The Messenger Also Matters: Value-Based Payment Can Support Outreach To Vulnerable Populations


The following excerpt comes from the July 10, 2017 article by Ruth C. Browne, Marilyn Fraser, Judith Killen, and Laura Tollen on the Health Affairs Blog.

With the proliferation of value-based payment initiatives and implementation of the Affordable Care Act’s (ACA’s) coverage expansions, states have had many opportunities in recent years to improve the health of vulnerable populations through health promotion, prevention, and care coordination. We believe value-based payment models can and must support accountable health care delivery systems in partnering with community-based “messengers” to engage vulnerable individuals in health education and promotion. We explore one such messenger program, ACCESS, a Brooklyn-based project of the Arthur Ashe Institute for Urban Health, which trains barbers and hairstylists to help formerly incarcerated men learn to recognize and act upon their own health risk factors. Value-based payment offers an opportunity to support programs such as this.

“Messengers,” as we define them here, are community health workers—those who serve “as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.” Unfortunately, there are few dedicated funding streams available to support the messenger role. Fee-for-service payment arrangements do not reimburse these activities. Value-based payment, on the other hand, not only highlights the need to support messengers but also potentially provides funding to do so.

Value-based payment programs hold the health care delivery system accountable for meeting health goals for entire enrolled or attributed populations, which requires more than just providing better medical care. Shortfalls in medical care are responsible for only an estimated 10 percent of early mortality in the United States, while individual health-related behavior is responsible for 40 percent. Even the finest delivery system can only expect to see a modest improvement in the health of its community if it focuses only on the very thing it has been designed to do—providing medical care to sick people. Value-based payment requires delivery systems to redefine nothing less than their product, place, and providers. The product must be health; the place must be where people live and work; and the providers must include credible, community-based messengers.

Credible messengers can bring to delivery systems important knowledge about social determinants of health that impact individuals’ ability to access and act upon health-related information. We focus here on one social determinant—incarceration. Individuals formerly incarcerated have become eligible for Medicaid in large numbers and, as such, participate in a variety of value-based payment initiatives. New York State, where the ACCESS program has been implemented, is moving aggressively toward value-based payment in Medicaid. In 2015, the state announced its intention to shift 80–90 percent of its Medicaid managed care provider payments from fee-for-service to value-based arrangements by 2020.

In the United States, nearly 700,000 state and federal prisoners are released annually, and more than 11 million cycle through local jails. Incarcerated individuals have poorer physical health status than the rest of the population, a high burden of mental health and substance abuse disorders, and, once they are released, are more likely than the general population to be uninsured. However, under the ACA, more than one-third of inmates released annually from state and federal prisons are estimated to be Medicaid-eligible. If this pattern holds true for those released from local jails as well, there are potentially millions of formerly incarcerated individuals newly eligible for Medicaid—and for the value-based payment initiatives that may come with it.

The burdens of incarceration are distributed unevenly. Sixty percent of New York State prisoners come from New York City, and two-thirds of the 28,000 people released each year return to the city. Some Brooklyn neighborhoods have especially high incidences of incarceration and concomitant prison spending, earning them the dubious honorific of “million-dollar blocks,” even though they are among the poorest neighborhoods in Brooklyn.

At the Arthur Ashe Institute for Urban Health (AAIUH), we found a striking overlap between Brooklyn’s million-dollar blocks and areas where we were already engaged in health-promotion activities. Founded in 1992, the AAIUH is an independent, nonprofit organization that collaborates with community members to incubate, test, and replicate neighborhood-based interventions to improve health conditions disproportionately affecting minorities. Arthur Ashe, a world-renowned African American tennis champion and social justice advocate, founded the AAIUH in partnership with the State University of New York Downstate Medical Center. Using community-based participatory research, the AAIUH navigates disparate worlds—the institutional universe of academic medicine and day-to-day life in multi-ethnic, multi-linguistic neighborhoods.

