there's a hospital, with advocates and community partners around the table talking about what needs they see in their community.

Mikelle Moore: And we all are using the same health indicators that our state level health department creates for us to describe health needs so that we're consistently using the same data that a group of experts, epidemiologists and others have said, "This is the most reliable data that we have as a state. Let's rely on this data as opposed to other data." And it's really created a great foundation for understanding needs. And also then complementing one another with when the public health colleagues say, "We'd really like to speak up on this issue at the legislature, but we can't," or, "We'd like to fund this, but it doesn't fit with our grant criteria." We can come in, in a complimentary and a non-duplicative way to address those needs a together.

Karen DeSalvo: So many public health agencies very much have that kind of partnership with their healthcare systems in their state. [inaudible 00:17:30] for non-healthcare folks, for the public health people thinking that they want to extend a hand to do some coordinated work and community assessment about what's a good way to open that conversation.

Mikelle Moore: I think that from a health system perspective, many health systems have outsourced their community health needs assessment. And I think a key to creating this type of collaboration and approaching it together is to talk about the value of using the needs assessment as a way to build community. That by engaging people together in the conversation and using the expertise of your health department instead of an outsourced vendor to provide the data components to this, you can begin the conversation with community about taking action and what does the community care about. Rather than thinking of the needs assessment as something to get done, or to buy, or a procure, think of it as the beginning of establishing community based problem solving to address the needs. And I think of a health department can approach a health system with what they can bring to the table in terms of that epidemiologist and resources to help conduct the assessment, and begin to think of doing that together so that it begins the hospital's work then in developing implementation plans.

Karen DeSalvo: Spend a little time sharing with the audience about the work you all have been doing with the communities that you're developing these projects. And as I said, build your social determinants effort through the Utah Alliance with them, not for them. There's been some pretty innovative approaches you all, and I want people to hear more about that.

Mikelle Moore: I love your statement that we need to work with the people we're trying to serve, not for them, and certainly not do things to them. And when we first identified Ogden in St. George as the communities that we thought had potential, we kind of reignited or added more energy to our existing community relationships by going to our existing partners and talking with them about our interest in working in this space and whether it would be welcomed. And in both cases were really invited to bring this additional lens and energy to the community. And that I think was foundational and important. We've very much tried to not create our own infrastructure, our own processes, but to build on existing efforts that were underway.

Mikelle Moore: And when we talked with those partners about what they needed in order to do more of what they were already trying to do, as well as accomplish the aims we had, we heard really a couple of remarkable things. One, that they didn't have good data infrastructure for communicating with one another around serving an individual or a family. And they really liked to have more of that capability. And second, that each constituent if you will, had a siloed understanding of the needs of the people they were trying to serve. And we're maxed out trying to address those needs. Really couldn't afford if you will, to back up and understand the broader picture. So we have committed to try to address both the data need, and the understanding of the people we're all trying to serve. So with the latter, we have undertaken a piece of research work. It's IRB approved research to go into 15 homes in Ogden, 15 homes in St. George, with researchers spending four to six hours in people's homes talking with them about their life story, and observing it in a very real way.

Mikelle Moore: Getting to see what they're facing that day with childcare issues, or taking care of an elderly family member. What's in their fridge, and how did it get there? What are their living situations and their history? Both from a health perspective, a behavioral health perspective, and even frankly beginning to understand some of their adverse child events and other things that are an important part of their life story. That is work that's now being aggregated and understood in a way that can be shared appropriately with our partners. And we intend to do at regular iterations throughout this work so that we can really help our entire team understand and be informed by what people's needs are, what their challenges are that they're facing, and try to design interventions that build on all the assets people are already wanting to bring to the table, but apply them in a way that's maybe more informed than it's been able to be before.

Karen DeSalvo: I'm so excited to see some of the results that work. To me, it speaks of your respect for the community, and also your interest in maintaining the dignity. And what I mean there is, in some places we all rush to address the social determinants of health, particularly those of us in healthcare who may not be as experienced in asking people hard questions, like whether they have a safe place [inaudible 00:23:01] or they have enough food to eat. There there are some potential downsides to making people who are trying to help and serve feel uncomfortable, and maybe even take away some of their dignity. So I look forward to more of what you all continue to learn about how to again help the community understand that this is about building resiliency and capabilities, and capacity in the community and not just about asking people questions that might feel uncomfortable for them to answer. There's going to be a lot on the journey of the social determinants for everyone to learn, including healthcare systems. And so thank you guys for really taking that extra effort to think hard about what it feels like literally to live in those communities and to do so by hours in people's homes, and make sure that you're kind of getting it right.

