U.S. Is Many Different Communities When it Comes to Health

The following excerpt comes from the November 1, 2017, article by Sternberg in US News and World Report.


The jigsaw puzzle of U.S. counties fits neatly together into a pleasing whole, displaying America as a land of many parts.

Within those parts, people in adjacent communities may have similar lifestyles and incomes. They may eat similar foods, enjoy the same music, picnic in the same parks and vacation at the same campgrounds or beaches.

But look more closely and you’ll find people living in neighboring communities often live very different lives. Residents in one county may suffer many more days of poor physical or mental health – or both – than those in the county next door. People in many communities even live longer than those in communities nearby, a pattern that extends nationwide.

Which is why community health assessments – including a new U.S. News ranking of the nation’s Healthiest Communities, to debut in March – are so valuable for identifying trouble spots and targeting remedies to where they’ll do the most good.

Think of them as diagnostic scans of what ails America, from soaring rates of obesity, hypertension, and diabetes to pervasive mental health problems and opioid abuse. The overlapping epidemics are having a profound impact nationwide. For the first time in nearly a century, life expectancy has begun to decline in major population groups, and not just in poor underprivileged neighborhoods. Death rates rose for white men, white women, and black men, and remained essentially unchanged for black women and Hispanic men and women.

“This is the first time we’ve really seen fairly marked decreases in life expectancy in key groups and not simply the socially disadvantaged,” says Dr. William Stead, chief strategy officer at Vanderbilt University Medical Center and McKesson Foundation professor of biomedical informatics.

In most measures of population health, the world’s richest country lags behind other developed countries, despite trillions spent each year on medical care.

“Waves of chronic disease are reaching historic rates,” says Tyler Norris, chief executive of the Well Being Trust, a $100-million nonprofit funded by Providence St. Joseph Health to help improve the nation’s mental and physical health. Chronic diseases not only reduce productivity, he says, they have driven health care costs so high that they are “unaffordable no matter who you are.”

Eighty percent of the growth in Medicare spending – now totaling nearly $650 billion a year – is due to chronic disease, says Kenneth Thorpe, of the Rollins School of Public Health at Emory University and chairman of the Partnership for Chronic Disease.

Tragically, this chronic-disease epidemic of diabetes, hypertension, heart disease, stroke, arthritis and other ailments is occurring against the backdrop of a revolution in medical care, one that ushered in countless innovations including antibiotics, blockbuster drugs, high-tech surgery and genetic medicine.

The roots of the problem run deep, anchored in national neglect of festering social problems and each community’s history, culture, economy, schools, hospitals, neighborhoods and sense of place. These so-called social determinants offer a way of assessing community health. They show that poor health and other social problems are more heavily concentrated in some neighborhoods than others, variations that may not be apparent when examined at the national or state levels.
Read the full article.

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Food Security, Social Determinants of Health Lower Hospital Use

The following excerpt comes from the November 1, 2017, article by  Sara Heath on Patient EngagementHIT.


Implementing public programs to supplement food security in low-income patients can help reduce hospital use within that population, according to a study published in both BMC Geriatrics and Population Health Management. This data suggests that addressing the social determinants of health can directly improve health outcomes.

Currently, nearly one-third of senior patients live on income less than 200 percent of the poverty line, a fact which the Maryland-based research team said impacts that healthcare industry. Low-income patients have a higher propensity for utilizing hospitals and the emergency department.

Previous efforts to meet health needs include expanding access to primary care, but researchers added that caring for social needs is also essential for health improvement.

“Excess hospital utilization in this population was once believed to be preventable by improving health care access,” the research team said. “However, disparities exist among older adults who have health insurance through Medicare, and are not attributable to access to primary care providers.”

Previous research has suggested that 85 percent of patient health is determined by the social determinants of health, as opposed to genetic makeup or other health-related factors such as healthcare access.

The social determinants of health include social factors like housing, education level, and food security, among others.

The Supplemental Nutrition Assistance Program (SNAP) is one such program suitable for addressing food security. The federally-funded program has proven effective in expanding food access for low-income individuals, and shown that food access may be tied to health outcomes, the team posited.