Among other projects, the AAIUH has a long history of training barbers and hairstylists to deliver health education related to breast cancer, cardiovascular disease, asthma, and diabetes in women, and HIV/AIDS and prostate cancer in men. When we began the ACCESS program in 2009, exploratory work revealed that more than 80 percent of barbers working in our ongoing projects had themselves spent at least one night in jail. This made them particularly credible messengers for our priority population of formerly incarcerated men and the supportive women in their lives. Guided by input from a community-based advisory board, we conducted focus groups of barbers, stylists, and customers to determine the best way to discuss incarceration and health, and which health issues would be most important to the community. Based on that input, the program emphasized cardiovascular disease, stress, and HIV/AIDS. We developed a health curriculum to increase awareness of these conditions, emphasizing prevention and the importance of “knowing your numbers”—that is, understanding health indicators such as blood pressure and cholesterol levels. The curriculum included a resource guide for community health and social services related to the priority conditions and services for the re-entry population.

We trained barbers and stylists to deliver the curriculum in six establishments in the Bedford-Stuyvesant and Crown Heights areas of Brooklyn, emphasizing that health messages must be delivered in a way that could be useful to any member of the community who might know someone who had been incarcerated, instead of focusing solely on the formerly incarcerated themselves. In addition to the health messages and the resource guide, ACCESS included an HIV-focused health education video played several times a day in participating salons and barbershops and 12 AAIUH-sponsored Health Resource Days held at these establishments.

The project evaluation consisted of pre- and post-intervention surveys of patrons. The pre-intervention survey assessed patrons’ familiarity with risk factors, prevention, and resources related to the priority conditions. For example, patrons were asked multiple-choice questions such as: “What are some of the warning signs of a heart attack? What is a normal blood pressure reading?” The post-intervention survey of the same individuals sought to determine whether they had been exposed to the intervention and whether their knowledge regarding any of the previously asked questions had changed. Survey respondents’ ability to identify ways to assess their cardiovascular disease risk increased from 44 percent to 62 percent, and understanding that condom use can decrease the spread of HIV increased from 77 percent to 88 percent.

Read the full article.

Glimpses of Community Engagement

Community engagement calls for cultural humility, patience, and the building of authentic relationships. In a series of short videos from the Division of Community Engagement at Virginia Commonwealth University, faculty members describe their personal experiences of working with community partners. The six videos discuss:

  • Why community engagement?
  • Cultural competencies
  • Community partners as co-educators
  • The nontraditional learning script
  • Why I identify as a community-engaged scholar
  • Breaking Down Silos

The videos are all available on YouTube.

Useful Resource: Urban Institute Health Policy Center

The Urban Institute conducts economic and policy research to offer analyses and recommendations to “”understand and solve real-world challenges.” Its Health Policy Center explores the United States’ health care problems and costs, evaluates how public policies affect lives and communities and provides insight into reforms.  The approach taken includes

  • Health Insurance Policy Simulation Model to forecast the effects of policy changes on insurance costs and coverage and on employers and individuals.
  • Analysis of data from major federal surveys to identify trends in health care coverage, costs, access, and quality.
  • Where federal and state surveys lack information, they collect and analyze qual­itative data through case studies and conduct surveys to track health insurance coverage and health outcomes in real time.
  • Provision of technical assistance to state and local policymakers as they put policies and programs into practice.
  • Study of disparities in access to care—by race and ethnicity and socioeconomic status, across states, and between public and private insur­ance—identifying where gaps exist and how to close them.

The Health Policy Center’s web portal provides access to publications, project descriptions, and blog posts. Recent publications include:

Visit the Urban Institute’s Health Policy Center to learn more.

CAB Member Profile: Reverend Michael Johnson


Reverend Michael Johnson

The Sentinel Surveillance to Monitor Progress toward Health Equity project aims to develop and implement a surveillance system to capture the information necessary to monitor progress towards health equity for health disparate populations. One key element of this project is the engagement of community members through a Community Advisory Board (CAB).  Recently, Reverend Michael Johnson, pastor of Faith Lutheran Church in Mobile, shared a little about his experiences with the CAB.


