Welcome to Well Beyond Medicine, the world's top-ranked children's health podcast, produced by Nemours Children's Health. Subscribe on any platform at nemourswellbeyond.org or find us on YouTube. Each week, we'll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor's office. I'm your host, Carol Vassar, and now that you're here, let's go. Let's go, oh, oh, well beyond medicine. Welcome to part two of our two-part series exploring how whole child health isn't just a concept. It's really a movement, and it's already transforming pediatric care for children all across the nation. Now, in part one, we took a look at how community partnerships and integrated care models are helping prevent chronic disease and supporting children's well-being no matter where they live, no matter where they learn, and as they grow. Today, we're turning to an engine that could make all of this sustainable, and that's innovative payment models. We'll hear from two children's health systems, Nemours Children's Health and Cincinnati Children's, who are redesigning financing so health systems can invest earlier, partner more deeply, and deliver care that truly supports the whole child. I am truly honored to welcome our guests for this episode, David Cruz. David is Executive Director of the Kidwell Network here at Nemours. Dr. Andrew Beck, who leads Population Health Research and Innovation at Cincinnati Children's. He's closely involved with their Healthvine Accountable Care Organization. And Jeff Stellar, Population Health Consultant with Cincinnati Children's and a leader in the Ohio Outcomes Acceleration for Kids or Oak Network. That's a groundbreaking statewide quality and learning collaborative. Now together, they are helping to shift pediatric care from pay for visits to pay for health, all the while unlocking new ways to improve outcomes for children and families. Now I'd love for you each to briefly tell us about your organizations and how they are helping to shift pediatric care from, as I mentioned, paying for visits to paying for health. David, we're going to start with you. You're with Nemours, but you're with a part of Nemours that I'm not very familiar with. So tell us about what you're doing. Thank you, Carol. I've been with Nemours for about five and a half years, and I am the executive director of the Kidwell Network. Kidwell is a clinically integrated network and accountable care organization. It's in fact the only clinically integrated network that's specifically focused on pediatrics in the Delaware Valley. We are very proud of that. We are also recognized by the state of Delaware as an accountable care organization. It is a wholly owned subsidiary of the Nemours Foundation. So our tie to the Nemours organization is very strong. But as a subsidiary, we have the opportunity and availability to be able to connect with our community practice partners. Right now, we've got 11 community practices as part of the network covering 15 different community locations. So we're very happy to have them as part of the network. What that allows us to do is negotiate with payers for value and alternative-based payment models on their behalf so that we are not only benefiting the children that are seen by Nemours, but that are seen in the community practices as well. That's a lot that's going on that I think we need to highlight even more in the future. Dr. Beck, I want to turn to you. You're With Cincinnati Children's, it's a well-known pediatric healthcare organization here in the U.S. You're also involved with their Healthvine Accountable Care Organization, similar to what Nemours and David are doing. Talk about that work. First of all, thanks for having us today. I would say one of the benefits of working at a place like Cincinnati Children's is that we are both this large tertiary care referral center for kids from all over the country, and in some cases all over the globe. But at our core, we're also the hospital for Metropolitan Cincinnati. And so one of the things that we've established as part of our mission is to be the leader in improving child health and to achieving excellent and equitable health outcomes for both the kids that walk through our doors, no matter where they come from, but also for the kids that live in our primary service area. I think one of the things that's helped us accelerate that work is this partnership called HealthFind, which is an arrangement with Ohio Medicaid and Ohio Medicaid managed care organizations to assume risk and responsibility for kids insured through Medicaid in our part of the state. And so now there are about 120,000 kids insured through the Healthvine arrangement that is truly value-based. And it's allowing us to think through what are the ways to truly achieve success and to achieve optimal outcomes for those kids in ways that are both financially beneficial, but also in line with our mission as a hospital. So this opportunity to really align our mission and our margin in ways that promote optimal outcomes for kids all across our metropolitan area. And Jeff, you're working closely with Cincinnati Children's. Tell us about your role here and tell us about Oak. Yes. While I'm employed at Cincinnati Children's, I spent 98% of my time with this awesome collaborative. Oak is a learning network that We launched on January 1st of 2024. We're pretty sure it's unique in the nation in that it is, the participants are the six children's hospitals in Ohio, the seven Medicaid managed care plans, Aetna Ohio Rise, which is a behavioral health wraparound program, and the Ohio Department of Medicaid, all coming together to focus on four distinct buckets of care. And so we have the chronic conditions bucket where we're focused on asthma, improving asthma outcomes, sickle cell outcomes, behavioral health, where we're focused on follow-up after the ED visit, and then well-child care, improving well-child compliance. And so what we're trying to do is, as a state, raise the standards. And we have set very ambitious goals. So over a three-year period, we are attempting to improve all of the outcomes I just mentioned by anywhere from 10 to 15 percent. And it's a really fantastic opportunity that we have all parties at the table