“By targeting financial support toward food needs, SNAP can improve access to a higher quality diet for food insecure adults,” the researchers explained.

“There is evidence of reduced caloric intake, poorer dietary quality, and greater risk of hypoglycemia for low-income adults at the end of the month when funds run low,” the research team continued. “Therefore, greater SNAP benefits may facilitate chronic disease management for nutrition-sensitive conditions, which may account for evidence of reduced chronic disease hospital utilization.”

The team looked at nearly 6,900 patients over the age of 65 who were dually eligible for Medicare and Medicaid between 2009 and 2012. Matching data about days spent in the hospital, healthcare costs, and emergency department visits with SNAP enrollment data showed that the program has an impact on healthcare.

SNAP benefits reduced the likelihood for hospitalization by 14 percent, and reduced the likelihood of each individual day in the hospital by 10 percent.

The program also reduced the likelihood of nursing home admissions by 23 percent, and reduced each additional day in the nursing home by 8 percent.

SNAP benefits had no statistically significant effect on ED utilization, but the researchers maintained that the results nonetheless showed great potential for SNAP in healthcare.

Specifically, the results proved that more than just increasing access to care can help reduce hospital and ED utilization.

“It is notable that all had access to both Medicare and Medicaid because policy makers have increased access to health care for low-income groups thinking that that alone would reduce high hospital utilization in low-income groups,” the researchers pointed out.

Read the full article.

 

Thinking about the Social Determinants of Health

Dr Crook EditedAt the end of November 2017, Dr. Errol Crook, Director of the Center for Healthy Communities and the Abraham Mitchell Chair of Internal Medicine at the USA College of Medicine, gave a presentation during Internal Medicine Grand Rounds on “The Social Determinants of Health: A Focus on Poverty.” Dr. Crook started by saying that he wanted to talk more about public health than focusing on one patient. Through the presentation, he explored:

  • Health equity and health disparities
  • Discussed socio-cultural determinants of health in the U.S. (and the world)
  • Reviewed the impact of poverty on health
  • Examined the importance of understanding how social factors may impact care of individual patients

Poverty in contextIn the discussion on poverty, Dr. Crook explained the importance of context and understanding that

  • Having an income does not remove the risk of poverty
  • Wealth and income are different as a person may have income but not the accumulated wealth to cover emergency expenses such as unforeseen health issues
  • People living in poverty usually work many hours and many jobs.

In other words, for people living in poverty or near it, health care and education costs are discretionary expenses. They have to decide between buying medication or seeking care and paying for gas to get to work.

With that background, he introduced two projects from the Center for Healthy Communities. First, The Impact of Labor Force/Labor Market Status On Access To Health Care with Dr. Kenneth Hudson as Principal Investigator explored the relationship between job types (good job, mediocre job, or bad job) and health. The study looked at a random sample of households in census tracts in Mobile, AL, with at least 50% of residents living at or below the federal poverty line. Dr. Hudson and his team found that

  • 91.5% of respondents were working
  • The majority of respondents were in bad jobs — those without health or retirement benefits and paying poverty wages
  • The participants spent a large percentage of income on basics such as rent and utilities
  • For those who did not acquire a job with health insurance or retirement benefits before the age of the 30, the most likely never would.

Dr. Crook also talked about the importance of data from The Sentinel Surveillance to Monitor Progress Towards Health Equity with Dr. Martha Arrieta as Principal Investigator. Given the difficulty of obtaining good information on the health status of individuals living in low-resource areas, the project used a sentinel surveillance approach to choose data collection sites that intersected with the daily lives of residents in three high poverty zip codes in Mobile, AL. The research produced a lot of information on the number of people below the age of 65 reporting having chronic diseases such as diabetes and high blood pressure. Dr. Crook emphasized that 68% of those responding to the survey felt that diabetes would result in severe complications regardless of what treatment or lifestyle changes a person underwent.