Tell us a little bit about yourself and your background.

I was born in Mobile and attended local public schools. After high school, I attended Bishop State Community College and, then, the University of South Alabama where I studied Civil and Structural Engineering. I completed my Master of Divinity at Concordia Theological Seminary in Fort Wayne, IN.  Before my pastorate here in Mobile, I pastored churches in Detroit, Birmingham, Memphis, and Baltimore.

How did you become involved with the Community Advisory Board for the Sentinel Surveillance Project?

I became involved by request of a previous [research office] employee, Andrea Hudson. She was aware of my years of community activism and involvement in providing initiatives for change.

Why did you decide to become part of the CAB?

We need to address the health disparities that cause much brokenness in our communities.  Participation in the CAB offers an opportunity to participate in important research that helps us understand these disparities and help mend the brokenness in our community.

Give us a few highlights of your time as a CAB member. Is there any one memory that stands out?

I appreciate the meetings, brainstorming ideas for effective health change, workshops and collaborating with others of the interest. If I had to identify a single memory/experience that has piqued my interest the most, that would be my recommendation and participation in the Bayou Health Disparity Fellows Program, of which I graduated May 9, 2017.

What community needs are you most concerned about?

Health Disparity change, diabetes, hypertension, obesity, drugs and alcohol addictions.

How do you see the sentinel surveillance project addressing these issues in the community?

Specifically, Dr. Arrieta’s sharing of information discovered through the research and community experience helps to educate also. Because of her personal interactions, it allows us to build relationships that are loving and caring for one another.

Have you ever been involved in research before, if so how is this similar or different?

I have been involved with research before on the data collection side. I desire to extend my interest is collaborating in academic, clinical trials and community samples through education and photovoice.

What have you learned about research through this process?

I learned that there are many causes of Health Disparity. There are also, needs and means for change, including policy change that would dissolve determinants causes.

Has the experience changed the way you consider or approach research in other areas of your life?

Yes, my viewpoint has changed tremendously. I am better educated and more motivated to be involved in the partnership and seeking means for health change for self and community.

Would you encourage others people in your life to participate in or be a part of leading/shaping research projects as a result of your involvement with Sentinel Surveillance?”

Yes, would definitely as I am encouraging others to get involved, get educated, participate and share in the movement of better health – better life.

Changes in NIH Funding for Early- and Mid-Career Investigators

On June 8, 2017, the NIH Director released a statement titled “Launching the Next Generation Researchers Initiative to Strengthen the Biomedical Research Enterprise” describing the commitments NIH is making to encourage early- and mid-career investigators in the biomedical research enterprise. The following excerpt discussing the new initiative comes from an NIH Open Mike blog article published on June 16, 2017,  by Mike Lauer.


As described in a June 8 NIH Director’s statement, and in recognition of the call for such action in the 21st Century Cures Act, we are naming this effort the Next Generation Researchers Initiative. We will take a multi-pronged approach to increase the number of NIH-funded early-stage and mid-career investigators and stabilize the career trajectory of scientists. We describe these approaches on a new web page that we will continue to update. Our activities address both research workforce stability, and evaluation of our investments in research. In brief, NIH will:

  • commit substantial funds from NIH’s base budget, beginning this year with about $210 million, and ramping to approximately $1.1 billion per year after five years (pending availability of funds) to support additional meritorious early-stage investigators and mid-career investigators
  • create a central inventory and track the impact of NIH institute and center funding decisions for early- and mid-career investigators with fundable scores to ensure this new strategy is effectively implemented in all areas of research
  • place greater emphasis on current NIH funding mechanisms aimed at early- and mid-career investigators
  • aim to fund most early-career investigators with R01 equivalent applications that score in the top 25th percentile
  • encourage multiple approaches to develop and test metrics that can be used to evaluate the effectiveness of our research portfolio, and assess the impact of NIH grant support on scientific progress, to ensure the best return on investment

