Portfolio Design for
Whether you are aware of it or not, the region you live in has a portfolio of investments being made toward the health and well-being of its population. Few of us really think about it that way, however, because it’s not a coordinated set of investments from some kind of single, regional purse. Instead it’s a group of mostly siloed investments that each organization impacting health and well-being is making on its own.
When regional stewards begin to wonder about their potential to bring about the kind of ecosystem their region really needs for health and well-being, it’s worth asking whether the region’s existing portfolio of investments is effective. And, if it isn’t, what’s the path stewards could take to ensure effective resource allocation in the future? The Portfolio Design for Healthier Regions project is working with stewards as they take on these important questions, to begin to figure out how to answer them.
What does it take for stewards to reallocate resources to improve their regional health ecosystem?
In 2018, ReThink Health released the Negotiating a Well-Being Portfolio Toolkit, a tool we had been testing with stewards working together in regions across the country for a few years prior. In our tests, we asked every steward in the room to consider where the investments they have some say in are directed, write them on sticky notes, and place them on the wheel.
The wheel has two sides: one for efforts that provide urgent services (the kind anyone under adversity would need to temporarily regain or restore their health and well-being) and one for the efforts that not only have the potential to improve health and well-being but also prevent harm and avert the need for urgent services. Efforts on this second side of the wheel seek to create vital, systemic conditions that people depend on to be healthy and well. They are usually tackling problems at the system level, whereas urgent services are tackling important problems with solutions that will only address the problem on a temporary, isolated basis. Urgent services will always be needed, but there is a question about how much they’ll be needed as stewards improve their region’s vital conditions.
What will it take for stewards to reallocate resources in different ways, over time, to pursue the equitable regional ecosystem they know they need for health and well-being?
With the region’s current investment portfolio now made more visible, stewards see they are doing great work they can be proud of. And yet when we move to the next part of the exercise, where we ask if that’s their ideal portfolio, stewards begin to have more strategic conversations almost immediately. They begin to consider how investing more in vital conditions could eventually alleviate adversity, avert costly urgent services, and assure more equitable opportunities for everyone to reach their full potential.
They also notice gaps in some urgent service areas and overabundance in others given health needs they currently face (which raises new questions, such as: do current epidemics, such as a mental health or opioid crisis in a region, have enough resources for relevant urgent services?). The sticky note placement also shows stewards where system level changes to bring about vital conditions in a region may be beginning to take shape and where they could expand.
Shifting the stewards’ mindsets in this way is just a start. We’d love to share a fairy tale ending: “and in the end, stewards made a strategy by which the ecosystem that produces well-being in the region could be transformed, and then all the money magically went to the right places to make it happen immediately.” But as with most fairy tales, that would be completely unrealistic. After all, every regional player involved has their own purse and most have vested interests in keeping and growing what’s in it.
Figuring out the Best Ways to Nudge Forward a Shift in Practice
ReThink Health’s Portfolio Design for Healthier Regions project is working with stewards from four regions who have agreed to be our learning partners in figuring out what it would take to begin to shift investment portfolios. These stewards “hold purse strings” (i.e., local governments, philanthropy, corporations, etc.) that may
significantly impact health and well-being in their respective regions. These stewards have “skin in the game,” making them the right partners for ensuring this project can help other stewards interested in pursuing regional portfolios that more effectively cultivate equitable health and well-being over time.
Together, we will develop tools and processes to help stewards:
- Each see their own, current contribution to their regional portfolio and use that as the basis for understanding their own role in the regional ecosystem for health and well-being as it exists today.
- Explore the processes and motivations that enable stewards to connect their own institutional interests and investments with an ecosystem designed to produce vital conditions in addition to meeting urgent needs.
- Understand the constraints inhibiting stewards from varying types of institutions as they are presented with opportunities to make shifts in their mindsets, their role in an interdependent ecosystem, and their approach to allocation of resources.
ReThink Health is working with stewards from four regions who have agreed to be our learning partners in figuring out what it would take to begin to shift investment portfolios.
