Unleashing Patient Potential to Reduce Chronic Disease Costs
Executive Summary
Spiraling healthcare costs have been of grave concern to prominent segments of industry, government, and the public for at least 50 years. And while the cross-sector battle rages on over the appropriate strategy for addressing them, there is one fact upon which clear-eyed industry analysts agree: There can be no solution to the healthcare crisis that does not address America’s unchecked epidemic of chronic disease, which afflicts more than half our citizens and consumes 86% of the exorbitant $3.2 trillion spent each year on care.
But our traditional healthcare delivery system, designed to excel at episodic acute care, has not made a dent in the problem. To prevent and reduce the cost of managing chronic disease, the system must learn to facilitate change in individual behavior, which has the greatest impact on health of any contributing factor, including healthcare. The Theory of Jobs to Be Done is a powerful tool toward this end.
Jobs Theory explains that everything people consciously choose to do (including doing nothing), they do to make progress according to their own priorities, in a particular set of circumstances. We call this progress a “job,” and it motivates individuals to search for solutions. Based on this insight, the theory asserts that the way to unleash patients’ potential to better manage their health is not to try to get them to prioritize health goals over the jobs they’re already striving to do. Instead, it’s to understand those jobs, and help patients accomplish them in ways that enhance their health, rather than detract from it.
For instance, a person striving to feel less lonely might “hire” a cat, a walking group, more hours on Instagram, or smoke breaks with colleagues to do that job. Each of these solutions has health consequences, ranging from positive to negative. Jobs Theory provides a framework for creating solutions for patients’ jobs that also have positive health consequences.
A jobs-based approach to healthcare delivery is particularly suited to chronic disease management, for five reasons:
- Takes into account patients’ full capacity to change, so patient and provider can establish realistic health improvement goals, and craft health solutions patients can absorb considering their unique circumstances.
- Works with patients’ existing beliefs about health, rather than requiring immediate change in perspective, and thus reduces barriers to adoption of health solutions.
- Illuminates the broader determinants of individual health status, enabling development of health solutions that address them, likely in partnership with experts in sectors beyond healthcare, such as social services.
- Clarifies the real competition to healthy behavior, so patients and providers can craft health solutions to patients’ jobs that outperform unhealthy alternatives.
- Shifts unit of performance from outcomes to progress. Chronic disease management is a long game, so progress in health improvement, not episodic care outcomes, must be the ultimate metric of success. Because jobs represent the progress people seek, organizations capable of delivering jobs-based health solutions are optimized to deliver on the metric of progress.
In researching a diverse range of organizations for this paper, we identified five core enablers of jobs-based healthcare delivery. The most fundamental of these is what we call a health-centric purpose. That’s an organizational purpose defined in terms of patient health and wellness impact, not the types of services provided.
Others include an explicit process for jobs discovery, and the practice of hot-spotting. The former enables accurate definition of the progress patients seek at a given life juncture, and the latter focuses innovation and resources with exceptional intensity on patients whose health improvement will yield the biggest cost savings.
Astute resource integration means organizational skill in mobilizing resources across functions, sectors and geography, and it’s essential for tailoring health solutions to patients’ unique circumstances. And finally, community interaction mechanisms help keep patients connected with peers in health improvement, and thereby with the overall care and self-management process.
There can be no remedy for America’s healthcare cost crisis that does not aggressively attack the scourge of chronic disease that drives so much suffering, and the majority of cost in our system today. But there’s a cavernous gap between the kind of care people need to avert or address chronic disease, and the episodic, acute care our traditional healthcare system is designed to provide. Using the Theory of Jobs to Be Done, innovators can bridge this gap by creating health solutions patients have the capacity to embrace, and which unleash their potential to manage their health more effectively and independently.
Introduction
Spiraling healthcare costs have been of grave concern for prominent segments of industry, government, and the public for at least 50 years, and the Affordable Care Act is only the most recent of numerous attempts by policymakers to address this issue. While the battle rages on over government’s appropriate role in healthcare, and thus the landmark law’s fate, there is one fact upon which the clear-eyed industry analysts agree: There can be no solution to the healthcare crisis that does not address America’s unchecked epidemic of chronic disease.
At present, chronic disease consumes 86% of the exorbitant $3.2 trillion the U.S. spends each year on care. More than half of all Americans suffer from at least one chronic disease, with heart disease, obesity, cancer, and type 2 diabetes numbering among the most common conditions. The list of chronic diseases is likely to grow, as scientific advances continue to make healthcare providers wildly successful at transforming terminal conditions into ones people can live with for months or years, while progress in precision medicine remains slow. These trends, coupled with the ticking time bombs of a growing elderly population and increasingly expensive treatments, promise to increase the human and economic costs of chronic disease.
But our healthcare system has not made a dent in the problem. Designed primarily for acute care (and performing suboptimally at that ), the traditional healthcare delivery model applies the same tactics used to address episodes of acute illness and injury—reactive, transactional, hospital-centric, and impersonal—to address chronic disease.
To prevent and reduce the cost of managing chronic disease, the system must learn to facilitate change in individual behavior, which has the greatest impact on health status of any contributing factor, including healthcare, by a long shot. For despite proven, widely-known methods of ameliorating some of the most deadly, burdensome, and costly conditions of our time—quit smoking, drink less, eat nutritiously, exercise regularly, and take prescribed medications—millions of people fail, every day, to do what they know is good for them.
