Health Goes Beyond Healthcare at Inaugural Conference

First Annual “Health And…” Conference Brings Together Education, Housing, and Healthcare Sectors To Achieve Shared Goals

Tuesday, April 19 2016

Most of us spend only a fraction of our time visiting a doctor or going to the hospital, and it is estimated that only 10-20 percent of our health is determined by medical treatment. Many other factors, like where we live, where we work or go to school, and whether we have access to parks, transportation, and healthy food contribute greatly to our health. These connections are supported by increasingly powerful research, sometimes drawing on vast troves of data, that demonstrates more convincingly than ever the impact of “social determinants” on health.

In the age of modern medicine, healthcare has focused on what can be done in the clinical setting, not in neighborhoods. However, that is beginning to change. Recent health policies, including the Affordable Care Act and state-level efforts, are creating stronger payment incentives for healthcare to begin to broaden its reach, requiring non-profit hospitals to put forward community health improvement plans and turning healthcare systems’ focus towards the health of their patient populations and broader community. 

What does a healthcare system engaged in community health look like? It can mean partnering with community groups to make healthcare more accessible and raise awareness about diseases for which their populations are at high risk. It can mean screening patients for social service needs and linking them directly to community-based resources to mitigate challenges of daily life that can interfere with maintaining good health. And it can even mean recognizing the role of other sectors to achieving health benefits, such as redesigning the urban environment to promote exercise and physical activity, improving access to public transportation, making health food more available and affordable, and addressing “root causes’’ of health and social ills—poor housing, underfunded schools, toxins in the environment, occupational safety and family and sick leave policies.

Recognizing that such a wide-scale focus requires communication between multiple sectors, the Department of Population Health at NYU Langone Medical Center launched a conference series called Health And this spring, focusing the day's agenda on place, education, and healthcare. The goal of the annual conferences is to bring together investigators, policymakers, practitioners and community leaders to better leverage the intersection of health and its many determinants.

The inaugural event focused on understanding the relationship between health and place, education, and healthcare, and the role precision medicine plays in population health.

The conference generated several big ideas and key themes that laid a foundation from which participants can work together in the future:

1. Society and health are inextricably linked. Although quality healthcare and individual health behaviors—smoking, diet, and exercise—are important to health, panelists emphasized that strong social structures are essential to promote health: good schools, a socially cohesive neighborhood, safe and affordable housing, clean air, and parks and bike lanes.

Our environment shapes our health in a myriad of ways. For instance, a study by Mariana Arcaya, ScD, MCP, an assistant professor in the Department of Urban Studies and Planning at MIT, followed women pushed by Hurricane Katrina to leave the Ninth Ward of New Orleans. Those who moved to areas of greater urban sprawl gained more weight, reporting that it was harder to walk in these less pedestrian-friendly towns and cities. Not only does neighborhood influence health, but health status also seems to influence the neighborhoods in which people choose to live, according to Dr. Arcaya. She found in another study that low-income individuals who had a child with health issues were less likely than those in better health to take advantage of a government voucher program to move to more affluent areas.

2. Place matters to health. Highlighting the power of place, a study by JAMA published on the same day as the conference, found that location matters to the life expectancy of low-income Americans. Poorer Americans lived as much as five years longer in more affluent cities like New York and San Francisco than in cities like Detroit and Gary, Indiana. “In many U.S. cities, large areas are cut off from economic centers of growth” and have limited resources, said Steven Woolf, MD, MPH, the conference keynote speaker and director of the Virginia Commonwealth University Center on Society and Health. Diminished access to primary care, insufficient funding for education, inadequate public transportation, racial segregation, and unsafe or unhealthy housing all contribute to poor health, Dr. Woolf wrote in an editorial about the JAMA study, which he discussed at the conference. Poor housing is associated with a wide variety of health risks, including exposure to lead paint, lack of window bars, structural defects, rodents and roaches, and poor ventilation, said Ingrid Gould Ellen, PhD, MPP, the director for Furman Center for Real Estate and Urban Policy, NYU Wagner.

3. There are things we can do early in people’s lives to set them on a healthy trajectory. Poverty and traumatic experiences in early childhood, like exposure to violence, affect how children learn and impact their health, said Laurie Brotman, PhD, professor in the Department of Population Health. Her program, ParentCorps, focuses on bringing together the key adults in children’s lives—parents, teachers, and other school personnel—to train them to impart to their students and children foundational skills for learning and development. Elected officials and policymakers are recognizing the importance of early childhood education, perhaps most notably by enacting universal pre-kindergarten programs. Cybele Raver, PhD, vice provost for research and faculty affairs at NYU pointed out that “pre-school may be one safe space in kids’ life if everything else is going wrong.”

