This document describes research conducted in Austin, Minnesota to understand community health needs and inform the design of a new healthcare delivery system using a patient-centered approach. Mixed qualitative and quantitative methods were used, including surveys of 487 community members. The research found significant disparities between English and Spanish-speaking residents in areas like income, education, employment, health insurance coverage, and access to care. These disparities represent barriers to achieving the goals of improved health outcomes and lower costs. The researchers conclude that effective healthcare system design should focus on creating health rather than just healthcare, and should be informed by deep understanding of community needs and context gained through design research methods.

1. SPECIAL ARTICLE
USING DESIGN RESEARCH TO GUIDE HEALTH REFORM
Health Reform: A Community Experience
Using Design Research as a Guide
M A. S , RN, MA; D L. W , MD; C N. C , MA; L G. L , MA;
A C. R , MBA; D C. A , MD; C P. H , MD; J K. B , RN, MS;
K H. S , MA; B R. S , MHA; N F. L R , MD
Meaningful health reform in the United States must improve the ture of an of ce practice or an integrated delivery system.
health of the population while lowering costs. In an effort to provide
a framework for doing so, the Institute of Health Care Improvement
In our view, this does not represent a true patient-centered
created the triple aim, which encompasses the goals of (1) improv- approach and does not truly assess and respond to the needs
ing individual health and experience with the health care system, of individual patients, families, and communities.
(2) improving population health, and (3) decreasing the rate of per
capita health care costs. Current reform efforts have focused on
At the Mayo Clinic Center for Innovation, our experience
the development of Patient-Centered Medical Homes (an innovative is that design research methods are more likely to be help-
team-based model of care that facilitates a partnership between ful in creating new delivery systems that will achieve the
the patient's personal physician coordinating care throughout a pa-
tient's lifetime to maximize health outcomes), but these relatively
triple aim. Design research is based on qualitative research:
narrow efforts are focused on office practice and payment methods smaller, targeted sample sizes are explored, and and
and are not generally oriented toward community needs. We sought questions are investigated. It can
to apply design research in assessing a community opportunity to
apply the triple aim as a strategy to transform health care delivery.
provide a deeper understanding of the For editorial
Mixed methodology provides greater insight into the unexpressed emotional, cultural, and aesthetic con- comment,
health needs of individuals and into the creation of delivery systems text of a product, providing an important see page 930
more likely to achieve the triple aim. In a small, midwestern town,
a mixed methods approach was used to assess community health
methodology for assessing the “experi-
needs to facilitate design and implementation of care delivery ence” goal of the triple aim.4 This method can help a health
systems. The research findings suggest that health system design care organization tailor health services to the true needs of
concepts should focus on the creation of health, not health care;
foster simplicity; create nurturing relationships; eliminate user fear;
the community it serves. An effective design concept must
and contain costs. These observations can be helpful to health care be created from observational, design research before proto-
professionals who are developing new methods of care delivery and typing and implementation. This article describes the appli-
policymakers and payers contemplating new payment systems to
achieve the goals of the triple aim.
cation of design research to a community and demonstrates
how results can be used to create design concepts for a new
Mayo Clin Proc. 2011;86(10):973-980 health care delivery system. This research method has the
potential to help health care systems achieve goals of better
AMC = Austin Medical Center; PCMH = Patient-Centered Medical Home design, especially when combined with health indices and
disparities data for the community.
From our perspective, emphasis on PCMHs is a neces-
G rowth in health care spending exceeds that of the
general economy and is unsustainable.1,2 Incessant in-
creases in health care costs reduce availability of affordable
sary component for coordinating care. Austin Medical Cen-
ter (AMC) de nes care coordination as a clinical program
that uses physician-led teams to provide patient-centered,
health insurance and threaten access to care. Meaningful evidence-based, and proactive clinical and management
health reform in the United States must improve the health support for patients with multiple chronic conditions. In
of the population while creating sustainability by reducing December 2009, AMC, part of the Mayo Clinic Health
costs. In an effort to provide a useful framework for achiev- System, implemented a care model based on the Minnesota
ing long-term health care reform, the Institute of Health Department of Health guidelines for PCMHs.5
Care Improvement created the , the goals of The city of Austin has approximately 23,000 resi-
which are (1) to improve individual health and experiences dents, with another 15,000 persons living in small ad-
with the health care system, (2) to improve population
health, and (3) to reduce per capita health care costs.3 From the Center for Innovation (M.A.S., C.N.C., L.G.L., K.H.S., B.R.S., N.F.L.)