Why? It isn’t that people don’t care about their health. Surveys and the $500+ billion consumer health and wellness market say people do care, a lot. Rather, people and life are complicated. So people find themselves absorbed in other problems, swept up by other ambitions, or trying to work with healthcare regimes that don’t fit their circumstances, instead of making the changes that nobody else can make for them.
In such context, it’s not health that people want, per se. So simply educating or reminding them about the negative health consequences of their behavior will not, in isolation, drive required behavior change. It’s something more than health, and something more specific, that people want. They want progress in their lives, as they themselves define it. A tech entrepreneur’s idea of progress might be furnishing the office she just leased before employees start on Monday. Progress for a senior citizen might be staying involved in his temple despite having lost the ability to drive. For a Medicaid beneficiary, progress might be keeping the electricity on, so his family can make progress in other areas.
Nor is it to say that all chronic diseases are equally sensitive to individual health behaviors. Medication adherence, nutritious eating, and regular exercise might slow progression of some diseases, while simply alleviating the symptoms of others. And there is new evidence that successful dieters have a hard time keeping weight off due to the body’s biological inclination to put it back on. We acknowledge the innumerable, interacting factors affecting both human behavior and chronic disease.
Our assertion is that healthcare innovators can unlock whatever potential individuals possess to consciously prevent or effectively manage chronic disease on their own by designing health solutions they’ll have the will and capacity to pull into their lives. The Theory of Jobs to Be Done is a powerful tool toward this end.
This paper represents our most extensive application of Jobs Theory in healthcare to date. For context, we begin with an overview of the theory as applied to the familiar world of consumer products. We then explain its use and benefits in the more complex realms of healthcare delivery and chronic disease management, and describe five organizational characteristics and capabilities, or enablers, that facilitate development of jobs-based chronic disease solutions.
Finally, we illustrate our observations throughout with examples from a diverse set of providers that implicitly take a jobs-based approach to care delivery. As such, we hope this paper serves as a comprehensive resource and inspiration for healthcare leaders and professionals innovating to meet the care delivery demands of the 21st century, and for the stakeholders across sectors aspiring to support them.
The Theory of Jobs to Be Done
Innovators the world over face the daily challenge of creating products that consumers will buy and use. Toward this end, many accumulate vast amounts of demographic, psychographic, and preference data on their target audience, and use it to infer “needs” those consumers are presumably trying to address, and product characteristics that will address those needs.
What is a job?
A “job” is the progress that an individual seeks in a given circumstance.
The progress sought encompasses a complex set of functional, social, and emotional needs and aspirations, which change in priority depending on the circumstances.
Successful innovations enable people to make desired progress. They perform jobs that formerly had inadequate solutions, or no solution at all.
Because jobs are driven by circumstance, the circumstance is the essential unit of innovation work – not user characteristics, product attributes, new technology, or trends.
Jobs to Be Done are usually ongoing or recurring. They are seldom “events.”
But knowing a woman is 38 years old, works in finance, and enjoys cooking doesn’t explain why she goes out to an Italian restaurant with friends one night, and orders in pasta bolognese at home the next. As the high rate of new product failure suggests, consumer characteristics, needs assessments and product preferences—which inform much product innovation—don’t explain purchase behavior. To improve their odds of success, innovators must understand the mechanism behind consumer choice so they can more predictably create products consumers will pull into their lives.
The Theory of Jobs to Be Done (JTBD) provides a framework for doing so. In keeping with Peter Drucker’s famous insight that customers rarely buy what the company thinks it is selling them, Jobs Theory explains that consumers don’t shop for brand promises, product categories, and features. Rather, they seek solutions for “jobs” that constantly arise in life—the progress they want to make in a given set of circumstances.
Nailing the job with coffee houses
To understand how these insights can help innovators predictably create products and services consumers will pull into their lives, consider the evolution of Starbucks retail locations.
Camp out for the day in an urban Starbucks, and you will see a continually morphing scene. First thing in the morning, professionals and students line up for a caffeine jolt en route to work or class. As that crowd dissipates, you notice a smattering of women and men in suits, sitting solo at tables, glancing between their newspapers and cell phone clocks. These are the job-hunters, killing time before an interview in the neighborhood.
Later, the stroller set rolls in—parents and babysitters looking for a few moments of relative calm and conversation after dropping an older kid off at school. The freelancers take over in late morning. Computers out, headphones in, they’re working for hours in their own world, while local workers swing through for a coffee break. By late afternoon, map-studying tourists and high-school kids ostensibly doing homework compete for space, and come evening it is a little bit of everything.
Each of these vignettes represents different consumers hiring Starbucks to do a different job. It isn’t easy to create one environment that can mean so many different things to so many different people, but that was CEO Howard Schultz’s intent from the beginning. Back in 1982 when he joined the young company, he saw the opportunity not only to bring quality coffee to America’s main streets, but to create a “third place” between consumers’ home and work, where they could do their own thing while feeling connected to a community.
