public health 2030: scenarios for the boston public health commission 1

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Public Health 2030: Scenarios for the Boston Public Health Commission

The Public Health 2030 Scenario Effort

Conducted by the Institute for Alternative Futures.Funded by the Robert Wood Johnson Foundation and the Kresge Foundation to:

• Explore key forces shaping public health

• Consider the future of public health functions, financing & sustainability

• Build expectable, challenging & visionary scenarios that facilitate preparation, imagination & aspiration

• Provide & widely distribute the scenarios as a tool for public health agencies, organizations & schools

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Scenario Zones

Visionary/Surprisingly Successful

Expectable

Challenging

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Public Health 2030: Scenarios for the Boston Public Health Commission

Scenario 1Smarter Public Health, Missed Opportunities

Scenario 2Under Water

Scenario 3Public Health as Chief Health Strategist

Scenario 4A Renaissance of Civic and Social Responsibility

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SCENARIO 1: SMARTER PUBLIC HEALTH, MISSED OPPORTUNITIES HIGHLIGHTS

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Boston economy grows in tandem with national economy.

– Mild national recessions in 2015 and 2022– Periodic federal and state cuts and program

eliminations

Scenario 1: Smarter Public Health, Missed Opportunities

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Climate change: increased sea-level rise, summer heat waves, and increased storm intensity and/or frequency.

Scenario 1: Smarter Public Health, Missed Opportunities

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2018 Hurricane - Called Boston's Hurricane Katrina- Evacuations OK but with disparities in recovery

Scenario 1: Smarter Public Health, Missed Opportunities

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In health care, 98% + access to care, and most care is integrated and capitated. • More people are effectively assessed and even treated

at home, yielding health care savings• Hospitals deploy community health workers (CHWs)

Scenario 1: Smarter Public Health, Missed Opportunities

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In health care, 98% + access to care, and most care is integrated and capitated. • Large health care provider systems routinely improve

neighborhood conditions

Scenario 1: Smarter Public Health, Missed Opportunities

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In health care, 98% + access to care, and most care is integrated and capitated. • Doc Watson, digital health coaches common

Scenario 1: Smarter Public Health, Missed Opportunities

“Dr. Watson” for Public HealthDigital coach (“avatar”)

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In health care, 98% + access to care, and most care is integrated and capitated. • BPHC retains its hold on homeless, addictions, and

emergency medical services (EMS)

Scenario 1: Smarter Public Health, Missed Opportunities

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Surveillance, emergency prep, analyses improve. – City integrates surveillance systems, Internet of

Things

Scenario 1: Smarter Public Health, Missed Opportunities

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Surveillance, emergency prep, analyses improve. – BPHC uses games, digital coaches, and simulations to

improve health education and emergency preparedness, mitigation, and recovery

Scenario 1: Smarter Public Health, Missed Opportunities

Personal Health Advocate Avatar

V2.1

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Surveillance, emergency prep, analyses improve. – BPHC more effectively analyzes and targets

community conditions shaping health

Scenario 1: Smarter Public Health, Missed Opportunities

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But ACOs create their own epidemiology or population health units, turn to universities and private companies for most advanced analytics.

Scenario 1: Smarter Public Health, Missed Opportunities

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Key Outcomes• Challenging for BPHC to consistently prove its value to

HC and get recognized for advisor and convener roles• BPHC achieves 3 overarching goals in obesity, low birth-

weight babies, and chlamydia

Scenario 1: Smarter Public Health, Missed Opportunities

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Key Outcomes• Fundamental problems of poverty, social exclusion and

homelessness remain• BPHC forced to do more with less funding and fewer

staff

Scenario 1: Smarter Public Health, Missed Opportunities

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SCENARIO 2: UNDER WATER HIGHLIGHTS

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Boston faces serious municipal finance challenges.

• City’s economic health & revenue drops

– National 2016 recession

– 2018 superstorm hits Boston

– Reduction in resident students; Decline of Boston education sector

Scenario 2: Under Water

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Over time, cuts leave BPHC to focus on:

– infectious disease control and prevention

– emergency preparedness– emergency medical services– homeless and addiction

services.

Scenario 2: Under Water

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Health worsens especially for working poor.• Federal health reform was only partially implemented,

partially repealed

Scenario 2: Under Water

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Health worsens especially for working poor.• Addictions funding is

integrated into primary care, demand for mental health services increases

• But payment reductions and provider shortages disproportionately affect the poor

Scenario 2: Under Water

Shortage of primary care providers

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Health worsens especially for working poor.• Digital health coaches

and “virtual doctor” services grow but vary in quality

Scenario 2: Under Water

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Climate change and superstorm drain resources, leave significant physical and economic damages.• Hotter summers and related droughts, more intense

storms throughout the year, greater potential for infectious diseases and mold

Scenario 2: Under Water

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Climate change and superstorm drain resources, leave significant physical and economic damages.• Full recovery from superstorm takes years

Scenario 2: Under Water

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Climate change and superstorm drain resources, leave significant physical and economic damages.• BPHC improves ability to forecast and warn about, for

example, likely asthma attacks by neighborhood.– But this often does not lead to earlier response and

prevention because of resource constraints

Scenario 2: Under Water

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BPHC struggles to be effective and heard.• Big Data - Corporations and

health care providers hire skilled analysts to do their own big data analytics

• Big Data - BPHC has to work with growing volume of data with large blind spots for low-income people and people of color

Scenario 2: Under Water

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BPHC struggles to be effective and heard.• Public health messaging is tuned out among

proliferating competition in a variety of channels, ads, and communications

Scenario 2: Under Water

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Key Outcomes• Health gaps between the "haves" and "have-nots"

worsens• Little to no community prevention

– stymied by challenges in funding– difficulties in recruiting cross-sectoral partners– lack of political will