to talk about systemic change. And a big part of that is how we look at the financial means of delivering this care. Explain again and make clear for our listeners, our viewers, that kind of relationship between Healthvine and Oak. It sounds like Oak is really looking from a statewide perspective, if I'm hearing you correctly. You are. Actually, Healthine is a participant in Oak. And so the way that we've divided Oak up, there are six regions in the state and each region is anchored by a children's hospital. And so Cincinnati Children's Help Find is the anchor institution for the Southwest region. And then within each region, each of the hospitals or accountable care organization is partnered with a managed care plan to, again, focus on how they can change it locally and then take the learnings from what they've learned in their region, bring it to the state. We pull out some of those universal pieces. And then the goal is to scale whatever is successful across the state to rapidly improve these outcomes. So you're integrating what you're learning across the state and implementing it in other places that may be in need of that kind of care and that kind of payment model. So you're really taking the best of the best and raising it to that state level in the state of Ohio. That's just stellar work right there. I'm wondering where each of you are seeing the biggest gains when payment begins to kind of align with prevention rather than aligning with volume. David, I'm going to throw that one to you first. We know that prevention creates health and we want to ensure that children are living their best lives and their best lives are healthy lives And so we know that if we can get them into the office we can speak with the children we can speak with the family so that they know what types of things can help them to continue to be healthy Jeff, Dr. Beck, would you agree with that? I don't see any downside to any of that. I do absolutely agree. I think this vision for whole child health becomes a whole lot easier to conceptualize and then to start to bring resources to. And so the things that I think of with that question are, one, increased ability to provide care that extends beyond the walls of the hospital. And so whether that means deployment of additional healthcare professionals like care managers or community health workers, or bolstered partnerships with healthcare professionals that are out in the community providing that longitudinal care, I think that's a real opportunity space for us to be as we're thinking about how to most effectively invest in child health and well-being. The second thing that I think it opens up is opportunities for innovation in clinical community partnerships with those entities that may exist outside the traditional healthcare sector, but absolutely play a role in promoting health and well-being. I think about schools or libraries or rec centers or community-based organizations and agencies that support achievement of the vital conditions for child thriving, like housing or economic opportunity or transportation. And then the third thing, which Jeff alluded to a moment ago and perhaps can speak even more to, is this opportunity for systemic policy change or advocacy in the sense of what are those policies that may exist that actually hamper our approach to achievement of health and well-being? And we've seen a few examples of that around prescribing processes or amounts of medications that can be prescribed in the realm of control of diagnoses and diseases like sickle cell disease to try and make it easier for families to access the medications or supports that they need to actually prevent the morbidity that could crop up. Jeff, I'd love to hear from you on some of those systemic and policy concerns and questions that Dr. Beck referred to. Yeah, and I think what Andy alluded to is spot on. And I think it's the unique that we have everybody at the table to talk about these. And we're finally looking at the system as a system. My experience has always been if you are on the care side, you don't have a lot of visibility to the inner workings of managed care or the department. And now we actually have this and we can start to say this policy doesn't make sense to us. And we can get a really clear explanation of why it might make sense to another party. And then we can find this common middle ground. And as Andy alluded to, one of the things we discovered early on was the burden that we place on our sickle cell population when we were only allowing a 30-day supply for hydroxyurea. Clinicians came forward and said, look, this is a huge burden on the families to get in here all the time. Can we extend this? Everybody took a look at it, agreed. It wasn't the best policy in the world. There weren't really any downsides to changing it. And so we got to change quickly. I can't imagine without Oak that that happens probably at all. And if it does, it takes much longer to do that. And I think part of what Andy alluded to that I'm seeing one of the biggest gains in Oak is that we are making invisible work visible. And by that, I mean so much of keeping a kid healthy is everything that occurs outside of the visit. We always focus so much on what can we do in that 10 to 15 minutes we have the child, but there's so much work outside of it. And so we're digging in to say, to Andy's point, how do we deploy community health workers? How do we get the kids most in need of care management, the right care manager? And how do we help them navigate what is an incredibly complex health system more easily? I think the other thing we're seeing that isn't necessarily a financial gain initially, but I think we're finally aligning some of the work streams as well. Because one thing I hear from families is I got a call from the care manager from my ACL on Monday. The payer called me on Tuesday and somebody who I've never met called me on Wednesday. Do you all ever talk to each other? Right. And so now we are now for I think for the first time in my career, I can tell families, actually, we are talking to each other and it's taking a while to get big improvements. But I think that's the biggest thing is we really have finally shined