“Patient-Centered Medical Homes (PCMHs),” “Ad- and Division of Health Care Policy (D.L.W.), Mayo Clinic, Rochester, MN, and
Austin Medical Center (A.C.R., D.C.A., C.P J.K.B.), Austin, MN.
.H.,
vanced Primary Care Practices” and “Accountable Care
Address reprint requests and correspondence to Mary Severson, RN, MA,
Organizations” have stirred considerable interest in the Mayo Clinic, Center for Innovation, 200 First Street SW, Rochester, MN,
United States for their potential to minimize health care 55905 (severson.mary@mayo.edu).
costs. However, most of these efforts are aimed at the struc- © 2011 Mayo Foundation for Medical Education and Research
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a

2. USING DESIGN RESEARCH TO GUIDE HEALTH REFORM
joining communities. According to 2000 Census data, lifestyle and habits, and environmental analysis. Initial
approximately 9% of residents live in poverty; 93% are contact was made via email, followed by often multiple
white; 6% are Hispanic/Latino; and the remainder are of face-to-face meetings. Because individual observations
other races. Of Austin households, approximately 35% could not readily be excluded, investigators did not use
include members 65 years or older and 29% have mem- speci c selection criteria but made every effort to obtain
bers younger than 18 years.6 a representative sample of the population by interacting
Austin Medical Center is a fully integrated medical with all social classes and age groups and by choosing
center incorporating 82 hospital beds, primary and spe- community sites likely to yield a heterogeneous and
cialty clinics, outpatient chemical dependency services, representative community sample.
home health care, and a hospice including a home oxygen Quantitative surveys were completed by participants in
program. Physicians are both employed and contracted to the semistructured, individual, and dyad/triad interviews.
work at AMC. The survey tool was created internally by the Mayo Clinic
The goal of AMC is to transform the experience of pa- Rochester Survey Research Center and the Center for In-
tients and/or their family members with the health care deliv- novation. The purpose of the survey tool was to determine
ery system to achieve better health for the individual patient a community baseline of demographic and health access
and the population as a whole, manage costs, and improve utilization issues.
value over time. This research was seen as an important op-
portunity to improve access to meet the health care needs
RESULTS
of the community, support AMC's continuous improvement
pillars (quality, safety, service, operations, and nance), and COMMUNITY BASELINE SURVEY
support AMC’s commitment to employees (healthy work- A total of 487 surveys were completed at multiple commu-
force and satisfying professional environment). nity locations. Community leaders acted as facilitators, help-
ing investigators to reach audiences. In-person distribution
of surveys was found to be most effective for higher response
METHODS
rates. Of the respondents, 86% (n=420) spoke English and
Primary qualitative and quantitative research methods were 14% (n=67) spoke Spanish. Among English speakers, 64%
conducted. The research goals were as follows: (1) to assess (n=269) were women and 36% (n=151) were men, whereas
and measure community health care utilization; (2) to ex- 45% (n=30) of the Spanish respondents were women and
plore unmet community needs, beliefs, values, self-percep- 55% (n=37) were men (Table 1).
tion, and cross cultural in uences; (3) to understand the con- Cultural Differences. Almost all the English speakers
text for the development of a PCMH in Austin, MN; (4) to were born in the United States, and more than half had
examine key user populations and stakeholders of a PCMH; lived in Austin for more than 30 years (Table 1). Three-
and (5) to identify the needs to be lled by the PCMH. fourths of Spanish respondents were born outside the
Secondary research included a literature review and an United States, and almost 60% had lived in Austin for less
environmental scan to examine previous and current exam- than 10 years (Table 1).
