Rethinking Healthcare Design: Dr. Athena Lorin Hall on Community-Driven Systems

In this episode of Taking Healthcare by Storm, Quality Insights Medical Director Dr. Jean Storm speaks with Athena Lorin Hall, MD, a pediatric hospitalist with nine years of experience who spent two additional years in a global health fellowship serving resource-limited communities before founding ZNA Health Network.

Dr. Hall explains how her work in Rwanda and the U.S. showed that many patient challenges stem from healthcare system design, with the United States excelling at emergency “rescue” care but falling short on prevention and primary care. She argues that centering lived experience and making communities co-designers of healthcare through efforts like ZNA Health Network can improve health, rebuild trust, and reduce clinician burnout.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

The views and opinions expressed by the host and guests are their own and do not necessarily reflect the views, positions, or policies of Quality Insights. Publication number QI-091126-GK

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Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

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Hi, everyone. Welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the medical director here at Quality Insights. And today I'm excited to welcome Dr. Athena Lorin Hall, founder of ZNA Health Network, and a pediatric hospitalist who is challenging us to rethink one of the biggest assumptions in health care, that our job is simply to fix illness. After working in Rwanda during a global health fellowship, Dr. Hall witnessed firsthand what happens when health care systems are built without truly understanding the communities they're meant to serve. Those experiences led her to some difficult questions that followed her back to the United States. Why do we spend so much of our time and resources rescuing people from illness instead of helping them stay healthy in the first place? Why are so many clinicians experiencing burnout? And I know firsthand what burnout feels like. And what would happen if we designed health care with communities instead of for them? Those questions ultimately led her to create ZNA Health Network, a learning and action network that brings together health care professionals, community leaders, and organizations to build healthier communities through partnership, prevention, and lived experience. Today we're going to explore what the United States does exceptionally well in health care, where we're falling short, why community may be one of the most overlooked prescriptions we have, it is truly hiding in plain sight, and what it would take to move from a health care system built around rescue to one centered on cultivating health. Dr. Hall, Athena, thank you so very much for joining us today. Yeah. Thank you so much, Jean. I'm excited to be here. I'm excited about this conversation, and I wanted to start around your journey which, as I mentioned, you had a global health fellowship in Rwanda, then it took you to practicing as a pediatric hospitalist, and now y- you're the founder of ZNA Health Network. Looking back, what were the defining moments that convinced you that there has to be a fundamentally better way, a different way, to think about health care? Yeah. The defining shift for me was realizing that a lot of the problems I was seeing in individual patients were actually failures in the design of the system. Before my global health fellowship, I thought that, being a doctor was having all the answers and being the expert, and I was really excited to come in and teach students and residents everything that I learned during my training. But instead, I found myself questioning a lot of the assumptions that I had about healthcare, and I started learning more from the local Rwandans. I cared for some of the, some families that sold their land and their livestock and nearly everything that they owned to pay for one child's medical bill. And that led them into deeper poverty. So we know that poverty leads to poor health outcomes, but the very act of them accessing care could make a family's long-term health worse. So I thought that was, like, just an issue, in low-income countries, but when I came back to the US, I saw that we had, you know, a different version of the same story here, where, two-thirds of bankruptcy cases are due to medical debt in the US. A lot of people have to miss work to go to appointments, and they struggle to pay for medications, and they have to choose between healthcare and basic necessities. So that's when I realized that these weren't isolated patient problems, they're actually signals about how our system is designed. So I changed from asking how do I become better at treating disease to how do we build systems that actually create health? Yeah. It is, yeah, it is, it is common sense, and that is a story that, you know, I've heard you know, I'm, in my time in nursing homes, how many families have to sell everything just to have basic nursing home care of their loved ones. And so it's happens over and over way too many times in this country. You've written that the United States is extraordinary at emergency care, which is great if you're in a car accident or you're having a heart attack. But our country struggles with prevention and cultivating health, clearly. What do you believe America truly does exceptionally well in healthcare, and where do you think we've gotten way off course? Yeah. Yeah, our healthcare system in the US is extraordinary at rescuing people, but it's less equipped at building long-term health. So, like, if you have a major trauma or you have delivered a pre-term baby