In this video posted by Hospitals and Health Networks Daily, Brian Castrucci of the de Beaumont Foundation explains why it’s more important than ever for hospital leaders and public health departments to work together. “Public health and hospitals need to come together to treat diseases that have origins well beyond clinical walls,” he says, “We’re not going to improve health outcomes if we don’t tackle the origins of disease.”
Health care in America is designed to manage the consequences rather than the causes of disease. It has created expensive solutions for those who are already sick. Nearly all of our health care spending ($3 trillion spent in 2014 in the United States) goes to direct medical care for genetic and medical issues.
However, 70 percent of what makes us sick — the cause of our health care problems — can be attributed to the influence of social, physical, and economic environments on health behaviors. This includes where you live, whether you have a job, whether you have access to fresh fruits and vegetables, how much money you make, issues of race/ethnicity, stress, and more.
Our consequences-based approach to health care will lead to a lifetime of medication, countless doctor visits, and the need for surgery and other costly interventions for those who are chronically ill. It has created communities where there is better access to MRIs than fresh fruits and vegetables and more urgent care facilities than places for free or low-cost physical activity, like parks and recreation centers. The United States spends more than any other country on treating sick patients, but when it comes to spending on the social services that would address the actual causes of disease, the United States ranks dead last. Why are we choosing to wait until people are sick? Why are we not tackling disease at its source? We need to focus on the causes of disease; we need to prioritize prevention.
The change we need will be BOLD and INNOVATIVE — we need to transform our medicalized culture, where everything is viewed as a condition or disease that can be addressed with the newest pill or medical treatment. Instead, we must learn to focus on the causes of disease, many of which are social and environmental — often referred to as the “UPSTREAM“ causes of disease. It will start at the LOCAL level, where action and change have the greatest chance of success, and it will leverage the incredible increase in the availability of electronic DATA — health data and other sources — to target resources effectively and measure impact.
No single organization or even one sector can make much of an impact on some of our most challenging social problems acting in isolation. It will require multisectoral partnerships. The BUILD Health Challenge seeks to increase the number and effectiveness of hospital, community, and local health department collaborations.
Hospitals, community leaders, and local health departments each bring unique but complementary resources, perspectives, and expertise to the collaboration. Hospitals and health systems can contribute not only financial resources but also their expertise, other existing resources, and health data that can shape interventions that extend beyond the hospital to the community. Local health departments are trained to identify public health concerns, intervene with evidence-based practices, and often are able to change regulations or policies that can help improve a community’s health. Nonprofit community-based organizations often have the best understanding of the challenges, priorities, and goals of affected communities as well as the solutions most likely to be embraced and sustained.
Each will need to re-imagine their individual missions, how they share data and resources, and how they partner in new and creative ways to improve community health.
The BUILD Health Challenge will identify promising partnerships and projects, nurture them with intensive expert assistance, and begin to identify the necessary pathways to mediate the root causes of disease and improve health outcomes. It creates an opportunity to test new models grounded in creative, collaborative thinking about what can be done in communities to improve health. These projects won’t have to focus specifically on health care, but they will need to tackle broad, systems-level issues like education, access to fresh food, and improving early childhood.
In the United States, we have made a long-term commitment of time and resources to managing the consequences of disease with no real plan to address the actual causes. As a result, we find ourselves in an unending cycle where our best technological, educational, and pharmacological innovations and advances are used to manage new consequences.
The BUILD Health Challenge is a step forward in breaking this cycle. It is an important part of a broader movement that seeks to reset a health care paradigm that has evolved over centuries. If we succeed, we will change from a nation obsessed with health care and managing the consequences of disease to one obsessed with tackling the real causes of disease leading to improvements in population and community health.
This post originally appeared in the Huffington Post on Dec. 5, 2014, and was updated Dec. 6, 2017.
The Advisory Board Company, de Beaumont Foundation, Kresge Foundation, and Robert Wood Johnson Foundation have announced the launch of the BUILD Health Challenge. The BUILD Health Challenge will identify and support health partnerships taking BOLD, UPSTREAM, INTEGRATED, LOCAL, and DATA-DRIVEN approaches to improving health in low-income, urban communities.
Unlike many population health initiatives, BUILD Health Challenge requires awardees to take a multi-sectoral approach, including at least one hospital or health system, the local health department, and a nonprofit organization (or coalition of local non-profits) in an equal partnership. The program evolved out of a wealth of research demonstrating that up to 70 percent of an individual’s health is determined by the interplay of physical, social, and economic environments, rather than health care and genetics.