ples of PCMH efforts, trends in community-based care, and Income Disparity. The disparity between the income
health care trends to educate the collective team and stimu- of English and Spanish speakers was remarkable. The
late thinking and dialogue. Some questions explored in the annual household income was greater than $50,000 for
secondary research are as follows: How are existing PCMH 30% of English speakers but less than $25,000 for 80%
efforts constructed and how is a PCMH de ned? What are of Spanish speakers; no Spanish speakers had an income
the design precedents in existing PCMHs? Who are the peo- greater than $50,000 (Table 1). More of the English-
ple involved? What are the technologies/tools used? What speaking than of the Spanish-speaking respondents
are PCMH environments like? What are the technological, worked full-time (43% vs 29%), and fewer were unem-
design, user, communication, and staf ng trends in PCMH ployed (40% vs 52%; Table 2).
efforts? Preliminary observations focused on uncovering the Levels of Education. Disparities in education be-
unmet needs and desires of the community regarding health tween English and Spanish speakers were also striking.
care and assessing its health care–related behavior. Three-fourths of the Spanish-speaking population had an
The qualitative process included embedding inves- eighth grade education, whereas virtually every English-
tigators in Austin and neighboring towns for approxi- speaking resident had a twelfth grade or higher education
mately 16 weeks to gather information and conduct (Table 1).
fieldwork. The investigators conducted in-depth, Relatively Low Self-Perception of Overall Health.
semistructured community interviews, observations of Perception of health was also very different between
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3. USING DESIGN RESEARCH TO GUIDE HEALTH REFORM
TABLE 1. Your Voice/Your Health Austin Survey Results (N=487)
About you—demographics and overall health status
English-speaking Spanish-speaking
US native (n=420) (n=67)
Yes 403 (96) 15 (23)
No 17 (4) 51 (77)
Sex (n=420) (n=67)
Male 151 (36) 37 (55)
Female 269 (64) 30 (45)
Marital status (n=420) (n=67)
Married 214 (51) 29 (43)
Living with someone 40 (10) 15 (22)
Separated 4 (1) 6 (9)
Divorced 43 (10) 3 (4)
Widowed 45 (11) 2 (3)
Never married 73 (17) 12 (18)
Residence in Austin (n=416) (n=65)
<1 y 11 (3) 2 (3)
1-5 y 26 (6) 19 (29)
5-10 y 32 (8) 19 (29)
>10 y 51 (12) 3 (5)
>20 y 57 (14) 6 (9)
>30 y 91 (22) 5 (8)
Entire life 148 (36) 11 (17)
Education (n=415) (n=64)
Grade 8 or less 17 (4) 47 (73)
High school or GED 136 (33) 12 (19)
Some college 140 (34) 1 (2)
College graduate 63 (15) 3 (5)
Graduate school 45 (11) 1 (2)
Other 13 (3) 0
Annual household income (n=393) (n=59)
$0-$25,000 140 (36) 47 (80)
$25,000-$50,000 133 (34) 12 (20)
$50,000-$75,000 77 (20) 0
$75,000-$100,000 31 (8) 0
>$100,000 12 (3) 0
Overall health status (n=419) (n=66)
Excellent 60 (14) 6 (9)
Very good 194 (46) 5 (8)
Good 119 (28) 29 (44)
Fair 33 (8) 25 (38)
Poor 13 (3) 1 (2)
Data are provided as number (percentage) of respondents unless otherwise indicated. Percentages
may not total 100% because of rounding.