4. Health is a community matter. Many panelists spoke about the importance of recognizing communities' role in promoting health. One way in which healthcare can do this is by going to communities rather than expecting they will come to us. Panelist Joseph Ravenell, MD, MS, assistant professor in the Departments of Population Health and Medicine, spoke about a unique program he launched in NYC. Black men have a disproportionate risk of high blood pressure and colorectal cancer, and are more likely to be uninsured and to hold jobs that do not provide sick time, and less likely to have a primary care provider. Dr. Ravenell’s Men’s Health Initiative visits black men in churches and barbershops to evaluate their risk and link them to care for colorectal cancer or hypertension. “When we place trusted people in trusted places, we actually have a chance to reduce barriers to health,” said Dr. Ravenell. “If we just focus on clinics, we’re going to miss many of the people who need interventions.”

Small primary care practices are another important part of community health, with two million New Yorkers seeing these providers, said panelist Donna Shelley, MD, MPH, associate professor in the Department of Population Health and Medicine. Dr. Shelley leads an initiative funded by the Agency for Healthcare Research and Quality to equip hundreds of small primary practices in New York City with evidence-based tools to prevent heart disease in their patients. These practices are often tightly integrated into communities, and the patients are "like family" according to one small provider with whom Dr. Shelley's program, called HealthyHearts NYC works . Morevoer, being a patient at a smaller primary practice is actually associated with fewer hospitalizations.

Community health workers or CHWs also may provide a key link between healthcare providers and communities. CHWs are “lay people who share life experiences with the patients they serve” and can help those patients navigate the healthcare system and link them to social services, said panelist Shreya Kangovi, MD, MSHP, executive director of the Penn Center for Community Health Workers at University of Pennsylvania’s Perelman School of Medicine. She said that CHWs and clinicians should integrate their efforts, and called for innovative research in this area to optimize the design and return on investment of this promising model.

5. The healthcare sector does not always need to lead to participate in multi-sector efforts. The healthcare sector does not have to lead all health-related efforts with communities but rather can serve convening function and have a seat at the table. In fact, many different groups have expertise to offer, said panelists. “It’s a scary burden to put onto healthcare—responsibility for dealing with social problems, for dealing with factors outside control of healthcare system,” said Dr. Woolf. He advised participants “not to think about how community gets engaged in healthcare…but how healthcare can get involved in what communities are doing.”

6. There is a need to evaluate how healthcare resources are allocated. Participants said that if community organizations are seen as a linchpin to getting good health, they will need to receive more funding, infrastructure, and other support since many of them are overburdened and underfunded and understaffed. Some participants called for a reexamination of the priorities of government funders. In a discussion about the President’s precision medicine initiative, Sandro Galea, MD, DrPH, dean of the Boston University School of Public Health, said a precision approach that focuses on individual treatment and biological research has not been moving us forward, pointing out that Americans’ health is the lowest among wealthy countries.

The good news is that new federal investment is specifically focusing on integrating attention to social determinants of health into healthcare settings. The Center for Medicare and Medicaid Innovation (CMMI) under the Centers for Medicare and Medicaid Services are launching accountable care communities. CMMI will allocate $157 million to 44 sites designated as accountable care communities across the country. These "ACCs" will screen all Medicare and Medicaid beneficiaries to identify unmet health-related social service needs, to test the effectiveness of community services navigation and referrals, and to support community-wide quality improvement programs, said Dawn Alley, PhD, deputy director of the Preventive and Population Health Care Models Group at the CMMI. She called this: “lifting up our gaze a bit from the clinical encounter and thinking about collective impact.”

7. Think about the whole picture, and evaluate programs using holistic measures. Although the healthcare, education, housing, and other sectors working in this space may have different goals, they are all addressing the same root cause issues, Dr. Woolf said. To evaluate cross-sector programs, “measurement can be a unifier,” said Marc Gourevitch, MD, MPH, chair of the Department of Population Health. Researchers could develop and measure themselves by “holistic” indexes to measure “well-being” or “quality-of-life,” he added. 

Additionally, healthcare providers, researchers, and public health officials tend to get excited about improving health, but this may not be a central priority of people in other sectors or of many Americans. As Dr. Woolf pointed out, “Americans don’t really talk about wanting better health; their priority is to live a good life.” This may mean framing good health not as the central achievable goal, but rather as part of a holistic approach of addressing root causes of social inequity like income and opportunity. Closing the day, Dr. Gourevitch said, "We must strike a balance between being holistic in our approach and leveraging our particular expertise in health and healthcare to advance population health and health equity."

--by Elaine Meyer

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