Innovative Finance Case Study: Wellness Trusts

coins-stock-photoIt is a long-standing conundrum of our health care system: with delivery and finance organized around the treatment and management of acute and chronic conditions, who pays to prevent disease—or support decisions and behaviors that contribute to wellbeing?

Wellness trusts have been championed by thought leaders over the years as a finance innovation for creating prevention infrastructure. Their goal: overcome informational, organizational, and financial silos by creating public-private partnerships whose broad outcomes are tied not to clinical processes but to the elimination of social determinants and population disparities. Data are shared indiscriminately across sectors with the hope of targeting greatest need. Partnerships are linked to clinical systems of care—but are not owned by it. Their independence fosters collaboration and better cross-sector coordination. A wellness trust is not circumscribed by typical accountability timeframes of one – two years, which helps them focus on longer-term results and an extended cost-savings horizon.

Although not yet widely practiced, the idea received its fair due in Massachusetts, where state officials created a Prevention and Wellness Trust Fund. A one-time assessment on large hospitals and select insurance companies generated $60 million to be spent over four years. The mission: reduce health care costs by preventing chronic conditions using research-based interventions, encourage healthy behaviors, and address health disparities. Based on evidence of interventions that generate a positive return within three – five years, the state public health department prioritized tobacco, asthma, hypertension, and elder falls prevention.

Asthma and the Lynn, Massachusetts Coalition

The city of Lynn, Massachusetts, was one of nine communities selected to participate in the state’s wellness trust experiment. With $5 million and four years to produce results, a coalition of six partnering organizations—each with differing agendas funding sources, performance measurements, governing bodies, and constituents—came together around a common prevention agenda. Prevention trustees included the city public schools, a federally qualified health center that operates eight school-based health centers (SBHCs), the local housing authority and community development agency, and the state’s Coalition for the Homeless.

The selection of pediatric asthma as a focus areas was a no-brainer for the group. It’s tailor-made for a city-wide, cross-sector prevention initiative. While managed effectively with medicine, the chronic disease is sensitive to behaviors and environmental triggers that can be controlled outside the medical complex. Schools are ideal settings to promote prevention, identify kids with early onset issues, and co-manage the condition with the health care home. Poor outcomes (ER visits and hospitalizations) are easily measured and monetized. And the benefits of effective prevention accrue to both the health (diverted ED visits) and education (more seat time in the classroom) systems.

One key to the program’s success was the use of trust funds to hire an asthma prevention specialist to coordinate and connect school and community based activities. The coordinator trained school nurses to better identify and manage asthma symptoms among the district’s estimated 2,000 asthmatics, developed school-wide campaigns to raise general awareness about asthma, strengthen linkages and warm referrals to community providers, and provide better wrap-around care. The community health center employed its school-based sites to add continuity and bench strength for the more complex asthma cases.

The prevention collaborative was equally concerned with environmental conditions that affect health. With its experience in serving families living in unstable or unsuitable housing, the Massachusetts Coalition for the Homeless was at the ready with training and personnel to conduct home visits. These home visits became an invaluable tool to help families better understand their child’s asthma triggers and give clinicians a better sense of the situation. The Coalition also had existing relationships with the local housing authorities, which were critical to eliminating environmental triggers in the residents’ homes. The Lynn schools, for their part, swapped out cleaning supplies for environmentally friendly products that don’t trigger asthma flare ups.

The pediatric asthma prevention work group met monthly to discuss progress on all cases and ensure that goals were being met, especially across partners. For example, if the home visit revealed a need to replace mildewed floor boards, and requested the work from the housing authority, the working group provided a place to check on the progress of that work. The monthly meetings also revealed previously unconsidered issues, and provided a resource to begin solving them. At one meeting, the group realized a hurdle for many families was the lack of laundry facilities in low-income and state run housing (washing bedding is a crucial intervention for chronic asthma). Through the working group, they were able to price out and help finance several solutions, including mobile laundry services.

Although the demonstration has ended and, at this time, is not likely to be repeated by the state, the investment produced a group of key agencies in Lynn committed to this prevention and wellness collaboration. The success in Lynn hints that wellness trusts may be a promising avenue for SBHCs to achieve financial sustainability. Advocates should keep a keen eye for local opportunities to get their centers involved in a wellness trust.

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