Applicants do not need to do anything special to be eligible for this funding consideration. Beginning this fiscal year, the NIH institute or center (IC) who would fund the grant will give your application special consideration for support if you are:

  • an early-stage investigator (within 10 years of completing your terminal research degree or medical residency and have not previously received a substantial independent NIH research award) and receive a score in the top 25th percentile (or an impact score of 35 if the application is not percentiled)
  • a mid-career investigator (within 10 years of receiving your first NIH R01 equivalent award) who scores in the 25th percentile, and either:
    • are at risk of losing all support, or,
    • are a particularly promising investigator currently supported by a single ongoing award (i.e, NIH will prioritize funding an additional concurrent research project grant award)


To learn more:

See the full article on the Open Mike blog.
Read the NIH Director’s statement.
Visit the  Next Generation Researchers Initiative web page.

Useful Resource: Coping with Emotional Issues related to Diabetes

The National Diabetes Education Program from the Centers for Disease Control and Prevention provides a series of educational resources for those living with diabetes. The portal Coping with Emotional Issues provides resources to help individuals cope with the emotional struggles that can accompany the disease. The resources include:

Visit the Coping with Emotional Issues Portal to learn more.

USA Health Partners with Feeding the Gulf Coast to Address Food Insecurities in Clinical Setting

The following article first appeared in the Med School Watercooler: The blog of the University of South Alabama College of Medicine on June 29, 2017.

USA Health recently partnered with Feeding the Gulf Coast to implement “Boxing Out Hunger,” an innovative program designed to improve health by addressing food insecurities in the clinical setting at Stanton Road Clinic.

“Being a board member for Feeding the Gulf Coast, I feel very strongly about what they do to help the community and, of course, I am very passionate about the work that USA Health does,” said Dr. Julee Waldrop, representing both the University of South Alabama and Feeding the Gulf Coast at a recent kick-off event. “The ‘Boxing Out Hunger’ program is truly a great partnership, and it is my hope that Feeding the Gulf Coast will be integrated into the entire health system.”

According to Kim Lawkis, nutrition programs director for Feeding the Gulf Coast, one in six adults and one in four children struggle with food insecurity. “Feeding the Gulf Coast was selected as one of only five food banks in the U.S. to participate in Feeding America’s Health Care Pilot Program,” she said. “This pilot focuses on our organization expanding access to fresh, healthy products and working with health care partners to help implement programs that directly address food insecurity and top priorities in their community health plan.”

The program — which is unique to our area — seeks to fill a nutritional gap that exists for many patients who visit Stanton Road Clinic. Through phase one of the partnership, Stanton Road Clinic will distribute 1,000 healthy pre-packaged boxes to food insecure patients that contain an assortment of shelf-stable ingredients such as canned produce, protein, dairy, and grains. The food box is intended to meet the immediate needs of patients at the clinic and educate them on the importance of a healthy diet. Recipe cards are also included in the food boxes, which provide tips for preparing the food.

Beth Poates, a social worker with USA Health, will determine eligibility for food boxes by screening all new and self-pay patients for food insecurity. If the patient screens positive for food insecurity, they will receive a food box that is tailored to their health concerns.  Patients who do not screen positive will be referred to the closest food bank.

Owen Bailey, chief executive officer for USA Health, said a visit to Boston Medical Center’s Food Pantry several years ago sparked his interest in implementing the “Boxing Out Hunger” program at USA Health. “Using their success as inspiration, it is my hope that USA Health and Feeding the Gulf Coast can create similar success in Mobile to address nutrition-related illnesses and improve the outcomes for our patients,” he said.