Dr. Crook closed his presentation by drawing together the threads of social factors, income and wealth disparities, employment status, and attitudes toward health into a single pattern focused on an individual patient and her health needs. He asked those attending to think about the patient’s future prospects based on what her educational and socio-economic status were. He encouraged those working in the clinics to think about these issues as they worked with individuals.

View Dr. Crook’s presentation online.

Why insurance really is a life or death issue, especially for minorities

The following excerpt comes from the article by Dr. Valerie Montgomery Rice posted on CNN on October 19,2017.


The study released this week by the American Cancer Society highlighted the significant role health insurance plays in the widening chasm of disparities in breast cancer mortality.

Progress on this front has been made. The Affordable Care Act (ACA) has resulted in the lowest uninsured rate ever recorded in our nation’s history: 8.8% down from 16% in 2009 before the ACA was signed into law, according to the Council for Economic Advisers and National Center for Health Statistics. It has provided life-saving preventive and diagnostic screenings, access to higher quality care and appropriate treatments, as well as increased opportunities for diverse women to participate in clinical trials.

As we recognize National Breast Cancer Awareness Month this month and continue the national debate over health reform, it is worth noting the impact that a lack of health insurance coverage has on women reaching their optimal level of health or health equity.

I began my medical career as an obstetrics and gynecology resident in the late 1980s at Atlanta’s Grady Memorial Hospital. Emergency rooms in hospitals such as Grady were a last resort for uninsured patients who, in many cases, struggled with undiagnosed cancer, high-risk pregnancies, heart disease, diabetes and other life-threatening diseases.

The disparities in coverage and access to quality care for patients whose cards were stacked against them were striking, especially for women battling breast cancer, which is the most common cancer among women in the United States and is the second leading cause of cancer deaths.

While a host of factors increase women’s risk for breast cancer, such as genetics, age, sex and race, studies show that these factors are exacerbated for underserved communities, black women in particular, where the disease can be a catastrophic difference between life and death.

Mammogram screening is universally accepted as the best weapon for early breast cancer detection. Covered by the ACA as a preventive service at no cost to the consumer, mammogram screenings are the first line of defense. With the elimination of cost we expected an increase in mammograms, particularly among minority women. We hoped it would lead to a decrease in racial/ethnic disparities in breast cancer. And now many studies have confirmed the ethnic gap narrowed between women who received screening prior to ACA, and after.

Why does this matter? If we know that early detection is the key to lowering breast cancer mortality rates among all women, then access to appropriate screenings, early treatment and counseling should be considered the standard of care.

Read the full article.

5 Things About the Importance of Addressing Social Determinants of Health

The following excerpt comes from the article by Laura Joszt that first appeared on AJMC.com on October 13, 2017.


More and more, physicians and other health providers are realizing that they cannot be responsible for just what happens inside the 4 walls of their clinic. The lives people live every day for the rest of the year have a profound impact on their health. Social determinants are the factors that contribute to a person’s health, such as where they live and work, their housing situation, and their access to healthy food.

Here are 5 reasons more people are paying attention to addressing social determinants of health.

  1. Holistic care

The United States spends more per capita on healthcare than any other developed nation and has no better outcomes. Other countries in the Organization for Economic Co-operation and Development spend more on social care than healthcare. Research has shown that higher social spending improves outcomes in conditions like obesity, asthma, mental illness, and type 2 diabetes.

  1. Food insecurity

A recent study in JAMA Internal Medicine found that addressing food insecurity was associated with significantly lower healthcare expenditures. The study looked at participation in the Supplemental Nutrition Assistance Program (SNAP), which serves 1 in 7 Americans and helps them buy food for their house.

  1. Community partnerships

With so much of a person’s life taking place outside of the health provider’s reach, community partnerships are key to ensure that once patients leave the doctor’s office, they have resources at hand to help.

  1. Focusing on education

Some public interventions focus on education because children receiving quality education are less likely to engage in risky or unhealthy behaviors. In the 1960s, the Perry Preschool Project in Michigan showed that disadvantaged 3- and 4-year-olds who received high-quality preschool education were less likely to smoke or abuse drugs or other substances. In addition, those children grew up to have a higher education, income, and health insurance coverage.