“Community conditions such as safe streets, affordable housing and economic opportunity play a powerful role in shaping health. Improving these community conditions will require cross-sector partnerships that share resources, responsibility and data in new ways,” said Chris Kabel, Senior Program Officer at Kresge. “BUILD Health will support such partnerships that focus their work in low-income, urban neighborhoods that are ready to create or enhance health-supporting resources and conditions.”
The BUILD Health Challenge will support up to fourteen partnerships in multiple phases of development through differentiated planning and implementation grants. Project plans must be focused on low-income, urban neighborhoods, but the funds may be used to support a range of activities including investments in technology, staff expansion, advocacy, and more.
“Primary care, public health, and nonprofits – not to mention the private sector – have been operating in their own silos for too long, and the result has been decades of one-off projects, some of which are successful, and some of which are not,” said Brian Castrucci, Chief Program and Strategy Officer at the de Beaumont Foundation. “This is a coordinated, collaborative effort to develop tested models for population health improvement that can be brought to scale. If BUILD succeeds, we will change the way that medicine, public health, and the community interact, leading to better outcomes.”
The need for BUILD Health has never been more pressing, as many cities, regions and states are experimenting with new methods to achieve better population health outcomes at lower costs. The BUILD Health partners aim to identify and accelerate the most promising models of collaboration that will promote health equity, reduce per capita health spending, share data and responsibility, and shift resources upstream.
“Today, hospitals and health systems are increasingly adopting a team-based approach to partner with patients to better manage their own health,” said Robert Musslewhite, Chairman and CEO, The Advisory Board Company. “To have the greatest impact on community health, this team concept must expand beyond providers to include other key players in our communities. I am excited for the BUILD Health Challenge to encourage these partnerships, to drive innovation in care coordination, and to measurably improve the health of our communities.”
“We know that in order to successfully address today’s most pressing health challenges, we need leadership from across sectors working together on sustainable long-term solutions,” said Abbey K. Cofsky, senior program officer at the Robert Wood Johnson Foundation. “We look forward to seeing the ways in which the BUILD Health Challenge will help spur this type of leadership and foster a culture of health in communities across the nation.”
The Ebola epidemic — like SARS, MERS, and H1N1 before it — shines a sudden and intense spotlight on the public health system. From our highest ranking government officials to the frontline workers who are responsible for disinfecting homes and interviewing contacts, every decision, action, and outcome is scrutinized and criticized. Under normal circumstances, the public health system is working to ensure that the places we live, work, and play are safe and that we are generally free to go about our lives without worrying that we’ll get sick from the food we eat or the water we drink.
When there is an infectious disease outbreak like Ebola, the narrative of fear overtakes the media and many of our political leaders. As criticism of the Centers for Disease Control and Prevention intensifies and impulsive and irrational solutions like a travel ban from West Africa are proposed, we are ignoring the true danger to the American people: our thinly stretched, overburdened public health system.
Most people don’t realize that there is no minimum national standard for state or local health departments. The public health workforce that you will be relying on in the case of a deadly outbreak is inconsistently and unequally funded, staffed, and trained. Without such standards, public health systems not only vary from state to state, but city to city.
Your city might have an excellent infectious disease program — or it might not. Your state might be ahead of the game in training health care workers to handle highly contagious individuals — or it might not. Even if your community has all the protections it needs, what about the next county over? Where we live may not be where we work and play. In an outbreak, diseases don’t respect city or county lines. That’s why the health of your own community is intrinsically tied to the strength of public health services in surrounding communities.
We are going to manage this current outbreak. Long term, however, we need more significant fixes to ensure the safety of all Americans against possibly more challenging outbreaks.
Simply put, we need a public health system in which all Americans are guaranteed basic public health protections regardless of where they live. To achieve this goal, the Institute of Medicine outlined a minimum package of services that would establish baseline standards for core public health functions like disease control, emergency preparedness, and environmental health protections, among others.
Another strategy to bring consistency to our nation’s public health system is the movement for health department accreditation. Health department accreditation creates a baseline level of access, professional standards, and accountability on which citizens can depend regardless of where they live. The national Public Health Accreditation Board (PHAB) accredited its first eleven health departments in 2013 and increased that number to 54 by September 2014. Both strategies will require funding and the political will to see it through as we prepare not just for the crises we face today, but for the unknown challenges that await us.
Our nation’s current underinvestment in public health places us all in jeopardy.
Whenever there is an outbreak, there is political and public outcry that dies out as soon as it is controlled. We have the great privilege of living largely free of fear from infectious disease, but it comes at a cost — investment in and ongoing support for the public health system.
There is increasingly talk about moving “upstream” to improve health and reduce health care costs, e.g., working to prevent disease before it happens by addressing the social and environmental determinants of health.