In subsequent years, Starbucks integrated a wide range of assets and experiences to deliver on that vision. From a functional perspective, the company invested in its coffee through rigorous grower selection and greatest hits in product development like the often-imitated pumpkin spice latté. It furnished stores with comfy sofas and chairs for chatting friends to lounge on, and high tables with bar stools where freelancers could park, plug into a power outlet, and enjoy free WiFi. Carefully curated musical playlists suited the crowd and time of day.
Starbucks also pursued corporate strategies, such as ethical sourcing, and stock options and health benefits for qualified part-time employees, which nailed important jobs for people who care a lot about social responsibility, or just need to feel better about their premium-priced coffee habit. From an emotional standpoint, Starbucks strived to create a feeling of connectedness for its customers. For instance, employees are encouraged to engage in warm but professional communication with customers, and community groups who want to use Starbucks space for regular meetings are welcomed.
This approach—selling coffee by satisfying seemingly unrelated jobs—was new when Starbucks started down this path, but it’s been broadly emulated since. Starbucks has rigorously defended the space it created, however, and today boasts over 25,000 stores in 75 countries, a market capitalization of over $84 billion, and a growth strategy focused on new store formats tailored to the jobs of coffee-loving consumers.
Jobs are made of needs, but needs are not jobs
Given the virtually unchallenged assumption in innovation practice that needs are the primary motivation behind consumer purchase decisions, it’s important to understand the distinction between needs and jobs.
Needs persist over time, regardless of circumstances. For example, safety, food, water, and health are needs. People require these things their entire lives, no matter who they are, where they live, what’s happening around them, or how they feel. Yet nobody spends every second of every day trying to fulfill these needs. It’s not even possible to do so. People must prioritize needs along with all of life’s other daily demands, goals, and opportunities, and decide how to allocate fixed resources among them. Jobs Theory explains how this prioritization and allocation result in adoption of a new solution.
As the Starbucks story illustrates, jobs don’t exist entirely apart from needs. Rather, they comprise the bundle of functional, social, and emotional needs and aspirations that take priority for an individual in a particular set of circumstances. Therefore, as Christensen et al. explain in Competing Against Luck, a well-defined job is a more powerful target for innovation than a need because it provides a high degree of specificity about the problem consumers want to solve.
While needs are undeniably important to consumers, they are too generic to explain behavior. For instance, knowing that everyone needs food does not explain why different people eat different foods, why some people eat when they’re not hungry, and others eat food they don’t like. In isolation, needs do not yield the information innovators require to satisfy them—the who, what, when, where, and why of a situation that determines how consumers will evaluate potential solutions.
Jobs do contain this information. Hence, crucially for innovators, they explain why the very same product could be the perfect solution for a consumer in one situation, and useless to them in another—even while addressing an important need for them. Ultimately, they explain why a conscientious, penny-pinching college student chooses to study at a crowded Starbucks instead of the school library, and many other choices consumers make every day, from the most insignificant, to the monumental.
Harnessing the forces of progress
Jobs Theory also tells us that a proposed solution’s “job performance” is not the only factor influencing consumers’ hiring decisions. In Competing Against Luck, Christensen explains that there are always two opposing forces battling for dominance in a consumer’s moment of choice: those compelling the adoption of a new solution, and those opposing it.
The forces compelling change include the “push” of the situation, or the size of the problem a consumer wants to solve, and the “pull,” or attractiveness, of the new solution purporting to solve it. Both these forces must reach a certain threshold of materiality to compel change. For instance, a problem that is merely inconvenient or annoying will not, on its own, drive someone to seek and embrace a new solution.
The forces opposing change include “habits of the present,” which may be driven by comfort with familiar practices or resignation to living with a problem; and anxieties about adopting new solutions, which accompany even the most compelling solutions. The list of potential anxieties—cost, learning requirements, or the simple specter of the unknown—is almost endless, and often overwhelming.
One important reason habits of the present block change is that people’s psychological aversion to loss is twice as strong as their attraction to gains, as Daniel Kahneman and Amos Tversky have demonstrated.17 Giving up on routines and solutions, particularly those performing reasonably well on social and emotional dimensions of a job, most definitely represents a loss.
In fact, anxiety about “firing” a status quo solution often proves a formidable barrier to change. Astute observers of human behavior can detect this in consumers grappling with decisions ranging from the truly life-changing—such as choice of disease treatment, educational path, or home purchase—to the utterly mundane, such as whether or not to purchase a mattress.
Marie Kondo, author of The New York Times bestseller, The Life-Changing Magic of Tidying Up, is one such observer. Her “KonMari method” of decluttering homes has become an international sensation precisely because it recognizes people’s surprising, almost embarrassing anguish about discarding possessions they no longer want, and offers them a remarkably simple solution for overcoming it.
Kondo relieves people’s anxiety about discarding items they no longer want, but which retain some kind of value, by cleverly repositioning the “firing” process as a gracious retirement ceremony in which they thank their possessions for a job well done. Her method is undoubtedly unconventional, but clearly does an important job for millions of people around the world who have read her book, watch her television show, and pay for her consulting services.
