Our Viewpoint: Improving population health outcomes by investing in community prevention

EHF's Lexi Nolen writes about the development and importance of the Texas CCHH Initiative in the national Health Affairs blog.

Screen Shot 2018-01-29 at 3.23.53 PM.png

Lexi Nolen FINAL.jpg
By Lexi Nolen
EHF’s Vice President for Impact
This post originally appeared in the Health Affairs Blog

Like many health funders across the country, the Episcopal Health Foundation (EHF) is investing in health system transformation through use of population health, community prevention interventions, and value-based payment systems. The justification for doing so is solidly based: population health is mostly shaped by social determinants of health. When we neglect to take into account the health impact of our policy, regulation, planning, and other decisions (in, for example, enforcement of housing policies, ensuring that transportation supports access to healthy food for low-income groups, or designing healthy suburbs), we are not accounting for the true cost of those decisions, and we are suggesting that it is fair to expect the health system to pick up the costs of harms that could have been prevented, often easily. Indeed, Texas’ poor health outcomes point to the need for deep transformation of its health system.

In addition to getting health system structures and incentives right, we need system leadership and on-the-ground skills to provide both high-quality health care services and high-quality prevention. Through a four-year, $10 million investment by EHF, the Texas Community Centered Health Homes (CCHH) Initiative is actively funding clinics to address underlying community conditions that affect health. EHF has worked with Prevention Institute for the past year to further develop and implement the CCHH model with thirteen community-based clinics in Texas.

A CCHH clinic not only acknowledges that community conditions outside the clinic walls affect patient outcomes, but also actively participates in improving those conditions. The CCHH approach creates more active roles for clinics in improving the health of both patients and neighborhoods, going beyond individual-level interventions to now promote change at the systems and community levels. Through partnerships with a variety of organizations, such as government agencies, health and human services groups, or business organizations, clinics engage in prevention strategies to improve population health.

Unless we focus on advancing population-level interventions and not just individual measures, we can’t make sufficient change to turn the tide of the health challenges we face as a nation. Chronic disease increasingly resembles an epidemic in terms of its spread across communities. And as George Albee, psychologist and former president of the American Psychological Association, said (according to his obituary in the New York Times), “No epidemic has ever been resolved solely by attention on the individual.” The value that the CCHH model adds to health systems transformation efforts is its specific focus on community-level prevention.

While it is not unusual for a clinic to focus on social determinants of health, it is far from common in practice—especially in particular regions of the country, such as the South, that are most in need of such approaches. When complemented by other areas of health system change, such as incentivizing value-based care and increasing health system efficiency and effectiveness, we believe that a focus on community prevention becomes a critical component of health system transformation.

Still, this is not easy work. EHF’s team spent much time determining whether the characteristics of the CCHH approach were the right fit for our region, which covers fifty-seven counties across central and east Texas. We talked with clinics and communities, had discussions with current grantees, and offered educational webinars on the CCHH model. We required clinics to commit time to diving deeper into the model even before we offered funding.

Financial And Technical Assistance Support
The first funding came through six-month, $25,000 Action Planning Grants that required further clinic participation in training webinars, along with individualized coaching. Following those initial grants, we’ve now established a cohort of thirteen clinics with eighteen-month or thirty-six-month grants to support implementation of the work in their communities, with the aim of showing on-the-ground impact and sustainability of the work.

EHF has built on the Kresge Foundation’s investments with Prevention Institute to create the model, as well as on prior on-the-ground implementation experiences by the Blue Cross and Blue Shield of North Carolina Foundation and the Louisiana Public Health Institute (the latter funded by the BP Deepwater Horizon Medical Benefits Class Action Settlement). Among many things, we are learning how to effectively support clinic and community teams in this work. Prevention Institute has honed in on seven key principles and associated practices, along with four core capacities, to develop a framework for the CCHH model. Through this framework, we are delivering training and coaching.

Advancing The Field
We are also investing in evaluation to further deepen our understanding of this work and its impact on population health and community change processes. Through independent evaluation, we are examining clinic implementation of the CCHH model, the effectiveness of clinic–community partnerships to advance community prevention interventions, and evidence of population health impacts. The evaluation is supporting further specification of the CCHH model and is expanding our understanding of the community and organizational conditions under which CCHH works best and the clinic characteristics that best support implementation of the CCHH model and make it most effective.

While the implementation phase only began in September 2017, Texas CCHH clinics are setting their sights high. Early efforts include:

  • Establishing a food council in a small city with significant incidence of hunger
  • Working with local land developers in Houston to create suburbs that better support healthy eating and active living
  • Developing community-level prevention approaches to mental illness
  • Reducing adverse childhood experiences (ACES) by addressing the ways community and systems structures can more strongly support prevention of them.

Along the way, EHF and the clinics are learning together what is required to implement the CCHH model. We’re addressing the technical issues of moving from data points to action and applying tools effectively. We’re also diving into the challenges of effective leadership, new ways of partnering, and how to address complex interactions of systems. Through these efforts, we aim to shift the vicious cycles of illness and social determinants of health—where failing to consider social determinants makes people more vulnerable to illness, and the cost to treat sick people undermines our ability to invest in prevention—to a virtuous cycle of prevention and good health.

EHF is also gathering from its experience lessons and resources for others to use. We’re actively interested in understanding the unique contribution that the CCHH model can make to accelerating health systems transformation. To that end, we are working with several other funders including Blue Shield of California Foundation, Kaiser Permanente Community Benefit, RCHN Community Health Foundation, the Kresge Foundation, and the Blue Cross and Blue Shield of North Carolina Foundation to identify that unique contribution and to figure out how best to build upon related efforts around the country.

In 1965, physician H. Jack Geiger cofounded the Delta Health Center in rural Mississippi, funded as a demonstration project by the federal Office of Economic Opportunity. Under Geiger’s leadership, and with John Hatch spearheading community organizing, the Delta Health Center emphasized a multipronged approach to health improvement that included integrated primary care and community action to improve conditions outside of the clinic walls, such as helping residents to develop a community agricultural cooperative to address malnutrition. Their clinic in Mound Bayou, Mississippi, was a precursor to today’s Federally Qualified Health Centers (FQHCs), which now stretch across the United States. Most of those FQHCs, however, do not yet fully accomplish the two leaders’ vision of transformation.

Ultimately, we want to move community prevention work into the mainstream. We have to turn the mythical stories of what Geiger and Hatch did into scalable approaches supported by health system transformation that any community clinic could advance and replicate. Our communities deserve it, and it’s about time.