Palm Beach County, FL
“In Palm Beach County, Florida, we recognize the urgency to address complex behavioral health challenges in a new way. We have committed to moving from a traditional decision-making framework (from a funder-provider driven structure) to a system of care with community voice at the helm. BeWellPBC as a countywide initiative is working alongside residents and system partners collectively with a focus on behavioral wellness and health equity. This initiative and key system stewards – Palm Beach County (Community Services and Youth Services Departments), Children’s Services Council, and Palm Health Foundation – are exploring behavioral health and wellness as it relates to social determinants of health and are focusing on civic muscle and belonging at the core of our solutions. Through the Regional Portfolio Design Project with Rethink Health, we are embarking on a journey to examine how we can re-allocate resources most effectively and efficiently across youth and family-serving systems and how we can incorporate homegrown talent and grassroots efforts to support every resident to feel hopeful, connected and empowered.”
– Lauren Zuchman, Executive Director, BeWellPBC
5 Healthy Towns, MI
“In our five-town region, our current approach to health and well-being swirls around our health care systems; primarily doctors and hospitals dealing with the diagnosis and treatment of injury and illness.
5 Healthy Towns Foundation and our partners, St. Joseph Mercy Chelsea (Trinity Health), the Department of Family Medicine at Michigan Medicine (University of Michigan) and Washtenaw County Community Mental Health, believe it’s time to reconsider our current approaches. We want to conduct an honest assessment of the way we serve our region. Then we plan to turn our attention to solutions we believe will prevent or delay chronic disease and enhance daily living.
With prevention as a focus we anticipate our work with ReThink Health on the Portfolio Design for Healthier Regions project with lead to us working better, together, to shift investments of expertise, time, and money to the places that truly impact health and well-being before it deteriorates and becomes illness.”
Meet Our Project Team
“My experience working in a part of Brooklyn where the life expectancy is 11 years shorter than in the neighboring Financial District—and infant mortality rates almost double NYC’s rate as a whole—made me want to change the system at the regional level to help improve these disparities.”—Anna Marie Creegan, Project Director
Joined Rippel: 2014
Current Roles: Anna is project director of the ReThink Health initiative’s Portfolio Design for Healthier Regions project.
Career: Anna led design and implementation for Rippel’s enterprise-wide evaluation framework, and has contributed to many R&D and place-based projects for the ReThink Health initiative. She also led the development of an assessment tool to measure regional progress along ReThink Health’s Pathway for Transforming Regional Health. Anna has over ten years of experience working with local and international health efforts across the US and Latin America, including as program manager for Community Planning and Health at nonprofit Community Solutions, where she led a health impact assessment and developed plans for revitalization, sustainability, and care coordination.
More about Anna: Anna loves traveling and the outdoors—especially hiking and skiing in her native Colorado Rocky Mountains—and seeing her young children growing to love it as well.
Education: University of Denver (MA), Fordham University (BA)
“ReThinking is the most practical thing any of us can do to change the future. It helps us see where we fit in a common system and shifts our own roles as change agents within a dynamic and democratic world.”—Bobby Milstein, Director of System Strategy
Joined Rippel: 2011
Current Roles: Bobby directs Rippel’s work on System Strategy, is a member of Rippel’s Strategy and Management Team, and is a Visiting Scientist at the MIT Sloan School of Management. Bobby is a principal contributor to the ReThink Health initiative’s projects Portfolio Design for Healthier Regions and Amplifying Stewardship Together. He also leads a suite of nationwide influence activities and coordinates ongoing development of the ReThink Health Dynamics Model, the Well-Being Portfolio Design Calculator , and other simulation tools that let leaders play out the consequences of their scenarios for change. In 2018, Bobby and four co-authors wrote the official brief that defines “health and well-being” as the central focus for the Healthy People 2030 Framework for the United States.
Career: Before joining Rippel, Bobby spent 20 years planning and evaluating system-oriented initiatives at the Centers for Disease Control and Prevention (CDC), where he was the principal architect of CDC’s framework for program evaluation. He received CDC’s Honor Award for Excellence in Innovation, the Applications Award from the System Dynamics Society, and Article of the Year awards for papers published in Health Affairs and Health Promotion Practice.