Karen DeSalvo: I want to move on to talking about a couple additional points. One is this idea that the healthcare system isn't just a set of payment models, or care models, or data. That we actually have humans that are working in the environment, and increasingly that the workforce in healthcare in particular is going to have to learn more about the fact that health is more than healthcare. And that there are these social determinants of health driving the large amount of people's health outcomes and that's going to take some training and some new kinds of leadership skills. It's a place where Intermountain has been a leader in other areas in the past, and I hope that you might give some reflections on ways that you all and how you'd like to see the country start to build a healthcare workforce that is more aware of the social determinants and more capable of addressing them.

Mikelle Moore: I think this is so important, Karen. Everyone I know who works in healthcare came to the field because of a passion to help others. Everyone I've worked with in my career feels some very human drive to do best work. We now can see very clearly the opportunity that we have to help our workforce understand that the person that they're caring for, and caring with, has a much deeper history and life experience than just their clinical experience, or the way that they're showing up or presenting clinically. And I think it really connects with what people want anyway in their caregiving experience as a healthcare professional. They want to connect with the person that they're serving, and address their needs. And so I actually think that this is going to be really easy work in some ways because it will help people serve and connect better with the people that they're trying to care for and with.

Mikelle Moore: So I'm very hopeful about it. I see two pieces for that work. I think one, we need to develop an infrastructure if you will, within healthcare delivery that gives caregivers information about people they're trying to care for. We have vital signs for the major functions of our bodies that healthcare workers are quick to screen upon arrival for any condition. And we're not applying that same approach to understanding people's financial issues, housing issues, and other things that are really going to contribute to the intervention we should provide. The medication we should prescribe, the resources should offer to a person in the clinical setting. And so I think we have to design care differently. And that's something we're looking at. We have selected screening tools that we our clinicians have said are the right ones to use in the clinical workflow for both children and adults.

Mikelle Moore: And we're working to implement those in the highest need areas of the company first, but with intent to be everywhere. And really then designing systems that make that work well in the workflow and provide the information needed to the right member of the team. And that brings me to kind of the second piece. It's developing the workforce in the sense of our approach to team based care. We've over time at Intermountain really transitioned from thinking about individual best practice, how to follow a care process model if you're a heart failure nurse or a cardiac surgeon, to thinking about the team based care we need to be providing to deliver services most effectively for a person or a population. And as we begin thinking about the social determinants, the care team is going to need to change. We need social workers as a part of the care team.

Mikelle Moore: We need community health workers, again as a part of the care team. There's a lot of community health worker programs underway across the country, a lot even here in Utah. And the most successful we're finding are those that really aren't happening separately. There's community health workers that are very connected to the community, the people that they're intending to serve and connect, and they're also viewed as a part of the care team. Nurses rely on them, social workers rely on them, and they're seen as an extension of that care team. So I think those are the two pieces that are going to be important in this work for us to get right. And I'm sure that there's a third and a fourth piece that I'm not thinking of and that we're going to learn from as we do this work. And that's really the point of our alliance work is to understand very clearly what works and what doesn't work and try to continuously improve.

Karen DeSalvo: I think that's really well said. I just want to go back to what you said at the very top about why people go into the practice of medicine or into healthcare. And what's exciting about this new chapter around social determinants of health is it's helping to create another bridge between the varied parts of a team that support patients and communities, meaning social work and behavioral health. But also housing agencies and etc. It's creating a real opportunity I think for learning, especially in areas like primary care which is my background. So lots of lots of work ahead in the space, but I think it's going to be welcomed by so many people because it's going to be a much better way to help address the needs of our patients.

Karen DeSalvo: Mikelle, I wanted to end on something that was more focused on you and less on your work, meaning your career as a healthcare leader. It's really already been so impactful, and I have been able to work with you and watch you, and know that this is a for you a passion about improving the health of people, and doing your best work all the time. And that's quite inspiring. I wonder if you could share with the audience a bit about yourself and your journey of leadership, and maybe some thoughts about what leadership requires in 2018 and beyond compared with maybe when you started a few years ago. And anything else that you think would be helpful to share.

Mikelle Moore: That's a lot to cover and I don't want to bore you. For as long as I can remember thinking about having a job someday, I wanted to work in healthcare. It felt to me like the place where I could improve the world, and I wanted to have impact and meaning in my life. And so I was a candy striper at 14 in the hospital near my home. And always thought I would go into healthcare. I was premed in undergraduate, and then decided I wanted to be a physical therapist, volunteered in physical therapy, realized I didn't like it. Frankly had a panic attack and didn't know, okay, if I don't like one-on-one healthcare delivery, how am I going to make a difference? How am I going to be meaningful in this world? And had the good fortune to meet the hospital administrator in the little hospital in Tucson where I was volunteering in the PT department, and got exposed to this whole idea that there were lots of people working in health care that weren't in the front line so to speak, of caring for an individual, but were helping create systems that made it possible to improve health for many.