  1. Additional investment needed

Significant investments need to be made into interventions that address social determinants of health in order to make a difference. But, the investment is worth it, according to speakers at the 2016 annual meeting of America’s Health Insurance Plans.
Read the full article.

Hospitals and the Social Determinants of Health

Recently, the American Hospital Association (AHA) released a one-page strategic document for its members to use in understanding and addressing the social determinants of health (SDOH). The document – Emerging Strategies to Ensure Health Care Services: Addressing Social Determinants of Health — provides three general strategies hospitals can use, briefly defines the SDOH, and discusses policy options that could assist hospitals in making a difference in community health.

The new guide was developed as one of several resources outlining various SDOH and how hospitals can respond. Currently, the series includes Housing and Food Insecurity with others planned for development.

Learn more about Community Health Initiatives from the AHA.

Why Medicaid Is The Platform Best Suited For Addressing Both Health Care And Social Needs

The following excerpt comes from the article by Katharine Witgert published September 7, 2017 on the Health Affairs Blog.


...The Medicaid program provides a plausible platform upon which to build a health infrastructure that incorporates the social determinants of health. Medicaid could provide a common entry point that links individuals and families not just to health care services, but also to social services that affect their health. Indeed, state Medicaid leaders have long embraced this concept and are experienced in building bridges that link health and social programs to meet the comprehensive needs of their citizens.

Where Medicaid Leads In Addressing Social Determinants

Medicaid programs have long been leaders in addressing social determinants of health. A range of innovations for incorporating social determinants of health have been tested in Medicaid programs across the country. State Medicaid programs make referrals to social services, directly connect individuals to needed services, align systems to share goals, and invest future savings to the health care system into social services programs. For example:

  • In Pennsylvania, the online health and human services programs eligibility system known as COMPASS allows individuals and families to simultaneously apply for Medicaid, the Children’s Health Insurance Program (CHIP), and the health insurance marketplace, together with programs that administer food stamps, school lunches, child care assistance, and other benefits. There is evidence from a range of social programs that transaction costs—the difficulty of applying—significantly influence take-up rates. Single applications can facilitate access.
  • Colorado’s Medicaid program divides the state into seven Regional Care Collaborative Organizations, each of which connects beneficiaries to health care providers as well as social and community services. The goal is to link every beneficiary with a primary care provider who not only serves as a central point of contact for medical care, but also assesses a person’s nonmedical needs.
  • Louisiana, meanwhile, has embedded permanent supportive housing into Medicaid home- and community-based services, allowing for better integrated care for individuals who are homeless or at risk of homelessness.
  • Recognizing the mutually reinforcing roles of health and education—health status influences a child’s ability to learn, for instance—Oregon began aligning its health care and early education systems around 2011. The Medicaid program and early learning systems share goals, staffing, and funding.

Additionally, Massachusetts, New York, Oregon, Utah, and Vermont are all testing strategies not only to link Medicaid and social services, but also to use Medicaid funds to actually deliver supportive services that affect social determinants of health. These value-based delivery system reforms include the creation of accountable care organizations, health homes, community health teams, and accountable communities for health.

Most recently, the Centers for Medicare and Medicaid Services (CMS) launched an initiative called Accountable Health Communities to better manage the health-related social needs of Medicare and Medicaid enrollees. The initiative will test whether systematically identifying and addressing the social determinants of health through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. Over the next five years, the model will provide support to community organizations that link enrollees to services that address housing instability, food insecurity, utility needs, interpersonal violence, and transportation needs. As CMS begins to test this model, there is reason for optimism, given Medicaid’s track record of integrating health care and social services.

Read the full article.

Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference?

The following excerpt comes from the Issue Brief written by Susan L. Hayes, Pamela Riley, David Radley, and Douglas McCarthy.  It was originally posted to the Commonwealth Fund website on August 24, 2017.


