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How Leadership and Organizational Structure Can Address Health-Related Social Needs and Advance Health Equity

The first panel, moderated by Philip Alberti of the Association of American Medical Colleges (AAMC), featured two speakers who spoke about how leadership and structure can support the work of addressing social and community needs beyond clinical care. The panel was intended to address how health care organizations can coordinate and organize these types of activities in a cohesive, effective, iterative, and evaluated manner. As Alberti explained, a goal could be coordinating and integrating siloed groups in an organization focused on community-partnered science, conducting community health needs assessments, and population health management, for example. A health care organization, he added, should “have its own internal house in order” in order to be an effective partner in a multisectoral collaboration to address health and health care inequities.

Highlights from the two presentations and subsequent discussion are provided in Box 3-1.

REDESIGNING A HEALTH SYSTEM TO CREATE WELL COMMUNITIES

Benjamin Carter of Trinity Health described what his organization is doing to manage and balance the ongoing tension between being a provider-based system with episodic health care management, population health management, and community health and well-being.

As Carter explained, Trinity Health is a $19.3 billion Catholic health care organization based in Livonia, Michigan. The organization operates

in 19 regions across 22 states. Its mission, which was established in 2013 when Catholic Health East and Trinity came together to form Trinity Health, is to be transformative and healing in the communities it serves. Its vision is to be a people-centered health system that delivers on the triple aim of better health, better care, and lower cost for individuals, populations, and communities. Its three core services are (1) episodic care, meaning fee-for-service care provided to individuals; (2) population health, which involves creating incentives to move to value-based care and alternative payment models; and (3) community health and well-being.

Trinity Health’s journey toward a well community has three focus areas: (1) transform communities through policy, systems, and environmental changes; (2) ensure care delivery models that assess and address the needs of vulnerable patients; and (3) expand use and availability of community-based services. As Carter explained, the organization also has three main strategic initiatives. The first is to address the social influences on health, which involves tackling at least one social influence of health in each community. The other two strategic initiatives are to reduce tobacco use and obesity across the health care system.

Carter described how Trinity Health is investing in policy, systems, and environmental change strategies to improve health. Its Transforming Communities Initiative began in March 2016 and operates in eight locations, providing $18 million in grants, which has resulted in $7 million in matching funds at the community level and $40 million in community loan investments. The program addresses social influencers such as housing, food, and transportation. Trinity Health operates the initiatives in collaboration with several national technical assistance partners.

For example, as Carter explained, to address food deserts and lack of food access in Springfield, Massachusetts, where 100 percent of students qualify for free or reduced-price meals, Trinity partnered with Sodexo and the Springfield public schools to create a $21 million culinary and nutrition center. Another example of a community partnership is the Wellspring Greenhouse, which provides local fresh produce for hospital operations.

Carter concluded by outlining Trinity Health’s four areas of focus in addressing health equity: (1) assess the delivery of equitable care; (2) develop equity plans; (3) provide cultural competency education; and (4) reflect the diversity of our communities, which the organization strives to do through employment, vendor relationships, and purchasing.

ENTERPRISE-WIDE INFRASTRUCTURE TO ADVANCE HEALTH EQUITY

Consuelo H. Wilkins of the Meharry-Vanderbilt Alliance, the Vanderbilt University Medical Center (VUMC), and the Meharry Medical College, spoke about VUMC’s approach to health equity. The health system began by exploring what it was already doing related to community health and health equity as part of a project with AAMC. As Wilkins explained, the research identified more than 180 internal programs and initiatives involving research, education, and community engagement focused on community health and health equity. When leaders in population health, diversity and inclusion, academic medicine, and nursing from across the health system gathered to discuss the existing health equity initiatives, they recognized that many of them were siloed and disconnected. Wilkins noted that one result of the discussions was the realization that the voices of the community needed to be included and reflected in the design of the system’s programs and activities. She lamented that much of VUMC’s work with communities could be viewed as a “helicopter” approach (i.e., short-lived or sporadic) rather than true, sustained investment in communities (e.g., in hiring practices and in engaging the community in decision making).

Wilkins described how VUMC has taken an enterprise-wide approach to addressing health disparities and advancing health equity. Earlier in

2019, the health system launched a new office of health equity intended to bring together education, training, research, community, and population health efforts from across the enterprise. Wilkins noted that this institutional investment in health equity is critical to the initiative’s success.

With respect to education and training of health professionals, VUMC is working to ensure that all health professionals across specialties have expertise in health equity. With respect to research, the health system is working to better understand social risks and the social determinants of health and how they can be addressed, as well as the intersection between genetics and race as a social construct.