or have complex cancer or something that requires, like, specialized surgery, then the US has some of the most advanced specialists and technologies and treatments. So it's really remarkable in that way. We've truly built, like, a disease management system and a rescue system here. So I see that strength as a hospitalist and urgent care provider. Whenever we have a kid that gets really sick, we're really quick about,, mobilizing knowledge and resources and getting a child the, the help that they need. But when somebody is, needing, a primary care physician, it can take weeks to get in to see somebody, sometimes months, oftentimes months. And we don't invest as much in public health and, building relationships and, like, the everyday conditions that keep people healthy. So it's not because people in our healthcare system don't care about prevention. It's just because the system financially rewards procedures and visits and treatment a lot more than, they reward the things that build health, like continuity and trust and prevention. So our opportunity is to build an equally remarkable health system as we have a rescue system. I agree, and that would s- probably save a lot more money, right, in the long run? Yeah. Not only would it, would it- ... help people be healthier, but it would save a lot more money. A, a lot less rescuing that we'd have to do. Yes. Yeah. One of the themes that runs through your work is the importance of community. Why do you believe that community isn't just a nice addition to healthcare? And I think that's how it's, it's pretty much seen now, is just like a it's nice. It's like a feel-good thing. But y- you say that it's actually one of the most powerful determinants of better outcomes. Yeah. Yeah, absolutely. , Community isn't just, like, where health is happening, it's actually where health can be created and where it is created every day. During my global health fellowship, I saw that some of the most well-intentioned healthcare programs failed because they were designed for communities instead of being designed with them. we've seen over and over that when decisions are made without the people who actually live with those decisions, then the solutions oftentimes miss the mark. 'Cause they can look good on paper, but then they don't actually fit everyday life for people. communities aren't meant to replace clinical expertise, but they have their own kind of expertise that we need to equally value along with the clinical expertise that we bring in. They understand their culture and their priorities and the strengths that they have and the daily realities that they experience. It's kind of like, the same sort of relationship that we have between provider and patient that would be ideal is what we need to have with our communities. Currently, we, ... a lot of physicians will write, you know, a treatment plan and hand it to a patient. And s- you know, sometimes that plan will work, but oftentimes it won't because it doesn't fit, like, their daily life. If they work a lot of jobs or they have, they don't have transportation or access to healthy food, then, that treatment plan may not fit their actual reality. So instead we need to have a partnership where we equally value the clinical expertise and that person's lived experience. And having that partnership between the healthcare institution and the community is just as important where we're really valuing from the beginning what that community needs and what they are advocating for. Yeah. It's a, it's so powerful, and I think we really do undervalue it in this country because it's not flashy, and it's not, it can't bring in big, uh, money, right? Right. Yeah. Yeah. Yeah. Yeah, we really love the, the short-term wins. But it's really the long-term, slow building of relationships and trust and the, you know, boring stuff like investing in people's you know, safe housing and, and basic needs that's actually gonna build health, so. Yes. Burnout is, um, s- become, uh, very common in healthcare. As someone who, I experienced burnout. I've seen many providers experience burnout. Many organizations are focusing on resilience training or wellness programs, but you've argued that's only treating the symptom. And we know, we know with chronic disease, treating just the symptoms doesn't fix the problem. It's like putting a Band-Aid over something when there's an, uh, you know, infection underneath there. Why do you feel burnout is so prevalent, and what do you believe is the deeper problem that we really need to look at solving? Yeah, so I think burnout is what happens when people come into healthcare to help other people, but the system is getting in the way of that. It's actually preventing them from providing the quality care that they want to give. And resilience does matter. It's important, y- and we do have, like, inherently stressful jobs especially emergency care physicians and people who are working in critical care. and having good sleep and boundaries and mental health support is all important, and that should be part of the offerings of our health system to support everybody. But resilience can't compensate indefinitely for a system that asks people to work in ways that are misaligned with their values, and misaligned with why they entered medicine in the first place. It's the repeated experience of knowing what you need to do for the patient, but not having the time or the resources or sometimes the authority or continuity to provide those things. We see it when, we have to deal with insurance denials for a treatment that you know a patient needs, or you're spending so much time documenting rather than connecting with the family that's sitting right next to you. I see it