English- and Spanish-speaking respondents. Of English- Where Do People Seek Care When Feeling Ill? Both
speaking respondents, 60% reported very good or excel- English and Spanish speakers most often sought care in
lent health, compared with less than 20% of Spanish- Austin when it was needed. However, Spanish-speaking
speaking respondents (Table 1). residents were much more likely to seek hospital care than
Gaps in Insurance Coverage. Insurance disparities English-speaking residents (Table 4).
were as substantial as income, employment, and educa- Barriers to Access. Disparities in access between
tion disparities. More than half of English speakers had English- and Spanish-speaking residents were related
employer-sponsored insurance vs only 7% of Spanish to lack of insurance and costs. Almost 80% of Spanish-
speakers (Table 3). speaking residents reported not seeking care because of
TABLE 2. Your Voice/Your Health Austin Survey Results: Work History
English-speaking Spanish-speaking
Work history (n=413) (n=66)
Full-time 179 (43) 19 (29)
Part-time 69 (17) 13 (20)
Not working 165 (40) 34 (52)
Data are provided as number (percentage) of respondents. Percentages may not
total 100% because of rounding.
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4. USING DESIGN RESEARCH TO GUIDE HEALTH REFORM
TABLE 3. Your Voice/Your Health Austin Survey Results: Insurance
English-speaking Spanish-speaking
(n= 420) (n= 67)
Insurance Yes No Yes No
Employer paid 221 (53) 199 (47) 5 (7) 62 (93)
Government paid 174 (41) 246 (59) 10 (15) 57 (85)
Pay for own insurance 40 (10) 380 (90) 2 (3) 65 (97)
Data are provided as number (percentage) of respondents. Percentages may not total 100% because
of rounding.
lack of health insurance vs only 11% of English-speaking feeling that varies from person to person and depends on the
residents. Cost was cited as a barrier to care more often by individual's baseline of health and wellness.
Spanish respondents (Table 4). The research observations in the community provided
valuable information about the obstacles and barriers to
DEFINITION OF HEALTH AND WELLNESS care and the means for successfully surmounting those
The community's de nition of health is succinctly summa- hurdles. When acting as caregivers, individuals observed
rized in a personal quotation from one respondent: “I want few incremental choices for help: they could either totally
to live a long and healthy life so that I can take care of my- relinquish control (typically with high nancial implica-
self and do what I need to do every day without constraints tions) or had to do everything themselves. One participant
because X count(s) on me.” Depending on the participant, stated: “Most of the time I just take care of things myself.
“X” could be a spouse, child, parent, neighbor, or colleague. I’d rather not bother anyone.” Since systems were not
For this community, our research found that means perceived as exible, individuals often encountered dif -
balance, health, and quality of life. Indeed, wellness was culty nding resources to help them adapt to their changing
often described as “quality of life” rather than “absence of needs and personal situations. Men, in particular, often did
illness or disease.” A signi cant number of people think they not ask for help and had trouble setting up systems to pro-
are “well” because illness is absent or has not affected their vide temporary relief for the caregiver. Another participant
quality of life. For the young, in particular, wellness is a said “I never think about getting help until it is almost too
TABLE 4. Your Voice/Your Health Austin Survey Results: Access to Care
English-speaking Spanish-speaking
Access to care
No. of respondents 420 67
Austin 329 (81) 48 (80)
Outside Austin 40 (10) 9 (15)
Don’t know 4 (1) 1 (2)
Both 32 (8) 2 (3)
Yes No Yes No
Type of access
No. of respondents 420 67
Community clinic 107 (25) 313 (75) 10 (15) 57 (85)
Walk-in clinic 183 (44) 237 (56) 39 (58) 28 (42)
Emergency department visit 52 (12) 368 (88) 6 (9) 61 (91)
Hospital 141 (34) 279 (66) 47 (70) 20 (30)
Veterans Affairs/military facility 20 (5) 400 (95) 4 (6) 63 (94)
Another community-based group 20 (5) 400 (95) 8 (12) 59 (88)
Stay at home and someone comes to you 15 (4) 405 (96) 8 (12) 59 (88)
Yes No Yes No
Barriers to access
No. of respondents 248 47
No health insurance 28 (11) 219 (88) 37 (79) 10 (21)
Cost of care 72 (29) 175 (71) 31 (66) 16 (34)
Other family member needs more care 12 (5) 235 (95) 0 47 (100)
Other needs more urgent 10 (4) 237 (96) 0 47 (100)
Transportation dif culties 13 (5) 234 (94) 1 (2) 46 (98)
Could not obtain an appointment 37 (15) 210 (85) 0 47 (100)
Could not get off work 15 (6) 232 (94) 0 47 (100)
Data are provided as number (percentage) unless otherwise indicated. Percentages may not total 100% because of rounding.
