During the workshop’s closing session, participants reflected on key points from the presentations and raised issues for further consideration. Prior to the open discussion, Michael Manganiello, founding partner of HCM Strategists, shared his perspectives, described successful community partnerships for promoting population health, and outlined potential next steps.
The roundtable stands at a pivotal moment, Manganiello said, as it faces the challenge of developing and implementing an overarching strategy to improve population health. Partnerships will be critical to the roundtable’s success. He noted that many organizations are pursuing successful initiatives to advance population health, and he encouraged roundtable members to invite representatives of those organizations to meetings, to work with them to identify best practices, and to consider partnering with them. The entertainment industry is a potential partner.
An important lesson learned from patient experiences during the HIV/AIDS epidemic, Manganiello said, is that people with chronic conditions need more than medical care to improve their health. If people do not have transportation, food, or housing, they cannot realize the benefits of treatment. Under Part D of the Ryan White Act, the federal government partnered with the private sector to create social support networks for people with HIV/AIDS. The program was successful, Manganiello said,
but it was eliminated after new drugs were developed that helped people live longer with the disease.
The Administration for Community Living (ACL) within the U.S. Department of Health and Human Services and the Manhattan Plaza Apartment complex have each successfully conducted community-based initiatives to improve the health of elderly populations. The ACL connects senior citizens with long-term care support services in every state. When that agency implemented an evidence-based program to help people with care transitions following hospital discharge, the rates of hospital readmission declined. When it added community-based support services—such as transportation, home-delivered meals, homemaker/chore services, medication management, and caregiver support—readmission rates declined even further. The program now is helping to reduce preventable hospital admissions as well as readmissions.
The Manhattan Plaza High Rise apartment complex, which provides federally subsidized housing for people in the performing arts, has partnered with community organizations—including the Actor’s Fund of America, the Manhattan Community Board Number Four, the Manhattan Plaza Rodney Kirk Center, and the Senior’s Community Survey Project—to provide support services such as transportation, caregiving, and nutrition assistance to elderly residents. These services have enabled residents, 46 percent of whom are over 60, to age in place and to avoid preventable hospitalizations and nursing home admissions. The number of residents who have entered nursing homes is extremely low—a total of 70 since 1977—and 97 percent of them die at home. Manganiello said that the complex does not appear to have many of the problems associated with other subsidized housing projects.
Identifying Next Steps
The next steps for the roundtable include formulating and implementing a population health strategy, developing tactics and messaging, and identifying the entities to effect change. Because the problems are considerable and because major changes are needed, the federal government should play a role in the transformation, Manganiello said. Voters should be engaged in the process. Public education will be challenging, he said, but roundtable members have the experience needed for the task. There are many potential partners.
When formulating a communication strategy, Manganiello suggested that roundtable members address several important questions: Who will
be the face of population health? What is the story to be told? How can traditional media be combined with social media effectively?
Answering Questions About Scope, Messaging, and Engagement
During the open discussion, workshop participants continued to explore important strategic questions, and Manganiello offered additional suggestions. Raymond Baxter of Kaiser Permanente said that the key takeaway for him was the enormity of the challenge in public health and population health. He stated that the wide range of issues discussed during the day, all of which in some ways fall under the umbrella of population health, still seemed to illustrate a disconnect between what the roundtable means by population health and what others think it is. Although the speakers shared important insights on how to shape messages and find the right venues for communicating to audiences, the roundtable still faces the big challenge of articulating its core message. And in order to do that, he said, the roundtable needs to state more clearly “just what population health is and what it isn’t.”
Finding the Right Messages and Messengers
Manganiello said he believes that children should not be the public face of population health. Because racism remains prevalent across the country, he said, communication initiatives should use messengers such as a middle-class, white Milwaukee fireman who drinks beer and watches football. If the story of population health is told from the fireman’s perspective, he predicted, social determinants will become a priority for everyone.
The key takeaway from the workshop, said José Montero of the New Hampshire Division of Public Health Services, was that roundtable members need to make important decisions about the population health message, desired behavior changes, and the target audience. Roundtable members know how to communicate effectively with national and state policy makers and should find ways to stimulate discussions of population health without actually mentioning the term. Perhaps the roundtable should focus less on developing a detailed population health strategy, he said, and focus more on finding real-life examples to convey the message. By enabling others to tell the story, roundtable members can maximize the impact of population health messages. Stories told through television and film speak for themselves.
Brian Sakurada of Novo Nordisk likewise encouraged colleagues to think about effective ways to tell the story of population health to key decision makers.
Judith Monroe of the Centers for Disease Control and Prevention highlighted several issues for further consideration. First, she asked colleagues to think about strategies to communicate the message that addressing social determinants of health ultimately will benefit everyone. Second, she noted that public service announcements (PSAs) linked with storylines on television and film have been effective communication tools. Because PSAs are expensive, she said, roundtable members should consider partnering with local television news stations on lower-cost messaging strategies. For example, a public health official could discuss important health information during a brief television interview following a news story. Monroe used this model successfully while serving as a state health official during the H1N1 epidemic. And, finally, she encouraged participants to think about how to use social media platforms effectively.