More about Bobby: Bobby once was a documentary filmmaker whose work was used by PBS to spotlight challenges of racism on college campuses. He also contributed storylines for The West Wing on how to get beyond zero-sum thinking when setting health priorities.
Education: Union Institute and University (PhD), Emory University (MPH), University of Michigan (BA)
“Before joining Rippel, my work was confined to individual nutrition and health interventions with specific populations, funded solely by grants. At Rippel, I get to be part of work that breaks through the silos to help stewards move down the path towards sustainability—both of their finances and their mission.”—Katherine Wright, Associate Director, Stewardship Practice
Joined Rippel: 2016
Current Roles: Katherine leads the cross-coordination of Rippel’s three ReThink Health initiative project teams focused on jumpstarting transformative change, and provides high-level research and content support to ReThink Health’s Portfolio Design for Healthier Regions and Hospital Systems in Transition teams. She also continues to promote and present on Beyond the Grant: A Sustainable Financing Workbook (published in 2018).
Career: Katherine previously worked on multiple sustainable financing and R&D projects for Rippel’s ReThink Health initiative, where she explored topics like social impact investing, resident engagement, and the potential of tax credits as a source of sustainable financing for population health. Notably, she co-authored Beyond the Grant: A Sustainable Financing Workbook. Katherine led the design of the workbook’s Financing Wizard that lets users create and practice the art of financial planning for their collaborative population health work. Before joining Rippel, Katherine coordinated and provided research and evaluation support for interventions focused on healthy eating, SNAP-ED, and women’s heart health with Tufts Friedman School of Nutrition Science and Policy, the Jean Mayer USDA Human Nutrition Research Center on Aging, and Michigan State University Extension.
More about Katherine: Katherine was ranked second in the Indiana SkillsUSA Commercial Baking competition, which helped inspire her career path to health and nutrition work.
Education: Friedman School of Nutrition Science and Policy at Tufts University (MS), Michigan State University (BS)
Human Systems Dynamics Institute
Human systems dynamics offers powerful theory and practice to transform intractable problems into patterns of possibility.
Well Being Legacy: The Vital Conditions
How is our well-being affected by the legacies of policy and investment choices made by prior leaders? What are we doing now to shape the vital conditions that we all depend on to reach our full potential? What legacies will our choices leave to the next generation?
Health Affairs Commentary: A Balanced Investment Portfolio for Health is Within Reach
In this commentary, David Kindig and our own Bobby Milstein summarize the evidence that a major reason US health investment performs poorly is that it’s out of balance, with too much spent on certain aspects of health care and not enough spent to ensure social, economic, and environmental conditions that are vital to maintaining health and well-being.
Cultivating Health and the Economy, Side by Side (Case Study 1 of 3)
This origin story of THRIVE (an initiative for transforming both the health and economy of Michigan’s Great Lakes Bay region) details how we helped them map their health ecosystem and plan their “Whole System Approach to Change”—which emphasizes learning and planning before acting, to avoid hasty “fixes that fail.”
No More Fragmentation: Crafting a Comprehensive Strategy for Regional Health and Well-Being
America’s health systems are hyper-fragmented—and here, we explore how a comprehensive regional strategy can be useful to counteract that fragmentation, as illustrated by the success of the Marshall Plan in revitalizing Europe post-World War 2.
Negotiating a Well-being Portfolio: A Toolkit
ReThink Health created these detailed instructions for a visually rich group exercise to help stewards create a balanced and impactful set of policies, programs, and practices that will transform the system that produces health and well-being in their region.
How System Stewards in Washington’s King County are Turning the Tide Toward Equitable Health and Well-Being
When stewards in Washington’s King County gathered, they recognized how their many strong, pre-existing initiatives could combine efforts across silos to find single solutions to multiple problems. One example is You Belong Here, a novel venture meant to increase belonging and social responsibility by building alignment and shared ownership of a common set of priorities and solutions to build a more equitable and thriving region.