Historically, in the United States, there has been a wide gulf between whites and members of minority groups in terms of health insurance coverage and access. Proponents of the Affordable Care Act (ACA) hoped that law’s major insurance coverage expansions and reforms would begin to bridge those gaps.

Evidence suggests that uninsured rates have declined among blacks and Hispanics under the ACA, but have these coverage gains reduced disparities between whites and ethnic and racial minorities? This brief seeks to answer that question and to examine if disparities in access to coverage and care are different in states that expanded Medicaid and states that did not.

We compared national averages between 2013 and 2015 for white, black, and Hispanic adults on three key measures of health care access to determine the effect of the ACA’s major coverage expansions on disparities:

  • the share of uninsured working-age adults ages 19 to 64
  • the share of adults age 18 and older who went without care because of costs in the past year
  • the share of adults age 18 and older without a usual source of care.

These measures align with those reported in the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition.

Additionally, we sought to determine if there were differences in disparities in states that chose to expand their Medicaid programs under the ACA and states that did not. For each indicator, we calculated the average rate for white, black, and Hispanic individuals in 2013 and in 2015 in two groups of states: the group of 27 states that, along with the District of Columbia, expanded their Medicaid programs under the ACA between January 1, 2014, and January 1, 2015, and the group of 23 states that had not expanded Medicaid as of that time.

As the current administration and Congress weigh how to move forward after the recent failed attempt to repeal and replace the ACA, it is useful to examine how successful the law has been in making health care available to racial and ethnic groups that have historically been left out.

Findings include:

  • Racial and Ethnic Disparities in Adult Uninsured Rates Narrowed After the ACA’s Major Coverage Expansions
  • Racial and Ethnic Disparities in Rates of Adults Who Went Without Care Because of Costs Narrowed After the ACA’s Major Coverage Expansions
  • Racial and Ethnic Disparities in Rates of Adults Without a Usual Source of Care Narrowed After the ACA’s Major Coverage Expansions
  • Disparities Between Hispanic and White Adult Uninsured Rates in Medicaid Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Black and White Adult Uninsured Rates in Medicaid Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Hispanic and White Adults Who Went Without Care Because of Costs in Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Black and White Adults Who Went Without Care Because of Costs in Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Hispanic and White Adults Without a Usual Source of Care in Medicaid Expansion States vs. Nonexpansion States, 2013–2015

Download the full issue brief.

2017 CHA Led Projects: Reaching the Community to Improve Health

This June, five Community Health Advocates(CHAs), submitted applications to the Center for Healthy Communities to implement short term, limited scope community projects addressing nutrition, health literacy, family health, and mental health. These projects are:

Nutrition through Gardening: CHA Lead, Sheena Billingsley
Starting in July, Sheena and her partners planned four health and nutrition awareness events at community gardens in the area. These events focused on educating community members on healthy eating and healthy living. Each consisted of

  • Hands on gardening activities
  • Healthy cooking demonstrations
  • Sustainable gardening techniques
  • Conversations with volunteer health professionals

As an incentive for participation, participants received personal growing space in the community garden located in their zip code.

Community Garden at Ridge Manor: CHA Lead, Frewin Osteen
The goal of this project is to increase and enhance home-based and community centered gardening though the construction of a Hoop House to demonstrate the feasibility of a new gardening method suited to small, protected areas.

Smart Grocery Shopping Workshop: CHA Lead, Barbara Hodnett
Through this workshop which was held in June, Ms. Hodnett offered an educational program designed to help participants develop shopping skills to save money while buying healthy foods. The workshop topics included:

  • Learning the typical layout of a grocery store
  • Arranging your pantry and food storage areas to maximize healthy choices
  • Reading labels to determine whether a product is a sound nutritional choice
  • Creating a healthy weekly meal plan

Workshop participants also participated in a walking field trip to practice applying the information they had learned.

Hearts to HEAL (Health Education and Literacy): CHA Lead, Porsche Blount
This five-day summer enrichment program aims to improve the health knowledge and literacy, reduce associated stigmas, improve self-self esteem, and help to create a positive self-image among adolescent girls aged 12 to 18. The topics addressed in the program are

  • Health literacy
  • Nutrition
  • Family Health
  • Mental Health

A pre/post test design will be used to measure the knowledge gained by participants in the program. Also, the final day of the enrichment experience will be an opportunity for the girls to give presentations about what they have learned.

