Beyond the black box: Transformation to a population health approach

Arthur was a very natural, funny and engaging presenter - he is definitely set to be a crowd favourite this conference.

He began his presentation by sharing his own context, explaining who his father was, and how beloved his mother was in the community where he grew up. As a child growing up in Florida he lived with influences such as NASA space launches teaching him the sky was literally the limit, and Disneyworld Florida showing the power of imagination and happiness.

Dr Evans is the Commissioner of the Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) in Philadelphia. He described Philadelphia as “the birthplace of America” with 1.5 million people - a culturally diverse group with a large immigrant population.

The goal for the city is that every citizen is healthy and well. Dr Evans presented quotes from leaders of his city, and our own Hon Peter Dunne to show while on opposite sides of the globe we are dealing with the same issues.

A paradigm shift

Mental health services are complex and they have a profound impact on our communities. Arthur suggested, and the audience agreed, that our current paradigm is not working. 

In the current system a person presents for the “black box of treatment” to occur - we view them as needing to be “fixed”. Under this current method we apply some sort of treatment, usually a mixture of medication and psychotherapy, then we send this person back out to their life. The audience volunteered the reasons why this system doesn't work:

  • too late
  • too disconnected from the context of a person’s life
  • assumes a person needs “fixing”
  • doesn’t necessarily value a person's strengths
  • treatments can actually get in the way of getting well
  • waiting  lists - services can’t cope with the demand, we don't have enough “black boxes”
  • focussed on sickness not wellness.

Philadelphia has moved to a recovery oriented system of care, one where the person is at the heart of the system and the context of where and how they live is considered - peer support, family, housing, nutrition, exercise, social support, work, school, spirituality along with treatment and rehab. Under this system the social determinants of health are not ignored.

Population health - trend or fad?

Arthur explained the US spent a lot on healthcare, but without getting the return - they weren’t getting the outcomes they wanted and needed. To combat this Philadelphia introduced a change in the way providers were funded, with a performance-based system introduced where providers are measured, scored and ranked. This fits well with the outcomes culture that New Zealand is moving more and more towards, where the focus is on improving treatment and outcomes.

Seven conceptual shifts to population health

Arthur finished his session by describing the seven changes required to move to a population health focus.

  1. Work upstream: intervene earlier. Examples included sending in trauma response teams when incidents occurred in the community rather than waiting for the fallout from these events.
  2. Broad set of strategies: moving beyond psychotherapy and medication. This is where programmes such as MH101 can help. In the US they have a goal of having as many people trained in mental health first aid as there are CPR. He illustrated this by saying if someone is having a heart attack in a crowded restaurant about 20 people can jump up and offer assistance but if someone voices a mental health concern in public people tend to freeze up, not know what to say or run the other way - and that we must change this.
  3. Working with people who aren’t diagnosed: inherent in every community is the ability to solve its own problems. An example was teaming up immigration services with some mental health screening - people who wouldn’t have presented at traditional services are now getting seen.
  4. Deliver health promotion interventions for mental and physical wellness: delivering information via ‘friendly looking not government looking’ websites, make online screening tools available and conducting screening in the community - “get a checkup for your neck up.”
  5. Working in non-treatment settings: addressing the social determinants of health - especially housing. Philadelphia has had a lot of success with the housing first approach, which has resulted in significant cost-savings for the city.
  6. Health activation and empowerment: getting people to take more ownership of their mental health status. Males of colour were identified as an at risk population group so a campaign using celebrities this group identified with was introduced with great results. 
  7. Working at the community level: arts projects have been a major focus with some amazing murals showcased via Arthur’s presentation. These collaborative community works have gone a long way to reducing stigma and discrimination, particularly with regards to a methadone treatment programme. Visit porchlightvirtualtour.org to see some of the works.

Arthur closed the session by closing the loop back to his family, this time his favoured grandmother. The change seen in her lifetime was huge - from slavery to an African-American president. Arthur feels confident that while we are calling for big ‘transformational’ changes in 20 years people will thank us for it.

"Change is possible - it’s all about reaching as many people as we can."