Pursuing Micro- Rather Than Macro-Level Strategies
Manganiello felt that the workshop had focused too much on high-level strategy and not enough on grassroots efforts. He noted that during the debate over embryonic stem cell research, advocates targeted communications in small media markets first. They held town hall meetings that were covered in local newspapers. Then national newspapers began covering the issue, and eventually national television shows and the President were discussing it. The campaign had macro-level goals and strategies, but it was conducted on a micro level. Ultimately it was successful. In the first executive order of his presidency, President Obama authorized federal funding for embryonic stem cell research.
James Knickman of the New York State Health Foundation likewise noted that many of the workshop discussions had focused on macro-level strategies to advance population health when, in fact, micro-level approaches may be more appropriate. Communications and outreach initiatives to promote place-based approaches to population health should perhaps focus on targeted communities rather than on a general television or social media audience. Finding the right blend of micro- and macro-level approaches will be critical to success, he said.
Broadening the Coalition to Advance Population Health
Sanne Magnan of the Institute for Clinical Systems Improvement encouraged colleagues to identify potential partners for comprehensive initiatives to advance population health. The community partnerships developed by the Administration for Community Living and the Manhattan Plaza Apartments exemplify the comprehensive, “all but the kitchen sink” approaches that Hornik recommended. The success of
these programs demonstrates that people in different political parties can work together toward common goals. She asked roundtable members to think about how the population health community can likewise work with people in both parties to achieve shared goals.
Workshop participant Floyd Morris reported that The California Endowment has partnered successfully with young people on a project to increase understanding of population health. Once youth group members understood the concept that neighborhoods, workplaces, and schools affect health, they took ownership of the idea. Young people have been adept at using social media to explain neighborhood barriers to health and propose solutions, he noted.
Moreover, they have taken a proactive approach to communicating with decision makers. The Endowment also has worked with young people on an initiative to address school discipline policies. The project, which began with a dialogue among young people about the need for change, has had a major impact on school discipline policies in several California communities and in Washington, DC.
Morris said that the Endowment’s Health Happens Here campaign is leveraging opportunities created by the Affordable Care Act (ACA) to advance population health. The campaign includes outreach to facilitate health insurance enrollment along with public education about important non-medical aspects of health. Campaign messages focus on strategies to navigate the health care system effectively, to maximize health benefits, and to maintain good health. Additionally, the campaign encourages patients—including the newly insured as well as those ineligible for coverage under the ACA—to confront barriers to healthy living and seize opportunities to promote health in their communities. These actions ultimately will lower the cost of health coverage, reduce preventable emergency room visits, and improve health outcomes, Morris said.
As the roundtable considers next steps, Manganiello suggested that members meet with the Young Invincibles, an advocacy organization for 18- to 34-year-olds. The group has tremendous influence with Democratic and Republican policy makers in Washington, he said, because both parties are seeking to build support among young adults. Manganiello has worked with the organization on policies related to student loan reform and college graduation rates.
Creating an Environment Conducive to Making Healthy Choices
Two additional questions for the roundtable to consider, said workshop participant Brooks Ballard of the Michael & Susan Dell Center for Health Living at the University of Texas, School of Public Health, are how to create an environment in which the healthy choice is the easy choice
and how to help people overcome barriers to making healthy choices. If people do not have transportation, child care, or access to healthy food, they may be unable to follow treatment plans for chronic conditions. He suggested that the National Diabetes Prevention program—a public–private partnership that has implemented local, evidence-based lifestyle change programs for people at high risk for type 2 diabetes—may be a useful model for future population health initiatives.
Finding the Right Language to Generate Bipartisan Support
Finding the right language to convey population health messages is difficult, said Marthe Gold of the New York Academy of Medicine and the City College of New York, because communication about social determinants is associated with a specific political agenda. Messages about the redistribution of resources do not resonate with political conservatives, and terms such as population health and social determinants generate negative reactions. Therefore, she said, roundtable members need to develop different messages about creating a healthier society at a reasonable cost.
People’s views are influenced by their gut-level reactions, Manganiello said. He reiterated his suggestion to tell the story of population health from the perspective of a Milwaukee fireman. Republicans will be receptive to messages that explain the impact of education and wages on the health of the fireman and his children, he said. To persuade policy makers, communication about population health should include data and evidence. Noting that the Stem Cell Research Enhancement Act passed with significant support among Republicans, Manganiello said that with the right messaging, population health can be viewed as a bipartisan issue.
David Kindig of the University of Wisconsin School of Medicine and Public Health, said that communication about population health should focus not only on social determinants, but also on multiple determinants, and it should clarify the appropriate role of medical care. Identifying messages that resonate with both political parties may be a communications challenge, he said, but population health does not need to be a partisan issue. Before moving forward in developing communication strategy, he said, the roundtable should decide which behaviors and populations to target.
George Isham of HealthPartners reiterated the need to identify a clear message and asked whether a consensus study could spark the conversations necessary to reach a decision about messaging. Communication that links population health with a wide range of American values could motivate policy makers in both political parties and help build a bipartisan
movement to advance population health. Roundtable members should focus on combining the successful communication strategies discussed during the workshop to tell the story of population health to policy makers, communities, and the general public. Workshop presenters could be important allies in the next step of the process, Isham said.