Within VUMC, the enterprise is considering how best to support the diverse 24,000 VUMC employees who have varying needs, priorities, social risks, and incomes. As an example of strong institutional commitment, Wilkins described how a health equity metric would be part of the executives’ performance goals and incentive plans across mission areas.

AUDIENCE DISCUSSION

Alberti began the audience discussion by pointing out that in the case of Trinity Health, the mission drove the infrastructure, strategy, and planning, while with VUMC, the organization’s new structure created a culture of health equity across the institution. He asked Carter and Wilkins the “chicken and egg” question of whether culture or structure should come first. Carter responded that in the case of Trinity Health, as a faith-based and provider-driven organization, community health and health equity have always been part of the mission. From a financial perspective, the organization invests in community benefit ministry, which includes the unfunded costs of Medicaid. However, he pointed out that community health was not receiving the attention and focus needed to make an improvement in the communities being served. In 2013, Trinity Health adopted a mission to be transformative, which drove it to approach community health, well-being, and health equity in a different way, which would involve firm commitments, accountability, and ongoing consideration of the effect on the community. Carter noted that having health equity as part of the organization’s mission and a priority of the board of directors and incentive systems was what made a difference regarding investment in—and the improvement of—community health.

Wilkins stated that, for her organization, structure was the vehicle for changing the culture. She suggested that with a relatively large, siloed organization like VUMC, it would be difficult to influence the culture without both leadership support and organizational structure. Wilkins noted that changing the culture internally has been more challenging than forming relationships with the community.

Wilkins described several barriers to institutional change. For example, academic leaders were pleased with the curriculum, yet there was student demand to add a health equity certificate program. As another example, VUMC provided grant funding for community organizations, but required them to complete detailed forms and pay up front for expenses. Wilkins suggested that changes to the culture are needed to remove barriers such as these. She pointed out that a wellness program designed for people who, for example, can afford child care and have not struggled with food insecurity may not work for people facing these and other social factors. She concluded by emphasizing that the structure provides the opportunity to change the culture through access to, and incentives for, leadership support.

Alberti asked Carter and Wilkins which person or entity at each of their organizations is accountable for the outcomes of their health equity work and how each of the stakeholders are involved in the development of metrics and incentives that are meaningful for all. Wilkins responded that at VUMC, her position is partially responsible for the outcomes of the work, and executive-level incentives and performance goals provide additional accountability. She would like for the community to do more to hold VUMC accountable for investing in projects that meet the community’s needs, including them in decision-making processes, and hiring from the community.

Carter noted that at Trinity Health, the board holds the organization accountable by requiring that 25 percent of the organization’s strategic plan be related to community health and well-being, equal to the weight given to financial success. The executives of all 19 regions have the same goals related to community health and well-being as the chief executive officer. In addition, there is a senior vice president for community health who is on the executive leadership team and vice presidents in each region responsible for objectives related to community health and well-being locally. Carter pointed out that much of the community health work is accomplished through partnerships.

Building on Alberti’s question about accountability, Sally Kraft of Dartmouth-Hitchcock asked about what accountability measures are being used and whether there are community health metrics. She noted that many factors outside of the health system may influence a community’s health status. Wilkins responded that, as a first step, VUMC is focused on identifying which measures are being used, or could be used, to collect data, using its employees as the sample population. The health system is working to develop metrics in all mission areas, including students’ competencies, knowledge, and willingness to work in underserved areas, and exploring better ways to integrate into students’ work the perspectives of the communities served.

Carter noted that Trinity Health has objective measurable outcomes related to issues such as reducing tobacco use and obesity. The health system uses electronic medical records to determine the extent to which it is making a difference in these areas. There is also a new metric related to social influences on health. Trinity Health uses process measures to assess its effect in the community in areas where it works in collaboration with community partners.

John Auerbach of Trust for America’s Health asked Carter and Wilkins whether their organizations have considered advocating for policy change at the federal, state, and local levels. Auerbach pointed out that in his experience as a former state health official, health systems were effective advocates, but often they did not prioritize policies that would improve overall health in the state. Carter responded that Trinity Health has been active in advocacy at the federal and state levels, including calling for legislation to increase the minimum tobacco sales age to 21, change opioid prescribing, increase housing access, and address gun violence. Given its large investment portfolio, the organization also engages in shareholder advocacy to influence companies such as CVS and Walmart to align with its priorities.

Mylynn Tufte of the North Dakota Department of Health asked Carter and Wilkins about how the language used can influence the level of support among people in their organizations who are not well versed in issues related to health equity. Wilkins responded that she sometimes uses different language to communicate about her work with different audiences within the medical center. She also pointed out that different communities may face different issues and use different words to describe their resources and needs.