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5. USING DESIGN RESEARCH TO GUIDE HEALTH REFORM
late. I think it has something to do with the idea of being ing included in the conversation. Patients are often frus-
carried off the eld…you know, like in football.” trated by not being able to digest information provided in
Understanding what it means to be well can facilitate a physician’s appointment. As they become older, many
early diagnosis and faster recuperation from an acute patients bring members of their family to their appoint-
health problem. However, wellness is a vague concept. ment to take notes to ensure that they remember important
Our observations demonstrated intriguing social dynamics points. When given information or records for their own
for identifying health and illness. Respondents commonly keeping, people feel empowered and are more motivated.
de ned wellness relative to their typical baseline. Those These insights may lead to consideration of a new model,
who had experienced illness had a much better under- in which people own their information and which would
standing of the meaning of wellness. They also gained a include open source data gathering, exchange, and shared
much greater ability to understand and articulate their con- access. This model includes the ability to view longi-
cerns regarding their bodies and at times to make decisions tudinal deidenti ed data for future health planning for
based not on a physician’s advice but instead on what their individual patients and the community.
bodies were telling them. Respondents sought out other Another example showed that many people feel isolated
networks to understand what “normal” meant and how physically and psychologically. Any existing “community”
they should be feeling. is lost once people become ill or become immobile in their
homes. Lack of transportation or fear of the unknown can
RESEARCH INSIGHTS prevent participation in new peer networks; the lack of active
The ndings are useful for creating design objects for new engagement in live peer networks can lead to psychological
health care delivery methods. The insights were framed into isolation and depression. Some turn to online social net-
themes classi ed as , , and works, others to existing peer groups that are not set up to
. The insights assist with health issues, and still others become withdrawn.
stem from respondents' feelings about their own health and These insights demonstrate the need for the following: (1)
wellness; the obstacles and barriers to care; and the means virtual and community social networking, (2) availability of
they have used to successfully surmount those hurdles. For support groups and awareness of that availability, (3) access
example, trust and transparency were perceived to be lack- to reliable transportation across the community, and (4) pos-
ing in health care professionals. If people do not trust an sible contact with a live person 24/7 online or via a hotline.
institution or individual, they are likely to seek care only in Our ndings also showed that people often hesitate to
extreme cases and default to their own judgment. begin certain exercise or nutrition programs because they
Cost and time were identi ed as primary barriers to do not perceive themselves as totally committed in the way
staying healthy and well. One research participant stated, they would like. Caregivers may feel as if they have few
“I wish I had more time and money for treatments and incremental choices for support: they can either totally relin-
expensive creams but kids come rst….” Although most quish control (typically with high nancial implications) or
people, primarily women, did not feel as if they had they must do everything themselves. Programs that are per-
enough time to be healthy, others (some older, some who ceived to be in exible are often abandoned or never begun,
had recovered from illness, empty nesters, and retirees) and resources that seem unable to adapt to changing needs
were equally frustrated by not knowing how to manage and evolving situations go unused. Some caregivers, men
the time they had. Some people felt so overwhelmed that in particular, do not ask for help and have trouble setting up
they had trouble carving out time for their health and well- systems that allow them temporary relief. People need care-
ness. In general, unless something forces a person's state giving systems that are inherently more exible and adjust-
of health to the forefront, it remains a low priority. When able. This type of “step-up or step-down” program may be
people transition to a life stage with more time, they often less intimidating initially and may also prevent drop off.