Among those championing this upstream approach is Rishi Manchanda, MD, In his TED book, The Upstream Doctors, Manchanda argues for more “upstreamists” — physicians who see their work as including a “duty not only to prescribe a clinical remedy but to tackle sickness at its source.”
As an example of upstream medicine in practice, Manchanda recounts the story of a former patient, Veronica, who suffered from severe chronic headaches. Her interaction with the health care system had resulted in inconclusive medical tests and an expensive visit to the emergency room, but no answers as to the cause of her headaches, let alone a solution.
Manchanda took a different approach.
He used a questionnaire to identify risk factors in her daily life and discovered that Veronica was exposed to mold and cockroach allergens that could be the cause of her health issues. Instead of subjecting her to more medical tests, she was referred to a tenants’ rights group and received a follow up visit from a community health worker from his practice. In three months, Veronica was feeling better and her headaches subsided.
Moving Beyond the Individual Patient
Veronica’s story illustrates how clinicians can effectively address the social determinants of health by using tools that assess a patient’s community and environmental circumstances, as well as by including non-medical providers as part of a health care team. This approach is a necessary evolution in the practice of medicine that will improve patient care.
But that’s not the whole story.
Even if clinicians address the social factors that contribute to a patient’s poor health, they are still working at the individual level, treating disease person by person. “Upstream” clinicians can be more effective if they partner with the existing, very capable governmental public health system.
Extending the health care team to include nurse practitioners, physician assistants, and other non-clinical staff including benefits counselors, behavioral and mental health counselors, community health workers, and pharmacy technicians brings value to the individual patient. A partnership with the public health department, on the other hand, allows us to improve health for the whole community.
If the local public health department had been involved in Manchanda’s practice, many more than just Veronica could have benefited.
Coordinated Surveillance and Investigation
Veronica’s story represents one snapshot of life within a large, thriving, complex community. This individual information has tremendous potential to tell us about the community and its health if it can be aggregated across individual medical practices and health care systems.
Sharing these data with public health officials allows for analysis at the community level and can identify places where several individuals have the same problem. When disease clusters are identified, public health departments have experts trained in disease investigation that can pinpoint social and environmental risk factors and then develop strategies tailored to reduce the incidence and complexity of disease.
If health care providers in a community had been sharing information about patients with the local health department, public health officials might have found that Veronica was not alone and many others were experiencing similar health concerns. The public health department could then gather information about where these people were living, potential environmental triggers, the frequency of tenant complaints filed with the local housing authority, and other variables that could help us understand the cause of this common health issue.
Community-Level Strategies and Actions
When a health issue is caused by a shared social or environmental factor, the local health department can act at a community level. For example, local health departments can engage local media to raise awareness of the problem or develop public education campaigns. If you have ever seen a public service announcement about wearing a seat belt, washing your hands to prevent flu, or vaccinating against disease, you probably have your public health department to thank.
These public health messages can have an even greater impact when they are tailored to specific neighborhoods and coordinated with health care providers. As a government agency, the local health department has regulatory and statutory options, which it can leverage to change health policies and promote regulations that directly address the root causes of disease.
In Veronica’s case, involving the local health department may have led to every rental property owner in the city receiving a letter reiterating their responsibilities as landlords. The local health department could have engaged the local housing authority to improve the oversight, monitoring, and enforcement of existing regulations or determine if new regulations were needed to improve housing conditions. In extreme cases, the local public health department could condemn buildings or revoke a property owner’s ability to rent a property.
Effectively Tackling Upstream Health Issues Requires Public Health Departments
Medicine alone cannot fix problems that are rooted in social and environmental determinants of health.
The Upstream Doctors presents a vision for clinical medicine that recognizes that treating disease is not enough. Manchanda’s perspective on upstream health issues is a step forward in transforming how we see and respond to issues of health and disease in our communities, but the local health department should be included as a partner that is skilled in addressing the social determinants of disease and capable of community-level action.
Today’s health care problems are rooted in individual health choices shaped by the many contexts in which people live. Medicine and public health simply cannot afford to continue to work in their separate silos. Public health and primary care professionals must start to see their work as components of an integrated health system if we are to improve health across the board, from clinic to community.
In The Upstream Doctors, Manchanda retells an oft-cited parable of three friends who see children drowning in a river. Two rush into the water to save the children. The third friend swims upstream, acting to “stop whoever or whatever is throwing these children in the water.”
Here’s a different spin to this story. What if that third friend recalled meeting the people who lived upstream and called them? With that phone call, they quickly take action to find and stop the problem at its source.
Both upstreaming solutions work, but isn’t it more effective to communicate with each other and align our resources rather than starting a series of long, upstream swims?