So it’s not enough to create a product that nails a Job to Be Done. Innovators need to understand precisely how the forces of progress are acting on consumers looking to fill that job. They then need to create an end-to-end shopping and purchase experience that nets out in a “hire” decision, given the strength with which those respective forces are blowing. These forces are particularly relevant when the jobs and their solutions are functionally complex, and socially and emotionally significant—as we’ll see when exploring their role in healthcare decisions.
An organization equipped to satisfy consumers’ Jobs to Be Done, therefore, has a set of unique capabilities ingrained into its operations and culture: (1) uncovering jobs, (2) designing the purchase and use experiences that fulfill consumers’ functional, social, and emotional criteria for a solution, and (3) aligning internal processes to deliver those experiences, or “integrating around the job.”
Jobs to Be Done in Healthcare
Over the last 50 years, the healthcare industry has undergone a gradual shift from a paternalistic “doctor knows best” attitude to a recognition that providers and patients must share responsibility in the quest to improve patient health. To help patients do their part in this new paradigm, providers must work with them to design treatments and self-care processes, or health solutions, that patients can realistically incorporate into their lives.
Jobs Theory is an important addition to the healthcare innovator’s toolkit toward this end. It explains that everything people do (including doing nothing), they do for a reason that’s valid to them, even when their behavior may seem self-defeating to others. That reason is to make progress according to their own priorities, in a particular set of circumstances. That is, to do a job.
Based on this insight, Jobs Theory asserts that the way to unleash patients’ potential to better manage their health is not to try to get them to prioritize health goals over the jobs they’re already striving to do. It’s to understand those jobs, and help patients find ways to do them that enhance their health, rather than detract from it.
As a very simple example, a person striving to feel less lonelymight hire a smoke break with colleagues each hour at work, log more hours on Instagram, adopt a cat, or join a walking group. Each of these “solutions” has health consequences, ranging from negative to positive. Only patients can ultimately identify the set of solutions competing for their attention, while providers must be expert in evaluating the solutions’ health consequences. Jobs Theory gives patients and providers a framework they can use together to identify, design, and facilitate patients’ adoption of solutions to their life jobs that have positive health consequences.
Iora Health, an innovative primary care provider operating across the U.S., offers important examples of how a jobs-based approach to healthcare delivery works in practice. Most fundamentally, as Iora’s Dr. Andrew Schutzbank explains, a jobs-based approach shifts the content of the provider-patient relationship from, “Here’s what you need to do, or else!” to “How can we help you live your life to solve more than one problem at a time?” And it transforms the interactions between provider and patient from a string of (often inefficient) transactions into a continuous, collaborative exploration of the patient’s circumstances, beliefs, values, and capabilities.
This exploration opens up a new universe of realistic health improvement opportunities that the provider, working in context of an innovative business model,22 can help the patient pursue. It also puts provider and patient on genuinely equal footing. Patients are expert in the primary realm of inquiry: their Jobs to Be Done, the success metrics for those jobs, the solutions they’re currently hiring to do them, and the kind of support they’d need to adopt healthier ones. Providers possess (or can develop) the scientific and practical expertise to help patients understand the patterns in, and health consequences of, their behavior; and to design health solutions that do patients’ jobs, while driving improvement in important clinical metrics.
Finally, stepping from the individual level to the system level of care delivery, Jobs Theory provides a “true north” for design of institutional processes, from resource allocation and performance measurement, to employee and external partnership development. When these are aligned with a jobs-based approach to care delivery, it’s not only a system’s health solutions that help patients make the progress they seek in life. Patients’ every encounter with the system contributes to that end as well.
Jobs Theory: A powerful tool in chronic disease management
A jobs-based approach to healthcare delivery is particularly suited to chronic disease management for five reasons.
1. Takes into account patients’ full capacity (not just willingness) to change. Asked if they want to improve their health, most people would say they do. But Jobs Theory helps healthcare providers get beyond those headlines to determine patients’ true capacity for change. This is the product not only of the patient’s will to change, but also of their unique circumstances and worldview. Analyzing jobs to discover and understand these interacting factors enables providers and patients to establish realistic health improvement goals, and craft health solutions patients can thoroughly absorb.
One provider explained to us how a jobs approach informed his interaction with a patient whose creeping weight gain, poor diet, and sedentary lifestyle put her at increasing risk of heart disease. He wanted to engage her in a health improvement plan. But instead of trying to cajole or guilt her into an all-consuming health improvement plan, he shared his clinical perspective about where she was on the health spectrum, where she should and could be, and what she would need to do to get there.
Then he began a dialogue with her about how much of that work she felt she could take on in the near term, while juggling a demanding career with parenting duties to three school-aged children. The result? “I can give you an effort of four out of 10 until the kids are out of high school. Then I can give you seven out of 10,” she said. With a clear understanding of the trade-offs the patient was willing to make for health within her particular circumstances, the physician could guide their collective efforts toward the most productive use of her current capacity for change.
2. Works with (not against) patients’ existing beliefs about health. Like consumer-goods purchase decisions, people’s health decisions are influenced by a constellation of factors beyond the objective merits of the solution under consideration. Our chronic care research and myriad provider interviews indicate that people’s unique beliefs about health—what it means, what it takes, whether it is desirable or attainable—are among the most influential of these. We’ve synthesized what we’ve learned about health beliefs into a notion we call the health reference point. A health reference point is the level of mental, emotional, and physical health people believe possible or necessary to make the progress they seek, at a particular life juncture, given their circumstances and the trade-offs they are willing to make.