Mikelle Moore: And I really liked that concept. And so began to learn more and more about it. And had some great opportunities to work in different settings at the Mayo Clinic in a health plan, and then to come to Intermountain Healthcare, which I saw as the leading integrated health system 20 years ago, with the greatest potential to truly improve the health of a community. When I met the leaders here at that time, they more than any other organization I interviewed with all over the country, really spoke to mission in a way that I didn't hear anywhere else about caring for improving the health of people in our service area. And I thought what better place to learn healthcare than here?

Mikelle Moore: And so I had the great fortune to be an administrative fellow here, and then to have a very dynamic and growing career in hospital administration where I ultimately was the administrator of LDS Hospital here in downtown Salt Lake, that is also the hospital that of all hospitals in Utah, has the highest share of charity care, serves more homeless people than anyone else in the state. Really, you don't think of Utah as being an urban setting with a lot of those types of big city problems. And yet at LSA Hospital, that's where we could see it all. And I loved that job. I loved my collegial relationships with physicians, and housekeepers, and nurses, and everyone in between as well as our neighbors who lived right around the hospital that I always needed to work with, making sure we had an eye for what was important to them.

Mikelle Moore: And I loved that job, but when I thought about what I wanted to do next, I didn't want to be a hospital administrator of another hospital. I really wanted to go on in improving health in the ways that I saw at LDS Hospital wasn't able to. In that setting, we would see some of the same patients in the emergency department on Monday as we would have seen on Saturday and the Friday before, and maybe even Friday morning instead of Friday afternoon. We saw a lot of people that we were able to help, the good doctors, and nurses, and social workers working in that emergency department did everything they could with the resources they had to improve outcomes for the people that were coming there. And yet it really wasn't having much of a lasting impact for some.

Mikelle Moore: And I thought that there had to be a better way to do that, and that Intermountain Healthcare really wanted to be an organization that was a part of doing something better. And so when I had the opportunity to apply for a position in community benefit, I asked the leadership at that time, would they be open to thinking about it differently? To thinking about not just how could we do good in our community, but how could we connect it upstream to things that would make a lasting impact in the health of people. And some of the people I was getting to know if you will at LDS Hospital. And so I did. I had that good fortune to come to the position with a CEO and CFP who really believed in, the ability to do community based work in a way that would improve health outcomes and help us in our journey to value based care as an organization.

Mikelle Moore: And so I've had the good fortune to lead a community benefit for about five years. And then under our new CEO, Marc Harrison's leadership, join the executive leadership team with a vision for community health, not just community benefit, but how can we be a part of improving community health. So I feel like I've won the lottery in terms of when I think about what I wanted to do as a 14 year old girl in a volunteer candy striper outfit and what I'm doing now, I don't think I could have ever imagined it. And yet it seems entirely perfect.

Karen DeSalvo: Well Mikelle Moore, I'm thankful for simile that you've applied. You’re not only talent, but also thankful for your passion and your heart to improving health. And I can't thank you enough for sharing with the audience not only your personal leadership journey, but also the great work that you're leading at Intermountain. You're setting a pathway for many others in this country around addressing health beyond healthcare and thinking about health for not only your community but showing how it can be done for others. And I just thank you for letting me be a part of that and look forward to seeing how we can make a strong and durable impact on communities, and [inaudible 00:36:58] that. So thank you so much for your time, and for being so candid with all of your answers. And I look forward to continuing this journey with you.

Mikelle Moore: Well Karen, I know I tell you this privately, but I'll say it very publicly here. There are just a few people I can think of over the course of my career who've helped shape how I think about healthcare and how I think about the roles we have. And you're one of them for me. You really help me to understand the role of the work that we're doing here in Utah, and the impact it can have nationally. And you're helping me to make sense of government. I'd say it's definitely a place where we need close partnership, and you're helping me to make sense of it all. So thank you for your guidance, and your friendship, and your leadership. You've inspired many here in Utah, and I think none more than me.

Mikelle Moore: Well Karen, thank you so much for spending time with me. It was a pleasure to be interviewed by you for an Intermountain podcast. And some of the things that we've talked about are a detailed in pages on our website. So I encourage anyone who wants to learn more about the Utah Alliance for the Determinants of Health or other work Intermountain's doing to improve healthcare in Utah and across our country, please go to Intermountain Health. Thank you Karen.

Karen DeSalvo: Thanks Mikelle.