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Suggested Citation:"4 Downstream: Addressing Patients' Health-Related Social Needs." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"4 Downstream: Addressing Patients' Health-Related Social Needs." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"4 Downstream: Addressing Patients' Health-Related Social Needs." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
×
Page 27
Suggested Citation:"4 Downstream: Addressing Patients' Health-Related Social Needs." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
×
Page 28
Suggested Citation:"4 Downstream: Addressing Patients' Health-Related Social Needs." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
×
Page 29
Suggested Citation:"4 Downstream: Addressing Patients' Health-Related Social Needs." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
×
Page 30
Suggested Citation:"4 Downstream: Addressing Patients' Health-Related Social Needs." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
×
Page 31
Suggested Citation:"4 Downstream: Addressing Patients' Health-Related Social Needs." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
×
Page 32

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4 Downstream: Addressing Patients’ Health-Related Social Needs Session moderator Sally Kraft of Dartmouth-Hitchcock opened the second panel session by explaining that it would showcase an outstand- ing partnership between Rush University Medical Center (Rush) and a coalition of organizations on the West Side of Chicago. The presentations would address the keys to successful partnership between a health system and community organizations. Highlights from the two presentations and subsequent discussion are provided in Box 4-1. RUSH SYSTEM FOR HEALTH: A CASE STUDY FOR HEALTH EQUITY Darlene Oliver Hightower from Rush began her presentation with some background on the health system. As she explained, Rush is a 180-year-old medical center located on the West Side of Chicago. With 10,000 employees and $2 billion in resources, it is the largest private employer on the West Side. In 2016, Rush changed its mission to focus on improving the health of the individuals in the diverse communities it serves. As Hightower pointed out, this involved improving the quality of care for its patients and community programs, partnerships, and interven- tions. The strategy to execute the mission included developing deeper community partnerships. Rush also completed its community health needs assessment in 2016, which revealed significant gaps in life expectancy among neighborhoods in Chicago. As Figure 4-1 shows, Hightower pointed out that life expec- tancy ranged from age 85 in downtown Chicago to age 69 in West Garfield 25 PREPUBLICATION COPY—Uncorrected Proofs

26 MODELS FOR POPULATION HEALTH IMPROVEMENT BOX 4-1 Key Points Made by Individual Speakers and Participants • n serving as an anchor institution, Rush University Medical Center (Rush) I intentionally and strategically invested in the West Side of Chicago by con- sidering its hiring practices, career paths, construction projects, supply chain, partnerships, vendors, investment in community economic development, and engagement of employees to volunteer in the surrounding community. In addition to using its own resources, by forming a collaborative, Rush could engage and persuade other health care institutions to make similar invest- ments. (Hightower) • t was important both for Rush and for the community members that they be I involved in the decision-making processes. (Jaco) •  rust between health systems and communities is important for realizing last- T ing change. (Kraft) •  he lived experience that community members bring should be recognized T and valued. (Jaco) •  actors key to the success of the health system–community partnership have F included health institutions’ intentionality and honesty about the role they have played in perpetuating and then addressing the disparities, having a well-known and well-respected health system champion, leveraging the power of the community, and bringing in resources from different sectors. (Jaco) • t is important to provide orientation and set expectations for health system I execu­ives around why community members want to participate and the experi­ t ence and expertise they contribute. (Hightower) Park. She said these data served as an impetus for action to address health disparities. In response to this stark data, as Hightower described, Rush embraced its role as an anchor institution.1 Accordingly, the health system deployed its resources to intentionally and strategically invest in the West Side. This involved consideration of hiring practices, career paths, construction, s ­ upply chain, partnerships, procurement, investment in community eco- nomic development, and engagement of employees to volunteer in the surrounding community. In addition to using its own resources, by forming a collaborative, Rush could engage and persuade other health care institu- tions in the Illinois Medical District to make similar investments. In partnership with the other anchor institutions, Rush developed the West Side Anchor Committee. In total, all partners involved had a com- bined 44,000 employees and supply chains worth more than $5 billion, 1 Rush University Medical Center is a member of the Healthcare Anchor Network, sup- ported through the Democracy Collaborative. See https://healthcareanchor.network/about- the-healthcare-anchor-network (accessed November 11, 2020). PREPUBLICATION COPY—Uncorrected Proofs

DOWNSTREAM 27 FIGURE 4-1  Map portraying the average life expectancy (at birth) in Chicago neighborhoods by subway stop. SOURCE: Hightower presentation, September 19, 2019. which would make them the largest employer in the state of Illinois. The committee identified five key areas in which each of the anchor institu- tions would work: 1. Hire locally and develop talent. 2. Use local labor for capital projects. 3. Buy and source locally. 4. Invest locally. 5. Volunteer and support community building. To elevate the anchor mission work within the health system and move it forward, Rush established executive leadership commitment and a new internal structure. Hightower concluded by pointing out that Rush’s commitment served as a catalyst for other organizations operating on the West Side of Chicago, including community-based organizations, social services agencies, philanthropy, and government, which led to the establishment of West Side United. MANY VOICES: ONE WEST SIDE Ayesha Jaco, West Side United, spoke about the West Side United coalition and the communities that it serves. As she explained, West Side PREPUBLICATION COPY—Uncorrected Proofs