Scenario 2: Under Water

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SCENARIO 3: PUBLIC HEALTH AS CHIEF HEALTH STRATEGIST HIGHLIGHTS

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Boston becomes a beacon for the rest of the nation in successfully improving health equity and racial justice.• Nationally, strong economic recovery; Prevention Fund

restored; “Health in all policies” movement takes hold • By 2016, MA passes a living wage law with automatic

cost-of-living adjustments• Boston’s citywide long term vision for health

Scenario 3: Public Health as Chief Health Strategist

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Health care integrates equity lens into clinical practice and outcomes, performance assessments and quality improvement activities.• Near-universal coverage in the state, excellent care• Systematic screening for health and SDH factors and

needs lead to shared investments and programs in systemic solutions for violence prevention and health

Scenario 3: Public Health as Chief Health Strategist

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Health care integrates equity lens into clinical practice and outcomes, performance assessments and quality improvement activities.• Digital health coaches, social networks, games and

simulations guide users toward healthy behaviors • Demand for EMS services declines with improved care,

services, and prevention

Scenario 3: Public Health as Chief Health Strategist

Digital health agents, gaming,

social networking

Prevention

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Mapping, games, and simulations facilitate community engagement and planning.• BPHD develops health dashboards for each community

to track progress• Virtual simulations and games of Boston’s health allow

for exploration and consideration of emergency scenarios and fair access to opportunities for health.

Scenario 3: Public Health as Chief Health Strategist

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BPHC uses its convening powers and connections to identify and accelerate promising opportunities and evidence-based practices, initiatives, and policies.• BPHC functions as health equity and health promotion

coach for Boston government. • Enhances and leads effective community health

endeavors.

Scenario 3: Public Health as Chief Health Strategist

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Key Outcomes• Health equity and racial justice improve.• Widespread community engagement.• Boston’s government becomes a role model. • BPHC is widely recognized as the City’s chief health

strategist.

Scenario 3: Public Health as Chief Health Strategist

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SCENARIO 4: A RENAISSANCE OF CIVIC AND SOCIAL RESPONSIBILITY HIGHLIGHTS

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Constraints fuel creativity.• Nationally, unemployment remains high, another major

recession in 2017 is followed by slow and uneven recovery

Scenario 4: A Renaissance of Civic and Social Responsibility

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Constraints fuel creativity.• Growing excitement around innovative health-improving

technologies and vibrant social movement of “civic hacking” (including development of apps to help people manage their health)

Scenario 4: A Renaissance of Civic and Social Responsibility

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Constraints fuel creativity.• BPHC uses prizes and current

funding sources to accelerate innovations and save costs

Scenario 4: A Renaissance of Civic and Social Responsibility

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Publicly available simulations and comprehensive data:• Enhance impact

assessments and evaluations

• Improve policy design• Facilitate funding streams

Scenario 4: A Renaissance of Civic and Social Responsibility

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Health care often presses beyond clinical needs to improve population health.• Virtually all Bostonians gain

access to effective health care

• Most care is provided through integrated and capitated ACOs

Scenario 4: A Renaissance of Civic and Social Responsibility

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Health care often presses beyond clinical needs to improve population health.• BPHC joins ACOs and other

providers in population and community health endeavors, often as a leader and/or coach

• Demand for EMS, homeless, and addiction services declines

Scenario 4: A Renaissance of Civic and Social Responsibility

Community Centered Health

Home

Triple Aim

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Key OutcomesMany BPHC functions are taken on by other institutions and consumers; BPHC increasingly shifted to emphasize its role in capacity-building, mapping, and incentivizing the development of public- and private-sector solutions and consumer tools.

Scenario 4: A Renaissance of Civic and Social Responsibility

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• BPHC's successes inspire other Boston agencies and organizations.

• BPHC monitors innovations and assures community representation in the innovation process.

Scenario 4: A Renaissance of Civic and Social Responsibility

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Key Outcomes• Health equity and racial justice improve• Innovation platform provides sophisticated decision-

making tool that is inclusive of all Bostonians

Scenario 4: A Renaissance of Civic and Social Responsibility

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Key Outcomes• Many BPHC functions are performed to large extents by

other institutions, public- and private-sector solutions, and consumer tools

• Widespread community engagement, innovation platform provides sophisticated decision-making tool that is inclusive of all Bostonians

Scenario 4: A Renaissance of Civic and Social Responsibility

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Scenario 1 Scenario 2 Scenario 3 Scenario 4

MACRO AND OPERATING ENVIRONMENTSEconomy

Technology

Health and health care

Citizen science and engagement

Climate Change effects and mitigation

BOSTON PUBLIC HEALTH COMMISSIONFunding

IT and informatics

Workforce

Surveillance and epidemiology

Health education and promotion

Chronic disease prevention and control

Infectious disease prevention and control

Violence preventionEtc.

See the scenario matrix for a side-by-side comparison of the scenarios across multiple dimensions

Rate the Likelihood & Preferability of Each Scenario

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Likelihood(0% to 100%)

Preferability(0 to 100)

Scenario 1: Smarter Public Health, Missed Opportunities

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Scenario 2: Under Water ? ?Scenario 3: Public Health as Chief Health Strategist

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Scenario 4: A Renaissance of Civic and Social Responsibility

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Feedback, please!Scenario Process• What did you learn from the scenario process?• Where there any new or surprising insights?• In what ways might it affect:

– How you monitor your organization’s environment– The strategies or tactics organization pursues– Your communications, relationships with partners?– What other learning or outcomes would you identify?

Scenario Workshop• What worked, or was successful about the Scenario

Workshop?• What would you change?