Interview With Nick Macchione, MS, MPH, FACHE

San Diego Physician: You’ve been the director of the County’s Health and Human Services Agency since June 2008. Describe your vision for the Agency, where you’d like to be in two to five years.

Nick Macchione: I spend a lot of time with my team talking about how the entire organization needs to grow and evolve in response to the rapidly changing healthcare environment. We talk about how the entire organization will be transformed with a new culture of doing business. For instance, we talk about how we can become more innovative and proactive in the way we serve our community, especially those who need it the most. I find these discussions extremely energizing for frontline staff, managers, and executives. It is also important to me to create an atmosphere of “buy-in” from the 5,700 people who work for this organization. To be successful across all our programs, each person in my organization should be passionate about the ways we directly and indirectly influence health. For example, I’m spending an enormous amount of time helping the employees that issue Medi-Cal or food stamp benefits realize they’re not just pushing an application; they’re part of an extended care team. They’re not just giving people money to buy something; they’re helping people get access to needed medical care. They’re influencing people’s health, which impacts our entire community.

In addition, within the next several years I would like to see our community as a whole embrace the World Health Organization’s definition of health, which encompasses the total person. Health is not the episodic, not just the physical piece or the mental piece, but rather the wellbeing of the total person. Part of embracing the broader definition of the total person’s health involves aligning services. It’s not just merging, for example, behavioral health and a new “physical health” department. My team will pursue a more holistic approach, and our innovation has the power to improve the health of thousands of people. To that end, we’re actively pursuing Healthy People 2010 and 2020. Our challenge is figuring out how we can best optimize our resources and talents — including our dedicated physicians, nurses, social workers, and eligibility workers — to improve the overall health, wellbeing, and self-sufficiency of children and families in San Diego County. For instance, we will work to leverage the resources of our social workers, eligibility workers, and our physicians, nurses, and community partners. We are looking to break down some of our departmental barriers so that everyone is on board with the same laser-like focus and priorities. That is my goal and our vision.

San Diego Physician: What specifically have you done to move the Agency in that direction?

Macchione: It’s about constantly engaging staff to achieve a shared vision of total health. So, this past fall I held forums with about 120 mid- and high-level staff across the entire Agency to plan our health strategy agenda for the next 10 years. I reached within and outside the Agency to find a dozen top-notch visionaries and experts in the fields of medicine, public health, and behavioral health. Dr. Joe Scherger, who was the medical director of the County Medical Services (CMS) program, is a great example of both a visionary and an expert who spoke on the topic of care and treatment services. Dr. Scherger and the other experts provided timely information in their respective fields, from trends, historical perspectives, technology innovations, cutting-edge models, and future needs to meet the changing environment. Most importantly, they challenged our assumptions and provided valuable insights as to where the health field is heading. We listened to their wisdom and experience and gleaned some powerful advice to employ in our own strategic planning process. We all came back and said “OK, what does this mean to us and our partners? What does it mean to our clients and community?” That process helped us begin to formulate some transformational goals.

And so, more importantly than the transformational goals we’re pursuing, such as, the 3-4-50 initiative — smoking, diet, and exercise cause four major diseases and approximately 50 percent of deaths — more importantly than everything is creating a meaningful and everlasting organizational culture change. With the right attitude and beliefs, we will be able to achieve many of our goals, including improving the utilization of care by frequent-users and looking at how we shift more of our workforce to be a mobile, remote workforce — meaning literally in the field — to really augment the clinicians, the clinics, and the hospitals. I think if we can get all 5,700 strong to see that they’re part of something bigger and more meaningful than the routine, transactional work that they’re doing, we’ve created knowledge workers who care about making a difference in the lives of people. And so what we’re after, more than the metrics to me, is, have I done a good enough job in creating knowledge workers with the right balance of heart, mind, and guts? Those are the people that connect with our physician offices, our nurses, community clinics, hospitals, and other health community-based agencies. That’s what I’m trying to accomplish.

San Diego Physician: Have you looked at the spiritual side of the “total person’s” health?

Macchione: If we’re talking about total health, we can’t lose sight of the importance of spiritual health. I’ve been talking with Vision San Diego and other members of the faith community about ways we can collaborate. It’s not about bringing religion into government, but rather how we address the health needs — physical, safety, and shelter needs — in addition to the spiritual needs of individuals in our community.

I recently talked with about 100 representatives of the local faith community. In Biblical terms, there is a responsibility to assist those who have been marginalized. I think there is an incredible opportunity for us to partner in some respect. Both government and the faith community have a certain duty to assist the most vulnerable individuals among us.

It’s wonderful that we have a new national focus for healthcare reform. Unfortunately, I think the focus has been predominately about access. Access is an onramp to the highway, but the highway is broken, and we have to repair the system as a whole. Access is a first step. To achieve overall system-wide change, we will continue looking for opportunities to partner with private, nonprofit, and faith-based organizations to improve the health of San Diegans. Together, we improve our ability to develop a more comprehensive and strategic approach to help those in our community who are suffering the most.

San Diego Physician: What would you want every physician to know if you had five minutes with them?

Macchione: First and most importantly, how much I and the entire Health and Human Services Agency appreciate what you, physicians, are doing in improving the health of our community.

Next, I would like physicians to know that we’re ultimately on the same team. We’ve got to get away from the “badge syndrome.” We’ve got the government badge. We’ve got the private physician badge. We’ve got the CEO badge. There are lots of different badges that often get in the way of working together. We can’t lose sight of the fact that we’re on the same health team. We have to look beyond our titles and remember that none of us can stand alone. Patients and community residents are dependent on all of us, government, private physicians, dentists, clinics, and hospitals. We need to work together and break down the barriers that stand in the way of a cohesive, high-quality system of care. And yes, there are a lot of effective partnerships out there in our region. That certainly applies to our relationship with Tom and his entire team at the San Diego County Medical Society and all of its physician members. But if there was ever a time to fully optimize partnerships at every level of the health field, it’s right now. We have some serious challenges, but we can minimize or even overcome them together. What we need to rethink, as a health team, is how we provide the necessary quality care, and a holistic approach, in the face of the current economic crisis. It’s a huge challenge, and I think it’s a mistake to think that the federal government alone can solve this for us locally. We need to come together, move forward, and begin to address the healthcare needs of our community.