According to Ali Shropshire, CRNP, family nurse practitioner and nurse manager for Stanton Road Clinic, the connection between adequate nutrition and health and healing is clearly documented in the medical literature. “We believe that the ‘Boxing Out Hunger Program’ will increase our patient compliance, decrease blood pressure, decrease blood sugar and overall decrease hospital utilization,” she said. “I am proud of the tremendous progress we have made and the opportunity to work with our new partner Feeding the Gulf Coast in achieving these goals.”

Dr. Errol Crook, director of the Center for Healthy Communities and professor and Abraham Mitchell Chair of internal medicine at the USA College of Medicine, said patients visiting Stanton Road Clinic often have insecurities that go beyond health. “Stanton Road Clinic is a community clinic, but we define community in a very broad sense,” he said. “We have patients who walk or take the bus here, but we also have patients who come from other counties. In addition to health, many of our patients experience insecurities in safety, shelter, and clothing. We are very happy to now have a way to address one of those insecurities, and by doing so we hope to one day be able to address the other major insecurities they experience.”

Read the full article.

Housing Assistance and Improved Health Care Access

The following comes from an article published  June 5, 2017 on EurekAlert!.

A new study examining the impact that access to affordable housing has on health showed that people receiving subsidized housing assistance were more likely to have medical insurance and less likely to have unmet medical need than other low income people who were on a US Department of Housing and Urban Development (HUD) wait list for the housing assistance benefit. Approximately 31 percent of the recipients of housing assistance were uninsured, as compared to about 37 percent of the future recipients.

Led by University of Maryland School of Public Health researcher Dr. Andrew Fenelon, the study analyzed data on adults ages 18-64 from the National Health Interview Survey that were linked to HUD data for the eight years from 2004-2012. The findings are published in Health Affairs, June 2017.

“We found that the benefits of giving people subsidized housing go beyond simply having access to affordable housing. Housing is good in and of itself, but even better is that with improved access to housing, you get improvements in access to health care, and ultimately better health outcomes,” said Dr. Fenelon, who is an assistant professor in the UMD SPH Department of Health Services Administration. He conducted the study in collaboration with researchers from HUD, the US Department of Health and Human Services, and the National Center for Health Statistics.

Housing assistance programs funded by HUD provide low-income people with access to safe and affordable housing. People receiving public housing subsidies are often in poor health, with increased need for mental health and chronic disease care. Access to health care has been shown to improve health, and housing instability is correlated with poor access to health care. Still, there are few studies that have explored whether housing assistance programs may lead to improvements in health.

Read the full article.

American Health Values Survey

The following comes from an article by Larry Bye and Alyssa Ghirardelli for the Robert Wood Johnson Foundation.

How we think about health—and the values, beliefs, experiences and attitudes that shape our thinking—affect how we approach our personal health challenges, as well as those that face society. Factors influencing health are equally complex—from access to quality care, to how individuals approach and manage health, to social determinants like access to housing and transportation.

The Robert Wood Johnson Foundation worked with researchers from NORC at the University of Chicago to better understand the extent to which health is a shared value in the United States.

The resulting American Health Values Survey examined insights from more than 10,000 adults around their values and beliefs related to health at both the individual and societal levels, including:

  • How health-conscious are we in our day-to-day living—from exercise to diet to getting preventive care?
  • How much do we value health equity—or the idea that all of us should have the basics to be as healthy as possible?
  • How much importance do we place on “social solidarity”—or the idea that the needs of others are as important as our own needs?
  • How do we view health care disparities—or how easy or difficult it may be for minority and low-income populations to receive quality health care?
  • How do social determinants such as education, housing, and income impact health?
  • Should the government or the private sector (or both) shoulder the responsibility for making our communities healthier places to live?
  • How do we view our “collective efficacy”—or our ability to work together to improve health in our communities?
  • How do we value civic engagement, or addressing health issues through charities, nonprofits, and voting?