do not know how to use it and end up doing nothing. Over- “Community” insights involve the speci c challenges
all, they perceive that hospitals “cost too much.” Although a community—the hospital, clinics, health care profes-
cost conscious about what they are spending, they are not sionals, and residents—faces in providing the appropri-
comparing costs over time. They have not embraced the ate level and type of health and wellness services. For
idea of “spending more to get more.” example, people who do not have an established and
Although people seem to want to own their health in- healthy relationship with a physician may not feel “cared
formation, they perceive that it does not belong entirely to for” in the traditional health system and may believe that
them. Many believe that physicians do not want to share health care professionals are not listening to them, spend-
or are withholding information or that they do not think ing enough time explaining their options, or listening to
patients would understand. Women, in particular, like be- how they feel about them.
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6. USING DESIGN RESEARCH TO GUIDE HEALTH REFORM
Such people may turn to alternative healers, nutrition- sages that speak to them at their particular life stage.
ists, and trainers for a more holistic experience, enjoying One research participant stated, “It’s funny…when I use
being treated as a “client.” To build and keep loyal cli- an anti-wrinkle cream, I’m thinking about what I’m go-
entele, these providers are going outside their expertise ing to look like in the future. But when I take vitamins,
to treat patients. Through various programs (formal and I’m not thinking about what I’m going to feel like in the
informal), they are mirroring women's language and ful- future from the inside.” When interacting with traditional
lling their need for communication: they are ghting for health systems, people do not feel “cared for” unless they
business by spending additional time listening to, check- have established a nurturing relationship with a particular
ing in with, and “caring” for their clients. This re ects health care professional. Community health partnerships
a pressing need for dialogue between patient and health could build and/or improve relationships between patients
care professional. For many people, that is at the root of and health care professionals. They would allow people
“feeling cared for.” To prioritize their own health, people to become familiar with the health care setting and health
need to feel as if their health care professional considers care professionals outside a necessary visit. People need
them a high priority. Increasingly, they are looking to to have a strong connection to the institution where they
nontraditional providers to meet this need. receive care; otherwise, they seek it elsewhere. Long-term
A new service integration model is needed to effec- investment in community relationships will help make the
tively coordinate existing services, including physical Austin community sustainable.
fitness, senior services, mental health, and childcare. Peer-to-peer networks can comfort patients by al-
Barriers to obtaining care were identified at a systemic lowing for freer, more relaxed communication than is
level and included difficulties navigating complex typical of most exchanges with health care profession-
health care systems, lack of insurance or the ability to als. Such networks can help address social isolation,
obtain insurance, lack of access (the ability to obtain of particular concern in the elderly population, whose
appointments when needed), hesitance to bother some- stoic attitude and hesitance to “bother someone” make
one, lack of education, lack of communication, and the them more vulnerable.
necessity to stay within a given health care system for
purposes of insurance coverage. It appears that a “big
DISCUSSION
picture, connecting view” is missing for both patients
and health care professionals, leading to misunder- Zuvekas and Taliaferro7 described disparities in health
standing and quality of care issues. Individual organiza- care access as experienced by racial/ethnic groups and
tions do not have enough time or energy to “spread the the uninsured; health care treatment and outcomes are
news” about other relevant services or to help people in uenced by a person’s ability to access the health care
navigate the entire system. There is a need for one “or- system. Freeman et al8 illustrated signs of deterioration
ganizational entity” that can handle service and staffing. in health care access for the nation’s poor, minorities, and
The hospital/clinics could be a much stronger partner uninsured. The access concept has been explored in previ-
in health and wellness if seen as part of an integrated ously published research. Khan and Bhardwaj9 suggested
community network with nonmedical entities, such as that potential access to health care relates to the avail-
physical fitness, mental health, transportation services, ability of health care resources (facilities and personnel)
and other resources. relative to their needs for services, whereas realized ac-
When people delay seeking care, they can develop co- cess relates to the actual use of such resources to satisfy
morbid conditions that complicate their treatment. By the those needs. Use is greatly in uenced by availability, as
time some seek help, their condition has become chronic, well as the inherent characteristics of the service system
with multiple factors and complexities. A design concept and those of potential users, which express themselves
for consideration is to explore “gap” clinics focused on as either barriers or facilitators.9 In this community, ac-
multiple comorbid conditions that would serve as con- cess to care is often considered dif cult because of the
duits for linking patients to more holistic wellness and complexity of the system and the anxiety associated with
primary care. Creating “open” referral systems to other navigating this complex environment. The results of our
community care providers is worth consideration. study suggest that the needs of the community can best
In the insights classi ed as being at the “intersection be met by simplifying processes and reducing anxiety.