Black Mental Health Matters: CHA Lead,  Zionne Williams
Through this two part project, Zionne and her partners hope to “break the stigma associated with mental health in minority communities and to bring much-needed awareness to the issues associated with mental health.” Part one of the project consists of a family-friendly community event to raise awareness of the importance of recognizing when someone may need help and how to connect those in need with the correct resource. The event included fun kid’s activities, food and entertainment, and presentations from mental health professionals.

The second part of the project is the development of a mental health awareness campaign through an online platform to promote health literacy, create an open dialogue with the community, and encourage potentially affected individuals to seek and complete treatment. To accomplish the goal, individuals will be invited to share their personal stories through visual, written and audio documentation that will be shared online.

These CHA led projects provide an important mechanism for the Center for Healthy Communities to support the CHAs in applying the knowledge they gain through CHC supported trainings to target health issues that are of greatest concern to them.  Through these projects they provide information in culturally relevant formats to improve the health of their neighbors.

Learn more about the CHA program.

I Had to ‘Unlearn’ Medicine to Treat Vulnerable Patients

The following excerpt comes from an August 14, 2017, posting written by Anita Ravi in the Fresh Perspectives: New Docs in Practice section of the AAFP website.


Two years ago, I started the PurpLE (Purpose: Listen & Engage) Clinic at the Institute for Family Health, a federally qualified health center in New York, N.Y. We offer a health home for people who have been victims of human trafficking and other trauma, and I meet patients of all genders, ages, documentation statuses and backgrounds who are encountering a range of medical issues.   

…. When I prescribed medications such as ibuprofen, reminding people to “avoid taking these on an empty stomach” was reflexive — until last year. A PurpLE Clinic patient seeking asylum after being tortured while living in his native country had an appointment to address ongoing pain related to his injuries. As I was prescribing him an anti-inflammatory medication, I didn’t think twice about saying, “Make sure you take this with food,” until I noticed his blank stare.

Ten minutes earlier, he had told me he had no income and relied on a friend who worked in a restaurant to bring leftovers to eat; sometimes there were none. I realized that what I was actually telling him with my prescription instructions was that I had been hearing but not listening. I needed to unlearn the idea that common medical advice has universal applicability, and instead learn that some prescriptions need their own treatment — such as assisting with food access — to help a patient.  

My assumptions regarding food have been tested in other ways, too. One patient called to let me know she was running late because she had a chance to get food and hadn’t eaten in three days. This was not an uncommon reason for patients to be delayed, so I said I completely understood, envisioning a very specific scenario.

When she arrived that evening, I asked what she had eaten, and she responded, “Nothing,” because she had only “collected $3.83 worth.” This patient was paying for food by collecting cans and bottles to recycle, and she had come up short.

Hunger is frequently addressed during PurpLE Clinic appointments because they are typically on weekends, when there is limited access to assistance such as food pantries.

“When was the last time you ate?” is something physicians ask when we order labs that require fasting. I’ve unlearned the purpose of this question. Having implemented a way to provide point-of-care access to food, I now ask “When was the last time you ate?” to ensure no one leaves the clinic hungry.

As I mentioned, patients at our clinic often come in later than scheduled for many reasons. Life is unpredictable. Some undocumented patients rely on informal networks for jobs and may find out the night before that a hair-braiding, construction or housekeeping job has become available. Some patients, however, always make it on time and never miss an appointment.

Other patients said they had to decide between eating a meal or paying subway fare — making appointment days particularly difficult. In New York City, where issues such as turnstile-hopping were resulting in arrest,(gothamist.com) it was troubling that attending appointments could be a link in the cycle of poverty and incarceration. To address this, I needed to unlearn that on-time appointments were a measure of success in health care delivery, and our team implemented a system that made subway cards available to patients.

Read the full post.