sometimes in kids returning over and over, because their real problem is something bigger underneath, like food security or they don't have access to primary care or, safe housing. But I don't really have the tools to do anything about it. The system isn't gonna support me to address those needs. So over time, we get disconnected from our purpose and We're feeling like we're constantly working against our values, and that just wears down on, on clinicians. And eventually they feel like they- it's just not sustainable. So we need to ask, like, why so many extraordinary people are struggling in our, in the same system instead of just offering all these band-aids, like you said. So yeah, it really suggests that the problem's way bigger than the individual, and we have to redesign the conditions that are causing distress in the first place. A- ab- absolutely. Absolutely. And, um, it's so nice to know that there's individuals like you, there are many of them out there, that are working on the solution here. And I, I really, I hope that we all succeed sooner rather than later because I think we're losing a lot of really good people in this system currently. Yeah. It is definitely worrisome how, how many people are leaving. Yeah. Yeah. Patients are frustrated, as we've heard. I've seen firsthand. Clinicians, as we said, exhausted or getting burned out. And the healthcare costs are continuing to rise. And- Patients are not trusting the system. Trust is definitely eroding. Are we approaching a breaking point in American healthcare, or do you see this as an opportunity for meaningful transformation? Or, I mean, I guess it could be both, right? Yeah. Yeah, I think it's, both a breaking point and a decision point. So, parts of our healthcare system have been already breaking for so many people, like patients who can't get in to see a primary care doctor or they can't afford their medicines or understand, like, how to navigate our fragmented system. Like, our system's already failed them and already broken to them in their eyes. And, you know, the nurses that have left, the bedside and doctors who are cutting back on their hours or just quitting medicine altogether. Yeah, so but I think that this strain on our health system is really illuminating the limitations of the old model, and making it, like, impossible to ignore that there are issues in the design of our healthcare system. But the risk here at this decision point is, are we gonna just try to keep patching things up, or are we actually going to shift the design of the system? And I think it makes a lot of people nervous to think about where do we even start? How do we redesign a whole healthcare system? Well, there are examples of, health systems and communities that have done that, and it is possible. It just really takes us, you know, having the will and collaborating together to make that happen. And we really need to bring the frontline workers and our community members to the, table in designing the system instead of just creating something f- far removed from where the patients are and where, where the people who are providing the care are. Yes. We need to bring in the people who are actually experiencing the system, who treat people in the system, who are taking care of the system- Yes ... to actually have input into the system. Absolutely. You place tremendous value on lived experience, and I’ve seen the value in this firsthand. And you often say that healthcare should be designed with communities rather than for them, as I mentioned in the introduction. So why is lived experience just as important as clinical expertise, and I think this is gonna be challenging to a lot of healthcare providers when we’re designing better healthcare systems? Yeah, I love this question 'cause it really, like, gets to the heart of things. Yeah, so clinical expertise tells us, like, what should work. This is ideally if, if everything is aligned in this person's life and, the conditions are perfect then that clinical expertise is so important. But we need to combine that with the lived experience of whether or not it would actually work in real life for that person and that individual. The clinicians and researchers bring essential knowledge about evidence and treatment and clinical outcomes, but living with the condition and understanding, like, the daily reality of navigating it, you know, what is confusing about it, k- you know, what becomes too much to afford or what's stigmatizing. All these things are important for us to consider when we're creating plans and, working with patients. We can't just hand down something to them and expect it to work perfectly in their lives if they are having to navigate so many other things in their lives. So when the frontline staffs and, and patients receiving the services aren't really involved in designing care, then, uh, the organizations often solves a problem that appears, like, on a spreadsheet while missing the problem that people are actually living. So including lived experience doesn't mean replacing the clinical evidence. It means combining it with the different forms of expertise that patients bring in, and seeing patients as experts in their own lives, as well as frontline staff as experts in what care actually looks like on the front lines. So yeah, having people closest to the problem involved in the design is really important instead of just doing that top-down control model. Yeah, and I, you know, I, I have talked to a lot of individuals who are in recovery, and they serve as peer support i- with other individuals who are in recovery, and that model works tremendously well. We've seen so much success and, and, and it's been studied. I still don't understand why we don't