between the individual and the community,” the unmet The integration and navigation of services and greater
needs of the public collide with the challenges faced access in terms of physical access, cost, and visibility
by a community in providing care. People prefer to be constitute a near-term win—not the creation of addi-
presented with options. People look for targeted mes- tional individual products and services. The point is to
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7. USING DESIGN RESEARCH TO GUIDE HEALTH REFORM
communicate to individuals how to care for themselves a static relationship that de nes for what and for whom
throughout their lifetime in a manner appropriate to each an agent is responsible. It is expressed by accountable
life stage and speci c individual situation and to equip agent 1 (A1), agent 2 (A2), which means that agent 1 is
them to make long-term behavior changes and adhere to accountable to agent 2 for performing tasks of this type.
personalized regimens. The agents themselves are implemented using a layered
Plsek and Greenhalgh10 urge abandoning linear models architecture, called .12 In the agent-driven mod-
and developing new conceptual frameworks. These frame- el, peer-to-peer networks and individuals drive the devel-
works should incorporate a dynamic, emergent, creative, opment of service infrastructure and navigation. Similar
and intuitive view of the world to replace traditional “re- to the open source model, the agent-driven model moves
duce and resolve” approaches to clinical care and service from the ground up, relying on peer networks to sustain
organization.10 Decreasing complexity in this community the exchange of critical information.
would mean developing both virtual and live aids to as- The “Living Labs” concept represents a user-centric
sist system navigation at life’s crucial transitions. The research methodology for sensing, prototyping, validating,
creation of health kiosks at community meeting points and re ning complex solutions in multiple and evolving
may allow easy access to information and appointment real-life contexts.13 Currently, a disparate system of health
scheduling; this includes bilingual health care profes- care professionals treats different aspects of wellness, pre-
sionals and navigation aids. This community would also vention, maintenance, and illness.
bene t from physician-guided assistance in prioritizing Currently, the open source model in combination with
conditions and how to treat them. Another concept worth the agent-driven model is most conducive to addressing
exploring is the provision of health education from the patients' unmet needs because they place the emphasis on
primary school level on up. Future health mapping could patients and their family members and friends. The open
help patients understand the life stages that lie ahead and source model empowers patients and gives them a degree
how their current behavior affects health issues that could of control in their health care. It provides people with the
arise at those stages. A navigator service and/or a 24-hour means and tools to take care of themselves.
hotline would also be useful. This community may bene t
from increased education and awareness of mental health
CONCLUSION
and stress-reduction services.
Redesigning the fragmented US mental health system Applying design research as an initial step in creating
requires knowing how service sectors share responsibility a new community health care delivery system yielded
for meeting health care needs.11 The complexity of the several new insights. First, such a community-focused
US mental health care system diffuses responsibilities for system should adopt a whole-person orientation that
patients over multiple service sectors, posing challenges seeks to reduce service isolation and increase accessi-
for patients, health care professionals, and policymak- bility. Second, it is critical to evaluate community-wide
ers.11 Our examination of Austin shows various service perceived barriers to care, such as use of outside service
network models that coexist and overlap. The existing network (transitory migration), community scal sustain-
model shows a fragmented service network. From the ability, and visioning. Third, chronic social conditions,
community perspective, the biggest service ow problems such as social and scal waste, the intersection between
center around the following: (1) overall network discon- individuals and community, and peer-to-peer health can
nect and perception of disconnect, (2) transportation and be improved through experience and investment in one’s
mobility, (3) transparency of information, (4) visibility of own well-being. Fourth, enduring solutions will facilitate
services, (5) service integration, (6) facilitation and bilin- healthy behaviors, simplify processes, improve access,
gual sources, and (7) burden of care issues. and reduce costs.
