Population Health Reimagined Through Integrated Care

Am J Manag Care. 2025;31(Spec. No. 6):SP379-SP381. https://doi.org/10.37765/ajmc.2025.89760

Louisiana has consistently ranked near the bottom in national health outcomes, prompting the launch of Ochsner Health’s Healthy State initiative—an effort grounded in the principles of integrated care and community partnership. “There’s a social responsibility that comes along with our presence in the state,” began Eboni Price-Haywood, MD, MPH, MMM, director of primary care research at Ochsner Health, who was a cochair of the Institute of Value-Based Medicine
(IVBM) event held in New Orleans, Louisiana, on April 10, 2025. Throughout the event, speakers from health systems, academia, and payers participated in panel discussions and delivered presentations relating to the Healthy State initiative.

The goals of Healthy State focus on implementing data-driven strategies to target key social and health determinants, such as tobacco use, food insecurity, education access, and cancer screening rates. Early progress has been apparent: Price-Haywood highlighted that more than 200,000 residents have quit smoking since 2014, fourth- and eighth-grade reading scores have risen, and cancer screening rates have greatly improved.

The Healthy State model evolved from a simple advisory board into a wide alliance involving health systems, universities, nonprofit institutions, and government agencies, recognizing that 80% of health outcomes are shaped by factors beyond health care systems.¹ Although challenges such as premature deaths, obesity, and economic hardship remain, collective, collaborative, and sustained efforts—as well as a patient-centered mindset—will be critical to long-term success.

To meet these needs, “we’re trying to bolster the workforce,” Price-Haywood said, “because we don’t have enough nurses, doctors, or behavioral health specialists, and we need to make it easier for people to go into those professions and stay in them.”

Strengthening the Health Care Workforce

Health systems and academic institutions are designing workforce development programs to go beyond clinical competency, with a renewed focus on cultural awareness, communication, and interprofessional collaboration.

“Health care is about the people we serve, and it’s equally about those who are serving,” said Missy Hopson, PhD, system vice president and chief learning and workforce development officer at Ochsner Health. Hopson illustrated how Ochsner Health’s Speed of Trust culture program was developed to cultivate trust among its team members, their leaders, and the organization. This foundation is built on listening first, understanding, and effectively communicating with one another as core behaviors. The success of the team and the care they provide hinges on a combination of technical skills and cultural competency. “Coming to work is about more than what you know how to do. How you show up has real implications—not just for how the patient feels, but how the team around you works together,” Hopson said.

Other speakers echoed these sentiments and the importance of embedding these values early in health professionals’ education. Kathleen Kennedy, PharmD, dean of the Xavier University of Louisiana College of Pharmacy, highlighted the program’s integrated curriculum that begins in a student’s first year. “We introduce our students to all of the different members of the team so that they get to learn about what they can do, what the others can do, and how to work together,” she said. Students also undergo implicit bias and communication training. Although the program is structured to help students convey health information in ways that resonate with patients, Kennedy emphasized how effective care often starts with listening.

Values-informed learning is not limited to large universities. At Delgado Community College, a new integrated facility enables nursing and allied health students to train together. “This is a game changer,” said Larissa Littleton-Steib, PhD, chancellor of Delgado Community College, pointing out how students can collaborate in hospital settings in ways that mimic real-world care teams. “It is so important for individuals to understand the health care profession and also to understand how they collaborate, the culture, and that you never stop learning,” she said.

At the system level, Mary “Toni” Flowers, PhD, MBA, chief social responsibility officer at LCMC Health and the other cochair of the IVBM event, highlighted the health system’s At the Helm leadership development program. This in-person, experiential training equips senior leaders to operationalize health equity and address bias across the health system. “Our senior leaders may not be at the bedside, but they set the tone,” Flowers said. “When equity is a priority at the top, it flows through the entire organization.” More than 1600 leaders have completed the training, which spans 3 years, with employees expressing appreciation for the investment in their growth and its impact on patient care.

The panel also drew attention to the pertinent barriers to building diverse, patient-centered workforces. Among these obstacles, they discussed how food and housing insecurity, financial stresses, childcare needs, transportation, and even awareness often interfere with students’ success or pursuit of health care careers.

Putting Patients First

“Value-based care promotes proactive, holistic care and enables providers to focus on outcomes rather than volume,” said Beau Raymond, MD, MMM, chief medical officer of Ochsner Health. As health systems shift toward value-based models, including bundled payments and shared savings, integrated care has become increasingly recognized as playing an essential part in improving patient outcomes.

Integrated care models coordinate services across medical, behavioral, and social domains to treat patients wholly. This approach has been demonstrated to reduce hospitalizations, improve the management of chronic disease, and enhance patient satisfaction.² Importantly, it helps ensure that care is proactive and continuous. “In a fee-for-service model, everything you do is reactive,” Raymond emphasized, arguing that these structures cannot adequately care for patients with complex needs.

Despite these benefits, panelists spoke about how the COVID-19 pandemic strained health care systems and the challenges it continues to present to building and sustaining collaborative care teams. As such, deliberate strategies are necessary for the success of integrated care, they argued.

Shondra Williams, PhD, president and CEO of InclusivCare, discussed the value of leveraging data to demonstrate the impact of integrated care because “the data allow those team members to understand how they contribute to the greater good.” Furthermore, employing technologies to enhance communication between team members and rethinking how to allocate time appropriately based on patient complexity were mentioned. Referencing the flawed fee-for-service model, Kenny Cole, MD, MS, system vice president of clinical improvement at Ochsner Health, called out its influence on standardizing the 15-minute office visit. “It’s based on economics and transaction-based financing,” he contended. “We have to think through how to change the financing in such a way to allow the amount of time that each problem requires.”

Throughout this discussion, trust emerged as a central theme—among team members, between patients and their providers, and within the health system as a whole. Integration relies on relationships as much as it relies on structure. Without trust, even the sturdiest frameworks can fall short, but as Ann Kay Logarbo, MD, chief medical officer at Aetna Better Health of Louisiana, noted, “When we build an environment of trust, then we can work together.”

Added Cole, “The patient is the most important member of the care team.” He explained that it’s the patient who “has the ball” and is trying to drive down a football field filled with challenges such as trauma, chronic disease, and systemic barriers. Integrated care teams must act as a support system to help clear a way forward, he said. However, to succeed, patients must also be empowered to advocate for themselves by asking questions, participating in decisions, and understanding their care plans. Culturally competent care, especially in community health centers, plays a key role in building this trust and engagement, the panelists agreed. Ultimately, integrated care will be most effective when patients feel heard, understood, and supported as active partners in their health.

Author Information: Mr Munz was an employee of MJH Life Sciences, the parent company of the publisher of Population Health, Equity & Outcomes.

REFERENCES

1. Deng IX, Shih P. Social determinants of health: the unaddressed variable accounting for 80% of health outcomes. CareJourney. September 18, 2020. Accessed April 30, 2025. https://carejourney.com/social-determinants-of-health
2. Zhang Y, Stokes J, Anselmi L, Bower P, Xu J. Can integrated care interventions strengthen primary care and improve outcomes for patients with chronic diseases? a systematic review and meta-analysis. Health Res Policy Syst. 2025;23(1):5. doi:10.1186/s12961-024-01260-1