do more of that in all aspects, of individuals with lived experience. It is powerful. Yeah. It absolutely is. I think just, the system was designed the way it was,, a long time ago, like in the late 1800s, where patients are considered, like, passive recipients of care, and the doctor just comes in and, provides a treatment and then that's the end of the story. But we're, we live in different times where we have chronic diseases and people struggling with a lot of different things, and we need to shift our care model to really appreciating the lived experience that patients bring in. For someone hearing about ZNA Health Network for the very first time, how would you describe it in one to two minutes? What is the- Yeah ... model? How does it fundamentally differ from the way healthcare organizations typically approach change? Yeah, I created ZNA Health Network because I saw that there are a lot of people that are passionate about shifting our healthcare system, but they often feel isolated from each other, and they're frustrated with how little that they can do on their own. So ZNA is a learning and action network that's focused on building healthcare that's more community-centered, relationship-driven, and has a whole health approach. So I wanted to bring people together from across sectors, so that we can not only look at what's going wrong in our system, but also learn from, models that are already working and connect people across those silos so that we can eventually support collaborative projects that are aligned with our mission. So , ZNA doesn't just assume change begins with, like, a large institution or you know, that we need to shift the minds and ideas of our leaders in healthcare. It's more of a grassroots effort and looking at, how can we partner with our communities and really center our healthcare system around their needs. It sounds very common sense, right? You know. Absolutely, yeah. Yeah. And the common sense things usually work, and that's why they're common sense. It's very simple, but that's- Yeah ... yeah. This is the last question. I ask an iteration of this question to all my guests, and e- eventually I think I'm gonna put together a big list and, maybe it'll be a podcast around just the answers to this question, and maybe we'll solve healthcare in the United States through that podcast. Who knows? Yeah. Yeah. Imagine that Congress handed you the keys to the US healthcare system tomorrow and said, "Dr. Hall, you get to make the first major change." What's the very first thing you would do, and why do you feel that that would have the greatest ripple effect? Yeah. I love this question so much. Yeah, I would make communities co-designers of the healthcare system instead of passive recipients of it. So that's, that's the first thing that I would do. I think that would have a huge ripple effect outward. 'Cause right now a lot of our biggest decisions are made from people that are far removed from clinical care and from the communities that they're trying to serve. They're designing around data, budgets and regulations and institutional priorities instead of what's actually happening on the ground. So then we get a system that's really good at optimizing care delivery, but not so great at creating health. But when communities have a genuine voice in the governance and decision-making, then they can change what success looks like. They can, instead of looking at how many patients they saw that month, they can look at, are people actually healthier? Do we trust our institutions and providers, and how can we you know, improve that trust? And are we making healthy choices easier for people? So once you change what, like who helps define success, then you naturally change what gets measured, what gets funded, and what gets rewarded. So that's when primary care becomes an investment instead of a cost, and longer visits are more valuable because relationships and trust are more valuable. Care teams become more comprehensive because communities know that health is shaped by much more than just physical symptoms. So this, we've actually seen this work, in the Nuka system of care in Alaska, where the communities are part owners of their healthcare system, so they get to choose what gets prioritized. And we've seen that they've had huge improvements in the health of their people because of that. So if we want healthcare to create health, we have to give people living with the consequences of the system a meaningful role in designing the system. I love that you have an, a success story. I mean, that's that's inspiring. Yeah. Most definitely. Yeah, it's really cool, 'cause it's actually something that we can learn from, and it's been tried and true, so it's not something we have to build from scratch. Yeah, and it's not just, it's just not, like, an idea. It's actually came into fruition and helped people. Yeah. Exactly. If people want to hear more about Zna Health Network or you, how can they learn more? Yeah, so you can follow me on LinkedIn at Athena Lorin Hall, and it's L-O-R-I-N. You can also go to the website, www.znahealthnetwork.com, and you can click Join the Movement, which, , sends you to the email newsletter. And, there you can get updates, and, once I relaunch the network, you can hop in and, and start, , being an active member, so. I encourage anyone who's interested to go ahead and, and learn more, and we will link all of those to the podcast episode page. Dr. Athena Lorin Hall, thank you so very much for joining me today. Thank you so much, Jean. This was a wonderful conversation.

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website. We would love to hear from you.

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