Everybody has a health reference point, whether they know it or not. It is the inner benchmark we measure ourselves against when someone asks, “How are you doing?” or when we’re considering whether we can (or need to) up our “health game.” The woman who could give her physician a “four out of 10” in health improvement effort arrived at this number by implicitly calculating her reference point—the amount of health improvement that was worth the amount of effort and compromise she was willing and able to make in her current circumstances.
The health reference point is shaped by an individual’s holistic inner and outer experience, including his or her clinical health status. And for each individual, it translates into a set of personal, circumstance-dependent health measures. In our research we learned about an elderly, wheelchairbound amputee on oxygen. While his physical condition was limiting, he managed to remain socially active, and enjoyed volunteering regularly for local causes. “As long as he can get out in the community and do all that, he feels healthy,” his physician told us. “So, if he’s up to it and his numbers are stable, I say, ‘You’re doing great!’”
Providers and patients collaborating to tackle chronic disease face a substantial challenge in understanding the interacting forces influencing patients’ health decisions, including the powerful health reference point. The forces of progress model provides a robust framework for doing so; coupled with the broader Jobs Theory, it illuminates options for designing health solutions that harness those forces in favor of health solution adoption.
3. Illuminates the broader determinants of individual health status. Jobs Theory provides a framework for uncovering the biological, psychological, and social factors driving an individual’s health behaviors, and integrating them into a holistic view. This enables a more complete view of people’s barriers to health, and development of whole-person solutions that address the broader determinants of health. The traditional healthcare delivery model has no explicit framework for doing this. Rather, it thwarts providers who seek it, and steers them toward clinical solutions for clinical problems.
Developing solutions that address the broader determinants of health is obviously difficult because no one stakeholder or discipline holds the expertise, means, or responsibility for doing so. But in enabling better, broader problem definition, Jobs Theory can help any stakeholder—from provider to family member to patient advocate—articulate unaddressed needs and find partners across disciplines in order to weave together solutions.
Such was the case with Angela, a patient at Iora Health.23 A recovering alcoholic, Angela was also seriously overweight and suffered from heart disease, arthritis, joint pain, and depression.
Iora’s implicitly jobs-based approach to developing health solutions prompted Angela’s care team to dig deeply into the circumstances behind these datapoints, and learn that Angela had no meaningful social support. Further, her recent job loss and resulting risk of losing her home were causing her great anxiety, and her estrangement from a beloved son had been a source of deep unhappiness for several years. What she wanted most was to get back into work. If she could do that, she felt, she might be able tackle the rest of her problems, health and otherwise.
With these insights, Iora was able to locate and help her enroll in a free local jobs training program. Once she began making progress on the Job to Be Done that was most important to her at that juncture, Angela’s anxiety began to abate, and her energy and emotional bandwidth for tackling other problems, including her health, expanded. In this manner, Angela and Iora continued to chip away at her particular barriers to health and introduce healthy habits into her life. Eighteen months later she was walking regularly, had dropped 20 pounds, and had begun interviewing for jobs.
4. Clarifies the real competition to healthy behavior. Jobs Theory enables providers to better understand what activities people are hiring instead of healthy behaviors. Such insights are critical so that providers can work with patients to craft health solutions that perform those jobs better than unhealthy alternatives.
Angela, the Iora patient we profiled above, again provides an instructive example. On Thanksgiving Day six months after engaging with Iora, Angela went on a drinking binge. Through a jobs lens, her healthcare team could see that this was not a case of alcohol in competition with sobriety— it was escapism in competition with heartache. Angela missed her son most acutely on holidays, when it seemed the rest of the world gathered in happy family units. Her job in those circumstances was thus to reduce the pain of that estrangement, and on this occasion, she hired alcohol to do it. Given the strong relationship she and her Iora care team had built to date, Angela felt comfortable telling them of her lapse, and the team was able to help her recognize other options for dealing with the pain holidays caused. The team introduced her to new approaches for managing the pain of separation without sabotaging her health, and techniques for opening up the lines of communication with her son. With her problem thus reframed, her solution set was too, and together they could address it. Six months later, Angela remained sober, and she and her son were slowly rebuilding their relationship.
5. Shifts unit of performance from “outcomes” to “progress.” Healthcare reform today places much hope on the shift from managing care transactions to managing care outcomes. While this will drive some positive benefits in terms of cost and quality, it won’t have a material impact on chronic disease. That’s because measuring success in terms of outcomes, as in terms of care transactions, trains an organization to focus on events that can be definitively resolved in the short term, in order to maximize easily quantified, reward-generating events.
But chronic disease prevention and management are very long games, so progress in continually improving health must be the metric of success. Such a focus trains an organization to solve for the long term, step by step, and illuminates a broader set of possible solutions. It puts short-term tactics having long-term health and cost pay-offs in scope, and encourages prudent innovation. And it allows tactics that might only work for a while, but could still have a material impact on reducing pain and cost.
Because jobs represent the progress people want to make in their lives, an organization designed to deliver health solutions that do people’s jobs is, by definition, set up to continually pursue and evaluate progress in a financially sustainable way.