A different service network model is the “open The triple aim offers a framework, but design research
source” community service network model. This is a provides a more detailed understanding of the needs of
“bottom up” approach to designing services with an the community based on actual observations that can be
overall emphasis on data transparency. People drive this used to guide health care professionals, policymakers, and
model insomuch as the model is meant to ful ll their payers in developing new ways to deliver care. Current
need for sharing, listening, transparency, access to infor- efforts at health care reform do not meet speci c patient
mation, choice, and creativity. care needs. To better do so, future system design concepts
“Agent-based systems” were developed to help man- should focus on creating nurturing relationships; creating
age the care process in real-world settings. They focus health, not health care; eliminating complexity for users;
on task allocation and accountability. Accountability is and managing costs.
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8. USING DESIGN RESEARCH TO GUIDE HEALTH REFORM
5. Minnesota Department of Health (MDH). Minnesota’s vision: a better state
of health. Health Care Homes (aka Medical Homes). http://www.health.state.
mn.us/healthreform/homes/index.html. Accessed June 24, 2011.
6. Austin, Minnesota census data and community pro le. AmericanTowns.
Com Web site. http://www.americantowns.com/mn/austin-information. Accessed
June 24, 2011.
7. Zuvekas SH, Taliaferro GS. Pathways to access: health insurance, the
health care delivery system, and racial/ethnic disparities, 1996-1999.
. 2003;22(2):139-153.
8. Freeman HE, Blendon RJ, Aiken LH, Sudman S, Mullinix CF, Corey
CR. Americans report on their access to health care. .
1987;6(1):6-8.
REFERENCES 9. Khan AA, Bhardwaj SM. Access to health care: A conceptual framework
1. Fenig EC. Despite the new mood, the economy not doing well. American and its relevance to Health Care Planning. . 1994;17(1):60-
Thinker Web site. Published January 14, 2011. http://www.americanthinker.com/ 76.
blog/2011/01/despite_the_new_mood_the_econo.html. Accessed June 24, 2011. 10. Plsek PE, Greenhalgh T. Complexity science: the challenge of complex-
2. Campbell KE. Report on healthcare spending shows government with 44% ity in health care. BMJ. 2001;323(7313):625-628.
share. American Thinker Web site. Published January 7, 2011. http://www.ameri- 11. Wang PS, Demler O, Olfson M, Pincus HA, Wells KB, Kessler RC.
canthinker.com/blog/2011/01/report_on_health_care_spending.html Accessed Changing pro les of service sectors used for mental health care in the United
June 24, 2011. States. . 2006;163(7):1187-1198.
3. Institute for Healthcare Improvement. The IHI Aim: better care for 12. Huang J, Jennings NR, Fox J. An agent-based approach to health care
individuals, better health for populations, and lower per Capita costs. IHI.org Web management. . 1995;9(4):401-420.
site. http://www.ihi.org/IHI/Programs/StrategicInitiatives/TripleAim.htm. Ac- 13. Eriksson M, Niitamo V-P, Kulkki S.
cessed June 24, 2011. Lulea
4. Saffer D. University of technology. Sweden: December 15, 2005;1-13. http://www.vin-
2nd ed. Berkley, CA: New Riders; 2010. http://www.designingforinter- nova.se/upload/dokument/Verksamhet/TITA/Stateoftheart_LivingLabs_Eriks-
action.com/designingforinteraction2_sample.pdf. Accessed June 24, 2011. son2005.pdf. Accessed June 27, 2011.
980
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
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