Delivered as a Presentation to OneCity (The implementation body for health reform programs at New York City Health + Hospitals) Executive Retreat July 28, 20016
Newswise — Decades of studies underscore that most health is built or lost outside the formal medical system.
To move from this frustration, clearly, it’s time for a new vision of health---a vision that absolutely includes poor communities as recognized and valued partners in building their own health.
In this new vision of health, communities are not simply defined by their needs, but seen for their assets. Their greatest assets, of course, are people. Using evidence-based peer-delivered self-care, wellness and other community health promotion activities provides key opportunities to address the social determinants of health. Fully using these opportunities generally means focusing on group processes---and training and employing---even part-time---people who are representative of the community, especially those with chronic disease, AIDS, disabilities, and other targeted conditions.
A community asset approach rests on two pillars which, in themselves, inherently leverage health outcomes across a range of programming.
First, a community asset approach builds “social capital” even as it delivers evidence-based programming. In the Health and Happiness Chapter of Bowling Alone, Robert Putnam’s extraordinary book about social connectedness, he emphasizes, “Of all the domains in which I have traced the consequences of social capital, in none is the importance of social connectedness so well established as in the case of health and well-being.”
Dozens of scientific studies show, “The positive contributions made by social integration and social support rival in strength the detrimental contributions of well-established biomedical risk factors like cigarette smoking, obesity, elevated blood pressure and physical inactivity. Statistically speaking, the evidence for the health consequences of social connectedness is as strong today as was the evidence for the health consequences of smoking at the time of the first surgeon general’s report on smoking.”
In other words, a support group can be as vital to health as smoking cessation.
The second pillar of the community asset approach to health is that, to the largest degree possible, people who actually live in high need communities themselves are involved through training---and through work---in implementing health and wellness projects. Just as we rarely talk about the vital role of social connectedness---the profound role of unemployment in ill health hardly receives focused attention.
An article in the Atlantic in March 2010 detailed the devastating impact of unemployment on health. Data shows “that people who were unemployed for long periods in their teens or early 20s are far more likely to develop a habit of heavy drinking by the time they approach middle age. They are also more likely to develop depressive symptoms. Prior drinking behavior and psychological history do not explain these problems—they result from unemployment itself.”
“Poor health related to unemployment... endures for a lifetime. Regardless of age, men were left with an elevated risk of dying in each year following their episode of unemployment, for the rest of their lives.”
In sum, programming that builds social capital and community employment puts any effort at health far ahead from the start. Yet, while no ordinary funding stream would pay for these pillars, the medical system could not use them.
However, the multi-billion dollar federal waiver funding that many states now have---usually with the goal of reducing emergency room visits and hospitalizations--- represent a major opportunity. Flawed and maddening as these state waivers can be, they are also the first real chance for health systems to start using community assets as a core approach to health.
There is an impressive range of evaluated health-building programs that also build social capital and employment---and demonstrably address the usual waiver goals of reducing hospitalizations and emergency room visits. Equal to the fact they exist, however, is the reality that they are not well known.
Today, I will just give a brief glimpse of some of the wonderful approaches ready to bring forward. There is, for example the Stanford Diabetes Self-Management Program, a six-session diabetes self-care course, delivered by trained peers who themselves have diabetes and which significantly improves patient activation and self-efficacy.
There is the peer specialist program, which in groundbreaking implementation at NYC Health + Hospitals, under Dr. Belkin, showed that peers, themselves, with a history of substance use, providing special support to patients with both behavioral and chronic health conditions, over a period of six months, reduced hospital days by 62% and behavioral health costs by almost 50%!
There are doulas, or birth coaches, who by definition under the NYC Department of Health’s program must come from the communities where they assist mothers. They provide one-on-one support to expectant mothers and through birth, reducing rates of complications and cesareans.
There is the remarkable foster grandparents program; trained retirees---who again must live in the communities they are helping---provide intensive tutoring for kids having trouble in school. The kids significantly improve their schoolwork, and long-term follow up of the grandparents shows measurable improvements in their own health.
And there is the Arches Program, which in New York City is currently administered under the Department of Probation. In Arches, older men with a criminal justice history mentor young men on probation. Within six months, half these young men are back in school or have found a job. Certainly the long-term benefit to the health of these young men is manifest in the research on unemployment; the immediate benefit of deterring them from the streets may well include their own lives.
It is never easy to change systems; when we look not just at these waivers administered through CMS, but at all the “plans” the state and federal government are purveying for health systems, it is natural to feel overwhelmed. But I truly ask you to remember that the next few years are incredibly decisive to the future.
Innovative programming that is implemented through waivers has a new chance to be sustained; it can also propel important changes in services reimbursed through Health Homes---and bring much better ideas to the expected widespread implementation of Value Based Payment systems.
Most community asset programming, to work well, has to be implemented by community organizations. OneCity and other health systems, because they are the fund holders and dominant local planners, hold the keys to implementation of any new programs supported through waiver funds. The community groups, of course, don’t believe this is fair---and it’s not fair. It’s not fair to anyone that there isn’t defined funding to bring forward the community models that are desperately needed for waiver success---models to at once unburden medical systems of burdens they can hardly cope with anymore while implementing community-based services that work better. It’s especially not fair that we are leaving the key asset of communities---namely their remarkable determination, when given any chance, to devote themselves to fighting endemic ill health---so extraordinarily wasted.
Look at the range of people successfully implementing these programs---people with diabetes on Medicaid, former prisoners, recovering drug users and women in the community who just want to help other women---who are often terribly alone---have a good birth experience.
For these people, we must change our vision!
I just request that you consider one last principle---that even in the biggest systems, people do count. What you do, how you change approaches, even without a formal policy, can absolutely change lives and health. The director of a supportive housing agency told me recently that the life of one his residents was totally renewed simply because she had obtained a 3-hour a week job as the patient advocate at a nursing home.
That’s three hours. I will close by telling you of the benefit of two hours. These are two hours that Dr. Anna Flattau, now the Medical Director of OneCity, spent training Health People peer educators to address the terrible toll of diabetes-related lower limb amputations in the Bronx. Anna worked with us to develop a two-hour workshop on good foot-care for diabetics with neuropathy. More, Dr. Flattau came and herself trained the peers to deliver this workshop. With a small state grant, the peers provided the workshop for 99 South Bronx residents with diabetes and neuropathy. Follow-up of the outcomes shows that before the workshop, only 41% of participants knew how to inspect their feet; after 93% said they were confident they knew---and actually were inspecting their feet.
This peer foot education had never been done before; it couldn’t have been done without Dr. Flattau but it’s now in the community and incorporated into our own waiver programming; and, those peers trained by Anna almost 2 years ago still glow when they talk about that training and how a prominent physician came to speak to them in a new way---a way that recognized their abilities to help their own community.
The progress, the hope, the health and happiness that community asset programming promotes is so worth struggling for. Equally, people who work so hard in this challenging environment, to me, especially deserve human satisfaction from their efforts. I hope so much that everyone, as we go forward, will know the extraordinary satisfaction that community asset programming brings to all involved.
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