Nailing the job with health solutions
A hypothetical case illustrates how these benefits of using Jobs Theory could play out in developing the chronic care plan for an individual.
Sabeena is 36 years old, 5’5” tall, and weighs 200 pounds. She has two young children and works as an IT service team leader. She used to play basketball in high school, but she gained the “freshman 15” at college, and another 30 pounds during each of her pregnancies. As a result, Sabeena has dangerously high blood pressure, difficulty breathing, poor mobility, and frequent pain in her knees. She remembers how good it felt to be fit, and worries she is now a bad example to her children. But having failed at weight loss many times before, she feels resigned to her poor condition.
Prevailing chronic care practices would lead physicians to classify Sabeena according to her clinical diagnoses—obese, hypertensive, pre-diabetic—and prescribe solutions proven effective for the “average” person with similar diagnoses. These might include medication to lower blood pressure and mitigate knee pain, coupled with exercise and healthy eating to promote weight loss. Then Sabeena would be expected to incorporate the new drug regimen into her life, and find and follow a weight-loss program on her own.
Hence the problem. These prescriptions require a high level of self-management that Sabeena would find difficult to attain, given the unique barriers to healthy behavior she grapples with every day. These include her parenting duties and varying shift schedule, which make promptly picking up medication renewals difficult, and routine exercise all but impossible. Then there are the free, cheesy hot lunch buffets wheeled into the staff lounge most weeks to reward team performance, which save her time and money. She lacks health-savvy friends and colleagues to mentor her in adopting healthy habits, and she’s afraid to try and fail again. And, at the end of the day, she lacks the emotional bandwidth to invest in anything beyond her highest priorities: her children and her work.
Sabeena needs more than just clinical solutions. She needs holistic health solutions that help her make progress in context of this broader web of circumstances.
With an eye on improving Sabeena’s long-term health, how would a jobs-based approach to solution development differ from a traditional approach? It would uncover the jobs arising in Sabeena’s day-to-day life that cause her to hire competitive solutions having unhealthy or health-neutral consequences.
Then it would create healthy solutions that do those jobs and fit her unique circumstances so well that Sabeena will hire them over all their competitors. For example, one important job Sabeena is hiring for is “help me excel at training my team.” This is progress she wants to make because it will improve her and her team’s performance, make them feel successful, and hopefully protect their jobs in an increasingly competitive market.
To make this progress, Sabeena must be able (among other things) to absorb a constant stream of emerging technical knowledge. This requires a high level of mental alertness, which she currently drinks six cups of sugary coffee a day to attain. So from a functional perspective, a jobs-based health solution would offer Sabeena a healthier means of staying alert. Importantly, that solution would result from a robust dialogue between her and her provider about the reasons behind her unhealthy behaviors (such as drinking sugary coffee), which she must understand in order to consistently identify and embrace healthier alternatives.
Training also requires a compelling communication style that Sabeena has struggled to develop. A health solution for Sabeena’s Job to Be Done, then, might reduce her knee pain so she could comfortably walk around the training room to engage more directly with trainees, rather than teaching from a seat at the front. It might also seek to improve Sabeena’s breathing, which is labored due to her excess weight, so she could speak in a more audible and assured manner.
From a social standpoint, the health solution for Sabeena’s Job to Be Done would connect her with peers also trying to improve their health, so they could share encouragement and ideas for overcoming day-to-day obstacles to change. Emotionally, the health solution would feel achievable, and progress would lead not only to health improvements, but to a sense of accomplishment that could improve her confidence and performance on the job, too.
There are more conventional solutions Sabeena could hire to do the job of “help me excel at training my team.” She could hire “train the trainer” sessions from her technology vendors, or a public speaking course at the local community college. Or she could spend every evening reading online technology journals while eating take-out pizza. Providers committed to a jobs-based approach to care delivery would continually work with Sabeena to create, and help her adopt, health solutions for this and her other important Jobs to Be Done, so that she could make consistent progress in improving her health over time.
Lessons from the field: Five enablers of jobs-based solutions
We have explored a number of organizations that, explicitly or implicitly, provide jobs-based health solutions. Spanning missions, disciplines, sectors, tax status (for- and nonprofit) and continents, these organizations illuminate the sheer breadth of innovation and impact that insightful application of Jobs Theory can enable. They further suggest five core enablers relevant to the development of jobs-based solutions for chronic disease. We describe these below, along with examples from representative organizations.
1. Health-centric purpose. An organization’s purpose determines both what it delivers to customers, and how it delivers it. Organizations best positioned to deliver jobs-based solutions for chronic disease ultimately define their purpose in terms of patient health and wellness, rather than primarily the types of services they provide. We call this a “health-centric” purpose.
A health-centric purpose allows organizations to innovate however necessary to create health solutions addressing patients’ ever-changing jobs. By contrast, organizations whose purpose is primarily defined by the services they provide, like many acute care hospitals or retail clinics, often find themselves in a continual loop of incremental innovations to optimize those services. And they have a devilishly hard time breaking out of it to understand and address patients’ jobs over time.