The Essential Components of a Comprehensive Transformation Strategy for Regional Health and Well-Being
A comprehensive regional strategy requires a credible, shared theory of system change and a plan to put that theory into action (a portfolio of interventions). Here are some key lessons about those essential components we learned through our work, including an example from our partnership with New Jersey’s Trenton Health Team.
Prototyping to Solve Complex System Challenges in Health and Health Care
Prototyping (purposefully testing out options with a learning mindset) is a great way for stewards to get a sense of how effective their portfolio of interventions might be. In this guest blog, Stacey Chang and Beto Lopez of the Design Institute for Health expand on the idea of prototyping and present a real-world example of its success.
Integrative Activity Assessment Tool
Stewards can use this ReThink Health tool to more effectively coordinate integrative activities, whether as broadly as across all sectors and organizations in their entire region, or simply for those involved with a down to the level of a specific regional project. The tool can help stewards identify which activities are already being handled well, and which ones have room to improve.
Beyond the Grant: A Sustainable Financing Workbook
Long-term, sustainable financing is a challenge for stewards (and their multisector partnerships and organizations) in regions across the country. So ReThink Health wrote this workbook, which offers modules with practical, user-friendly tools to answer common financing questions and develop action plans for moving beyond the grant.
Going Big: Addressing Big Challenges in Health and the Economy (Case Study 2 of 3)
This case study shares lessons learned and helpful strategies from THRIVE (an initiative for transforming both the health and economy of Michigan’s Great Lakes Bay region) based on their work to design big, bold plans to transform their health ecosystem using the ReThink Health Dynamics Model.
Regional Stewards: Nudging Systems Toward Health and Well-Being
Stewards can’t control outcomes in a complex adaptive system, but they can nudge them in the right direction. Using the ReThink Health Pathway, stewards can contribute to shifting mental models away from health care alone and toward the full range of factors that produce health and well-being.
Stepping Out: Launching the First Stage of Interventions to Transform a Regional System for Health and Well-being (Case Study 3 of 3)
This case study shares lessons learned from the story of how THRIVE (an initiative for transforming both the health and economy of Michigan’s Great Lakes Bay region) developed, fine-tuned, and began to launch an interdependent portfolio of interventions based on a strategy we helped them develop and test using our Dynamics Model.
Deciding Where To Invest Is Easier Than We Imagine: Portfolios Everywhere Ought to Prioritize an Equitable Economy and a Connected Society
In a new study released by The Milbank Quarterly, ReThink Health’s Bobby Milstein and Jack Homer found that determining strategic priorities may be a whole lot easier than we think.
What Will it Take for Regional Leaders to Reallocate Resources in Ways that Ensure Our Well-Being?
This month, The ReThinkers’ Blog is introducing ReThink Health’s three projects in which we are working with national and regional stewards as they discover what it takes to drive transformative change and produce...
Insight Spotlight Series: Portfolio Design for Healthier Regions
This week the spotlight is on the Portfolio Design for Healthier Regions project, through which ReThink Health is exploring and advancing system stewardship with local stewards, who are collaborating to design regional portfolios for equitable health and well-being in their communities.
Regional Leaders Learn How to Invest Resources to Ensure Health and Well-Being
How can stewards shift from making siloed investments on their own to coordinating their investments as part of a regional portfolio that advances health, well-being, and equity? We set out to answer this question through our Portfolio Design for Healthier Regions project.
Leveraging Philanthropy to Cultivate Interdependence
Philanthropic stewards can play an important role in creating greater cohesion within health systems. As we look inside our Portfolio Design for Healthier Regions project, we share the voices of two health foundation stewards who are recognizing that philanthropy’s higher tolerance for risk, uncertainty, vulnerability, and flexibility can catalyze change through intentional interdependence. Read how these stewards are amplifying and modeling interdependence as they nudge complex systems toward equitable well-being.
Cultivating Belonging and Civic Muscle to Advance Equity
ReThink Health’s Portfolio Design for Healthier Regions asks the big question: What will it take for stewards to change the way they allocate resources and create equitable regional systems for health and well-being?
How Stewards can Drive Social Change
The Portfolio Design for Healthier Regions project is helping stewards explore their potential to bring about more equitable health and well-being in their regions.