The data from this large national survey were used to create a typology of the American public, reflecting a wide range and diversity of values and beliefs toward health. Six groups emerged from this analysis:

Health Egalitarians (23% of U.S. adults) do not place as much importance at the individual level on personal health as other Americans, and they are less likely to put health first in their daily lives. At the societal level, they are more likely to strongly embrace health equity, but less likely to believe that disparities for different populations exist, or that social determinants influence health. Health Egalitarians also believe government should generally be doing more to promote health, and are more likely than others to believe that building healthier communities is a high priority.

Equity Advocates (16%) are less likely to be highly engaged in personal health—whether through prevention, care seeking, or prayer/meditation. At the societal level, they are more likely to be strongly concerned about equality of opportunity, social solidarity, and health equity. Equity Advocates broadly agree about the existence of disparities, but are less likely to believe that social determinants influence health. They are highly trusting of science and the health care system, and more likely to believe that government generally should do more to promote health.

Committed Activists (18%) are very engaged in their personal health. The majority put health first in daily life, whether through disease prevention, seeking care, frequent prayer or meditation, or openness to alternative medicine. At the societal level, Committed Activists are more likely to believe that health care disparities exist and that the social determinants of health, as well as “non-social determinants” like stress, air and water quality, care access and genetic inheritance, play a role in influencing health. They overwhelmingly believe that health should be a top federal priority.

Self-Reliant Individualists (12%) are very likely to put health first in their daily lives. They are also the most likely of the groups to believe that ordinary people can decide for themselves “what is true” without the need for experts. At the societal level, Self-Reliant Individualists are much less likely to strongly believe in equality of opportunity to succeed, social solidarity, and health equity—or to believe race/ethnic and income-based disparities exist. They are less likely to believe that health should be a top priority for government, but are more likely to be civically engaged through charities or voting based on health issues.

Disinterested Skeptics (17%) do not place high importance on personal health, and are the least health-conscious of the segments. At the societal level, they are less likely to believe in equality of opportunity to succeed, that disparities exist, or that social and non-social determinants have a very strong influence on health. Disinterested Skeptics are much less likely to believe that government should do more to promote health at the federal or community level, and are less likely to be civically engaged.

Private-Sector Champions (14%) are more likely to be oriented toward prevention and seeking care at the personal level, and are much more likely to pray or meditate. They have the least trust in science and the health care system, and often place trust in the wisdom of ordinary people. At the societal level, Private-Sector Champions are less likely to believe that health care disparities exist, but overwhelmingly more likely to believe that social and non-social determinants are important influencers of health. They are the most likely to believe that the private sector should influence health in communities, while less likely to view a role for government.

See the original article.

Read the full report.


Learning Opportunity: The Impact of Early Childhood Education on Health and Well-Being: The Latest Research from Policies for Action

On Wednesday, July 12, 2017 the Urban Institute will host the forum The Impact of Early Childhood Education on Health and Well-Being: The Latest Research from Policies for Action with an option for live streaming. The following comes from the event announcement.

The Urban Institute, in collaboration with Policies for Action (P4A), a signature research program of the Robert Wood Johnson Foundation, invites you to a forum to share P4A’s latest findings on early education’s lasting impacts on health and well-being and learn from policymakers designing and implementing programs at the city and state levels.

Charged with fostering a healthy, competitive workforce, policymakers are looking for the best way to invest in the youngest members of our communities. Although different combinations of educational, health, and social supports are likely to underpin high-quality early childhood education, focusing on health leads to high returns for children and their families. This forum will spark a positive dialogue on the importance of health in early childhood investments and will identify avenues for cross-disciplinary engagement and research around early childhood education and health.

The forum will feature research from two notable scholars:

  • Sherry Glied, dean and professor of public service at New York University’s Wagner Graduate School of Public Service, will present her work on the improved health outcomes of low-income children newly enrolled in New York City’s universal prekindergarten program, Pre-K for All.
  • Jorge Luis Garcia, senior research assistant in the Center for the Economics of Human Development at the University of Chicago, will present new research spearheaded by Nobel laureate James Heckman on the long-term health and well-being impacts of high-quality, birth-to-age-five child care programs.

Please see the forum announcement for more information.