Drawing from the organizations we studied, examples of a health-centric purpose include Kaiser Permanente’s “Total Health” philosophy, which entails “helping members maximize their well-being and live happier, healthier lives.” In Britain, the Bromley by Bow Centre aims to help local residents “build up the skills and confidence they need to progress in life.”
Mission statements and external communications may fully articulate an organization’s health-centric purpose, or merely hint at it. But an organization’s business model tells a more complete story. A business model encompasses the resources, processes, and profit formula an organization creates and leverages to deliver on its value proposition to patients, as well as the organizational culture that emerges in context of the business model.
Intermountain Healthcare, a large nonprofit health system operating across Utah and Idaho, views the communities it serves as its shareholders, and its purpose to maximize value for them through delivery of high-value care. As Intermountain articulates it, “We’re brought together by our desire to preserve and restore health, and to help our patients live their lives to the fullest potential.”
Over the last three decades, Intermountain has intentionally evolved its mission statement, business model, and culture to enable its purpose, and the 1990s saw the first major strategic leap toward this end. “If you looked at our financial measures at that time, you would have to believe we were in the facilities management business,” recalled Dr. Brent James, executive director of Intermountain’s Institute for Healthcare Delivery Research. “That’s when we realized there was a big disconnect between the value we needed to deliver to our patients, and what we were paid and organized to do.”
To repair it, they analyzed more than 1,400 care processes to determine those having the biggest impact on the most patients. Then they spent over a decade building systems to capture the right data to manage and continually improve these. Concurrently, they began a shift away from fee-for-service payments toward a profit formula that would reward, rather than penalize, improvements in care effectiveness. Counting premiums from Intermountain’s own health insurance plans, capitated Medicare and Medicaid payments, and bundled payments from commercial insurers, Intermountain estimates that upwards of 70% of its payments today are tied to the value of care delivered.
Intermountain took another strategic leap in 2014 to extend its capabilities beyond traditional acute care delivery and into the realm of population health management. At the outset this entailed a new mission, “Helping people live the healthiest lives possible,” and comprehensive effort to shift organizational culture from a narrow focus on care quality and cost to a broader focus on long-term health and care affordability. It subsequently included explicit agreements between providers, insurers, and patients to share accountability for patients’ health; redesigned governance and care processes enabling them to do so; and more robust preventive care and chronic disease management capabilities.
2. Explicit process for jobs discovery. Organizations aiming to provide jobs-based solutions must consistently excel at identifying the jobs of the customers they serve. However, prevailing methods for gathering customer information—including qualitative focus groups, quantitative surveys, and big data analysis—are insufficient and even misleading in this task. That’s because jobs are circumstance-based, and no two human beings live in the exact same circumstances. Moreover, circumstances are always changing, so job discovery is a process, not an event.
At Iora Health, the core process for jobs discovery is ongoing communication between members and their personal Iora health coaches. This facilitates a robust and trusting relationship in which members feel comfortable revealing their thoughts, feelings and experiences. To support such communication, Iora “hires for empathy, trains for the job,” according to its CEO, Rushika Fernandopulle. Also, coaches use communication techniques informed by cognitive science, such as motivational interviewing, to help members articulate the progress they seek at a life juncture, and develop the mental perspective and daily habits needed to achieve them.
At the Culm Valley Integrated Centre for Health in Great Britain, a primary care practice is integrated with co-located complementary therapy practices, patient self-diagnostic facilities, public gardens, and a healthy café. Patients’ jobs are embedded in care processes by the patients themselves, who have formal and informal roles in running many aspects of the Centre. They participate in facilities planning and resource allocation, interview physician candidates, and conduct annual assessments of each partner in the practice. And they lead health education sessions, as well as fitness and wellness programs including garden walks, tai chi, and knitting socials.
With patient co-management as the mechanism for job discovery, physicians “encourage selfhelp and a wider approach to diagnosis and treatment based on the views of the patients themselves.” They appear to be succeeding, as England’s primary care regulator, the Care Quality Commission, rated the practice as outstanding in 2017.
3. Hot-spotting. Addressing chronic disease in a financially sustainable way requires some form of “hot-spotting”—focusing with exceptional intensity on patients in a population whose health improvement will yield the biggest savings. Hot-spotting facilitates a jobs-based approach because it demands that organizations gain a holistic view of patients’ circumstances. This in turn sheds light on both their Jobs to Be Done, and the medical and nonmedical factors affecting their health, so that the organization can develop health solutions that address both.
For more than 20 years, Boston-based social enterprise Health Leads has been helping healthcare organizations address patients’ unmet social needs in order to improve overall health. In 2015, Health Leads joined up with Kaiser Permanente (KP) to create a new care approach for the 1% of KP patients driving over 20% of the health system’s costs. Designed to reduce costly utilization by improving targeted patients’ holistic health and wellness, the KP Health Leads program not only provides KP’s standard, highly coordinated medical care. It also identifies patients’ unmet health-related social needs, and connects patients with community resources that can help fulfill them, from housing and transportation services to food banks and financial counselors. Program managers then stay in touch with patients to ensure they’re getting the help they need.
“We believe that adopting a ‘whole patient’ perspective for our high-cost, high-need patients will give us the best chance of improving their health outcomes,” Dr. Nirav Shah, KP’s senior vice president and chief operating officer of clinical operations, and colleagues wrote in the New England Journal of Medicin Catalyst.