a light on the fact that keeping kids healthy, so much of that is outside the traditional health care system. I would add to something that Jeff said. It's not just these three different organizations called me over the course of the past three days. It's also I had to say the same story three separate times. And so when we are able to coordinate care and coordinate with each other, the family doesn't necessarily have to go through that experience of telling the same thing over and over again. I'm sure we've all been there. We have that thing that we just have to keep saying. And you know, you have to keep saying in order to get what you need. And really being able to put the family, the patient and family at the center of the care and have everyone know and understand what it is that they need is really important. And I think that the patients and families really appreciate that and they experience it in a way that we from the outside looking in can't ever experience it until we're in their shoes. I'm wondering, across all of your organizations, there are kids with chronic conditions like asthma, they have behavioral health needs, nutrition-related issues. They are heavily influencing children's health outcomes. How are these innovative payment models really helping earlier identification and intervention before a child has a crisis? Dr. Beck, I want to start with you. I think one of the things that I would say is that these models and the breadth of data that are accumulated underlying these models alongside a population level accountability allows us to identify patterns more readily and ideally move upstream of the outcomes that we're hoping to prevent. So just for instance, take asthma. Asthma is the most common chronic disease we see. It is the most common reason or at least chronic reasons why a child's hospitalized or visits the emergency department, often jockeying for first place with depression and anxiety. We know that there are ways to prevent asthma morbidity. And one of the ways that we've tried to work upstream is through a series of data overlays that allow us to say, where are all the breadth of asthma cases that we're seeing? Where are the hospitalizations that are emerging? And how might we overlay a map of those admissions or ED visits with maps of housing code violations or transportation access points or traffic-related pollution exposure? And then how might we use those patterns that might be recognized to drive direct change or direct partnership with community-based housing organizations, legal aid, or the city of Cincinnati to think about how to optimize housing stock within some of those same areas. So I think some of it is finding those patients who may be most likely to benefit from close care, who may be most likely to benefit from controller medications. But part of it is also identifying patterns in lived experience and context, which may be driving some of the morbidity or the excess morbidity, the potentially preventable morbidity that we see across a large swath of population. David, are you seeing similar outcomes and similar information that you're able to pull out of the data that you see? Yeah absolutely I think the focus on social drivers and health related social needs is ever increasingly important I think even so bringing it back to even in the PCP office the primary care providers office we focusing in a lot of our contracts on things like education for the patient and family physical activity counseling nutrition counseling BMI counseling so that it not just hey here what your height and weight was today It's here's how your BMI affects your health. Here's how nutrition affects your health and physical activity and things that you could be doing to everyone's point outside of our four walls that might make you a little bit healthier. And by including or integrating those things into our contract, we know that it's just as important to our payer partners and to the state that it is to us and to our provider partners. Jeff, what are you seeing in Ohio from the data on a statewide level? Because we're able to centralize the data and view it in an anonymized manner, what we can still do is a child who last year lived in Cincinnati and then moved 45 minutes north to Dayton, we're able to still do that continuity of care because we're also viewing this as a system, right? And so now that child is in Dayton, Dayton can talk to Cincinnati, we can really make sure that that child is being seen. And I think the other piece, and this is happening via Oak, and I also think via contracting, and I think this is what David was getting at a little bit, everybody's assuming full risk for these kids. And I think that is finally changing people's perception of when I have a child in front of me, I am responsible for that child's whole health. And so if I'm a primary care pediatrician and they tell me there's a behavioral health issue, I need to address that. And these financial models allow them to do that, whether it is because they have an integrated behavioral health specialist down the hall that they can walk them or they have the means to say, I'm going to extend this visit 15 minutes because we have an extra staff member who can work with them and I can pull them in. And I think that's really what is driving a lot of this change as well. And I think that's happening across the state in Ohio. Jeff, you've given some really great examples of how the system can benefit a kid. The example moving from Cincinnati to Dayton and continuing with access, continuing with quality of care. David, I'd love to know of any examples of successes you've seen through improvements in quality or access related to KidWell. I've always been envious of the position that Ohio's in. We have a very different position. We have three counties in Delaware. And if someone moves from Newcastle County, the very northern county, to Sussex County, the very southern county, they are still in our care. It is not a new children's hospital. I'm sure there are more covered lives in one region in Ohio than we have in our entire state. But what that allows us to do, to Jeff's point, is keep that whole picture of that child. We know where they're going. We have their data. And a way that we've been able to be successful is in our lead screening rates. A few years ago, we were maybe in the 70% range, and we recognized that wasn't good enough. We weren't doing justice to our patients and families. And we partnered with our payers to ensure that every practice had either a lead screening machine in their office, the opportunity to use filter paper or a great relationship with a lab that was close by. And we've gotten those rates to above the 95th percentile in the country. And so being able to partner with all three different types of organizations has really driven our screening rates to be one of the top. We're very proud of that. Dr. Beck, I'm going to throw the same question to you. Success is with Healthvine. So I think Healthvine has allowed us to do a number of things across the hospital. As Jeff has mentioned, Oak is a learning network. We've also tried to implement some of those principles inside the hospital with teams across clinics, sites of care, and conditions. A population health learning network that really is promoting optimal whole child outcomes no matter where children are seen across our enterprise. And so just as a few examples, this network was developed initially with four teams, and we've since grown to 22 teams, with the theory that although conditions or sites of care may differ, asthma is not diabetes, is not depression, the drivers of the suboptimal outcomes across populations and for specific population subgroups are oftentimes quite similar. And the network has provided some structure for us to learn about how we might optimize access, address social drivers of health, enhance trust and relationships with our patients and families across those settings. And it's led to successes like the increased adherence to preventive visits in the sickle cell center that is leading to improved adherence to hydroxyurea and more therapeutic fetal hemoglobin levels. And it's led to increased rates at which kids with type 1 diabetes are using evidence-based technologies to manage their disease. And it's led on the inpatient setting for kids admitted with asthma to achieve or receive more consistent evidence-based care and connections to outpatient providers that are showing signs of reducing readmission rates. And I think part of the magic here is bringing these teams together so that they can learn learn from one another, and highlight the work that they're doing in their realm and ways in which that work may translate to other parts of the hospital. Now, we have a lot of clinicians who listen and watch a lot of providers in the hospitals and in the healthcare settings. If they want to get started with whole child health models that pay for health rather than sick visits, how would you recommend they get started, David? That's a really tough question because it has to come from the entire organization. It needs to be the driver, the mission of the organization to say, we want to make this change. There's a lot of infrastructure build that has to happen, whether it's resources or data or information security or lots of things that allow you to be able to share the information back and forth or have the resources to go out into the community. the organizational leadership really needs to be the driver. And that driver gets the frontline excited, right? It's the why did we put a man on the moon? And that needs to be the mission of the organization. And I'm fortunate to work for an organization that our executive leadership, they are the drivers of the alternative payment models and structures. And they really care about the individual patient and family. It's not just how can we be financially sustainable, which, don't get me wrong, is very important. But how do we think about our patients and families individually and collectively so that we can make sure we have the healthiest generation of kids? I'm wondering what the federal government and states can do to incentivize whole child health. It looks like Ohio is and Delaware is already doing this. How can we incentivize whole child health financing models that move them forward toward paying for health? David, what can other states do? That's a loaded question. I said it earlier, I think the recognition that healthy kids make healthy adults, and this isn't a short term endeavor. We oftentimes are looking what's going to happen in our next fiscal year or in our next performance period. And these aren't things that we can change in one year, maybe we'll see a slight increase, maybe we'll reach our 2% goal. But in order to get those really big gains that you're looking for, this is a 5, 10-year, maybe 18-year endeavor as you think about kids transitioning from pediatrics to adult. And so as we think about funding sources and as we think about measurement, we have to do it longitudinally so that we can understand if the work that we're doing has been effective. Of course, we need to go through our standard improvement cycles to say this did or didn't work in a short term. Let maybe adjust But it is not let make a change today for tomorrow Let make a change now for the future And focusing on that is I think really important at both the federal and state level That's pretty powerful. Jeff, Dr. Beck, anything to add? I'll jump in real quick. I think that I think the biggest thing that the federal, the state governments can do is allow the local decision makers to make those decisions because they are the closest to it. Right. I think what we're seeing in Ohio, we're innovating locally. We're innovating at the state level. So continuing to create the conditions for that innovation. Right. Because the solutions in Ohio, certainly there are some universals. But it's very different than, say, Massachusetts, or even as David said, just the geography of Delaware is so much different than Ohio. It changes it. So really giving that power not just to the states, but then within the states, giving the power to the local areas. I also think we have to, as a collective, start to look at how we reimburse non-clinical work. Because as we've talked about this whole time, so much of being a healthy child occurs outside of the health