At the time of this writing, KP and Health Leads had not published data regarding the impact of their efforts on the health and care costs of their targeted population. But significant results from other hot-spotting programs suggest its powerful potential to illuminate the jobs of highcost, high-need patients, and help providers address them with health solutions patients can embrace.
In another example, MedStar in Fort Worth, Texas focuses on high 9-1-1 and emergency department (ED) utilizers. Mobile healthcare providers proactively visit these people at home to perform medical assessments, coach them in health self-management, and refer them to local resources for additional health-related needs. Since 2009, the program has generated an estimated $9 million in savings due to reduction in ambulance transports, ED utilization, and hospital admissions.
4. Astute resource integration. Organizations that nail consumers’ Jobs to Be Done integrate resources across functions, sectors, and even geography to help consumers make the progress they seek. In healthcare, integration can encompass a wide range of resources, including clinical professionals, nonclinical professionals such as health coaches or peer mentors, data and Health Information Technology, physical space design, community social services, and patients’ social networks. Astute integration specifies how each of the relevant resources must work with every other resource to promote patients’ long-term health.
As American communities reel in response to epidemic opioid addiction, experts are increasingly viewing addiction as a chronic condition that can be effectively managed through integrated care. At Aware Recovery Care, a venture-funded start-up operating in the Northeast, “integration” means much more than primary care physicians and clinical specialists collaborating on care plans.
As described in a concept study by Dr. Ellen Lockard Edens, associate fellowship director of addiction psychiatry at Yale University, Aware’s addiction recovery program integrates care resources from numerous dimensions to help clients learn how to maintain sobriety in the real world. Unlike the dominant recovery model, which offers short stints of care in a controlled inpatient environment, Aware care lasts a full year, and takes place in the client’s home and community. This improves chances that Aware and the client will identify and address the full range of circumstances that enabled addiction to take root.
Further, a multidisciplinary medical team works with a highly-trained peer advisor to assess Aware clients’ physical, emotional, and social barriers to recovery, and craft a plan to tackle them. Then the treatments themselves combine medical intervention with psychological therapies, education in sobriety self-management, and wellness approaches like meditation and exercise. As reported by Kaiser Health News, Aware’s yearlong program costs about the same as a couple of months in a traditional program, but achieves approximately twice the sobriety rate.
5. Community interaction mechanisms. Human beings are social animals, so many people seek progress in the form of connection with others having similar passions, problems, or goals. It’s no surprise, then, that some of the most popular consumer fitness programs and digital applications today include functionality and forums to help users do that job. The resulting interactions give users pleasure, purpose, a sense of belonging, problemsolving support, and more. Innovators can make chronic care solutions more effective by incorporating community features that keep consumers engaged with their peers, and therefore the program, and which reinforce health-promoting ideas and behavior.
Weight Watchers, an international membership organization facilitating healthy weight loss, understands its members’ social Jobs to Be Done. Weekly member meetings facilitated by Weight Watchers employees, who have themselves succeeded at weight loss, are therefore core to the company’s strategy and impact.
Aransas Savas, a “super leader” at Weight Watchers, observes that peer interaction at meetings gives members reasons beyond self-interest to stay engaged in the program. She cites the example of members who find it so gratifying to support their peers that they continue to attend meetings despite feeling discouraged about their own progress, or even having met their goals. Doing so creates a virtuous circle in which helping others improves their confidence and self-esteem, which in turn facilitates their progress in achieving or maintaining a healthy weight.
Savas also says meeting interactions help members reframe their health challenges in a more positive, productive light. “You learn you’re not the only one,” she says. “You learn there are going to be hard times, and to appreciate them as part of the journey, not proof of failure. You get a sense of hope and belief that change can happen.” Such interaction also gives members the opportunity to shed entrenched views obstructing their progress, and embrace new solutions— when they’re ready. “After people have suggested a new approach 20 times, by the 21st time you might actually believe it’s worth a try!” Savas said.
Weight Watchers also offers a social media network for members, called Connect, within its mobile app. Gary Foster, Weight Watchers chief scientific officer, describes the peer support enabled by these community features as warm and nonjudgmental. “It’s also part of scalability,” he says. “It expands the treatment net so it’s not just leader to member, but member to member.”
Conclusion
There can be no remedy for America’s healthcare cost crisis that does not aggressively attack poor health itself, and specifically, the scourge of chronic disease that drives so much suffering and the majority of cost in our system today. But there’s a cavernous gap between the kind of care chronically ill people need, and the episodic, acute care our traditional healthcare system is designed to provide. Using the Theory of Jobs to Be Done, healthcare innovators can bridge this gap by creating health solutions that people have both the will and the capacity to embrace, and which unleash their potential to manage their health more effectively and independently.
Jobs-based innovation can flourish in all kinds of organizations. Those we studied for this paper are diverse—some are American, some are British; some are for-profit, others are nonprofit; some are rooted in the healthcare and consumer wellness industries, while others grew out of local communities. Collectively, they offer valuable insights into the optimal conditions for jobs-based innovation in healthcare, and its potential to mitigate the human and economic costs of chronic disease.