system. And so how do we ensure that having the CHWs who are going out into the community, connecting with our hard to reach families, reestablishing trust in communities that have historically not trusted the health system, that's expensive. But it's also really expensive to have an entire generation of kids that is unwell and we're taking care of them. And so I think part of this is also just shifting the paradigm. And I think, as David said, the other thing, and I know this is so difficult in politics, but you have to have a longer time horizon. I think we have to have some willingness to say, I might only be in office for two, four, six years, but I'm establishing the foundation to ensure that that two-year-old is going to be a healthy 18-year-old in 16 years. And so I think that's one of the biggest things as well. And that, I think, goes beyond the government, right? That's everybody taking a longer time horizon on this. But I think that is absolutely critical for us to start shifting this. Real quick, as we finish up today, final question. If we reconvene in three years, five years, 18 years, as David referred to earlier, what do you think success looks like for Kidwell, for Healthvine, for Oak, and for the children and families you serve? Jeff, I'm going to go to you first. I think Oak being wildly successful would be family self-selecting into the health system. So if Oak is really successful, we're not having to call families nonstop to try and get them in for their visits. They want to get in for their visits because we have shifted the culture of health care. I think success a couple of years from now could also look like other states adopting an Oak model. I think as Andy mentioned, the learning network model is incredibly powerful. And what it does is you pull out the universal learnings and then you take them back to your local area to adapt. And so I think the beauty is I would love to see in three years another couple of states trying a similar approach where we are really driving systemic change by bringing the key players in the system together. And then lastly, I think Ohio would no longer be middle of the pack in the basic child health outcomes. This may be a little controversial to my friends in Ohio, but we have two of the best children's hospitals in the world in the state of Ohio. And we are middle of the pack when it comes to child thriving, well visits, mental health. And so I think that if Oak is successful in three years, you're going to see us having jumped into the top 10. Dr. Beck? That's where I was too. Ultimately, what we're trying to accomplish is optimal outcomes for every child in ways that allow them to achieve their true potential. And so I think there are things that I'd love to see in three years at a patient or family level, fewer kids hospitalized, fewer kids in the emergency departments, more kids in school achieving to the best of their ability. I think beyond that as a system, I'd love for us, and Jeff talked about the state, I'll talk about greater Cincinnati, is for us to, as a region, center the health and well-being of children and families in ways that crosses sectors. that we, Cincinnati Children's, we Healthvine, we Health Care can play a significant role, but we're doing that alongside our colleagues in public health, education, city government, and other sectors that we know to be so influential in optimizing the lived experience of kids and families. David, last word. What does success look like in three, five, 18 years? I think it's everything that was described, Jeff. I love the idea of bringing together payers and the state and the providers and the patients and families into a single room and asking, what does health, what does healthcare look like in five, 10 years for you? How can we improve it? They say the best time to plant a tree was five years ago. And the second best time is today. And so we need to make sure that we're continuing to do that and have those conversations. I think taking it beyond, And right, of course, clinical outcomes and patient and family success. And Dr. Beck alluded to it, things that are beyond our control, maybe kindergarten readiness, high school graduation rates, economic development, things that we think are not related to health care. But I'm not sure who said it. The all health focus in everything that we do is really an important piece of what our success could look like. David Cruz is the executive director of the Kidwell Network. part of Nemours Children's Health. We also heard from Dr. Andrew Beck, Director of Population Health and Health Equity Research and Innovation at Cincinnati Children's, along with Jeff Stellar, who at the time of our recording session in December 2025 was a population health consultant with Cincinnati Children's and a leader in the Ohio Outcomes Acceleration for Kids program, also known as Oak. Jeff has since moved into a new role in his field, and we wish him all the best. Thanks to our guests for their insights on moving whole child health forward in real time, ultimately benefiting the children all of our organizations serve, your children. Getting at the issues that help move whole child health forward is something we're passionate about here on the Nemours Well Beyond Medicine podcast. In fact, the issues that affect children's health that are happening outside the walls of a hospital or a clinician's office are the issues we bring to light each week on the podcast. Have a podcast idea? The floor is yours. Head over to nemourswellbeyond.org, leave us a voicemail, or send us an email with your episode ideas. While you're there, check out podcast episodes you may have missed, leave us a review, and subscribe to the podcast, as well as to our monthly e-newsletter. That's nemourswellbeyond.org. Our production team for this episode includes Lauren Tata, Susan Masucci, Cheryl Monn, and Alex Wall. Video production by Britt Moore. Audio production by Steve Savino and yours truly. Join us next time as we talk about the cost of loneliness for both children and adults and what could be done to mitigate it. I'm Carol Vassar. Until next time, remember, we can change children's health for good. Well beyond medicine.