28 MODELS FOR POPULATION HEALTH IMPROVEMENT United spans 10 Chicago West Side communities that have historically been disenfranchised and disinvested because of historical racism and other factors. Many of the communities were devastated during the 1968 riots following Martin Luther King, Jr.’s assassination and have not been rebuilt. Jaco asserted that these factors are key drivers of the current con- ditions in the communities. West Side United has six collaborating organizations that came together to address community health and economic wellness in nearby communities on the West Side. The six participating organizations are Rush, which serves as the lead organization; Lurie Children’s Hospital ­ of Chicago; UI Health; Cook County Health; Sinai Health System; and AMITA Health. The collaborative has a shared vision of improving neigh- borhood health by examining inequities in health care, education, eco- nomic vitality, and the physical environment using cross-sector, place- based strategies. Rush led the collaborative by bringing together partners to address the audacious goal of decreasing the gap in life expectancy by 50 percent between the Loop downtown and the 10 West Side communities depicted in Figure 4-1 by the year 2030. Jaco noted that it was important for Rush to ensure that the community was involved in the initiative. The health system did not want to create another prescriptive model that dictated to the community what it needed. As Jaco described, Rush held listening sessions with community members from March through July 2017. Rush learned that commu- nity members wanted safe neighborhoods, access to care, equitable educa- ­ tion, and jobs. Sixteen community members, half of whom were residents and half represented nonprofit and government entities, joined a planning committee to consider how to develop strategies. West Side United was officially launched in February 2018, when stakeholders from across the city convened to discuss plans for 10 initiatives. A leadership council, composed of executives and visionaries from the hospitals, was formed to guide the work and ensure support across the health systems. A small team of strategy, operations, and programmatic staff execute the agreed- upon strategies. One key point made in the listening sessions drives the work of West Side United: “Nothing for us without us,” meaning that nothing for the community should be built without its involvement. A community advi- sory council, composed of 18 people who live or work in the community or represent nonprofit organizations based there, replaced the planning committee, which was dissolved 6 months after the establishment of the initiative. Jaco noted that in December 2018, six community advisory council members joined the six hospital chief executive officers on the leadership council. PREPUBLICATION COPY—Uncorrected Proofs

DOWNSTREAM 29 West Side United has specific goals related to local hiring, which led to the participating organizations, for the first time, sharing hiring data. Par- ticipating organizations committed to hiring 3,500 people from the West Side by 2021, an increase from the 1,000 people currently employed. The coalition also launched employee career pathways to support advance- ment of nonclinical workers at the participating institutions. For example, one program supports an 18-month medical assistant pathway, with reim- bursement for tuition and transportation provided. Another example Jaco described is the Small Business Grant Pool, which was piloted in 2018 with $85,000 in total grants provided to sup- port capital improvement and hiring of additional staff at seven small businesses. In 2019, a generous donation from JPMorgan Chase increased grant funding to $500,000 total for up to 30 grants, with the goal of help- ing to rebuild some of the communities that had not recovered since 1968. Jaco used Figure 4-2 to describe West Side United’s model. In the top left, storm clouds of systemic racism, disinvestment, and short-term focus create the current conditions. In the middle, community members build the bridge to overcome the challenges. At the bottom, institutions and partners build the pillars of the bridge. In closing, Jaco used Figure 4-3 to describe West Side United’s work from the perspective of residents and community organizations on one FIGURE 4-2  A portrayal of West Side United’s theory of change. SOURCE: Jaco presentation, September 19, 2019. PREPUBLICATION COPY—Uncorrected Proofs

30 MODELS FOR POPULATION HEALTH IMPROVEMENT FIGURE 4-3  A portrayal of West Side United’s work with residents and commu- nity organizations and health care systems. SOURCE: Jaco presentation, September 19, 2019. side and health care systems on the other and how they work toward their shared vision of the community. On the resident and community organization side, people come to the table with their expertise, set their egos aside, and help to reformat the map. On the health care system side, health care systems come to the table as equal partners and work to build a shared vision for decreasing the gap in life expectancy. AUDIENCE DISCUSSION Kraft opened the session’s discussions by saying “Change happens at the speed of trust.” She asked Hightower and Jaco to describe success- ful practices for building trust between health systems and communities. Hightower responded that it is important for health systems to follow through on their commitments to communities, including showing up at events and providing grant funding. She emphasized the importance of shared decision making between health systems and communities, rather than health systems simply receiving feedback from community members. Jaco added that it is important for community members to have PREPUBLICATION COPY—Uncorrected Proofs

DOWNSTREAM 31 specific ways to participate that validate them as experts in their own experience, such as serving as ambassadors for their communities. She noted it is also helpful for other community members to see members of their community involved in the project leadership. A participant asked Jaco about recommendations for getting health system executives into the community to understand the community’s experience firsthand. Jaco answered in the affirmative, saying that the 18-member community advisory council includes representatives from all 10 West Side communities, each of whom have invited C-suite executives to be present in their communities. For example, a community tour could allow health system executives to better understand, appreciate, and sup- port local communities by tasting their food, seeing the murals, interact- ing with residents, and learning about key organizations. As another example, health system leadership participated in an information session for the small business grants, which provided an opportunity for 170 small business owners in the West Side communities to interact with the health system leadership. Hightower also reiterated the importance of showing up to events when invited. Building on the prior question, Jennifer Little of Klamath County Public Health in Oregon asked Jaco and Hightower how they train com- munity members to feel prepared to speak with health system executives. Jaco responded that they engage community members based on their level of expertise. For example, those involved in education or small businesses participate in those subcommittees. They are also working with United Way to plan a training or fellowship for community members focused on development and diversity. She noted the importance of emphasizing that community members are experts and bring value to the discussion. Wilkins added that it is equally important to provide orientation and set expectations for health system executives when working with com- munity members. She suggested ensuring executives not only understand why community members want to speak with them but that they also understand the lived experience of the people in the community. Marc Gourevitch of New York University Langone Health asked Hightower about what the catalyst was for institutional level change at Rush in 2015 that led it to decide to invest in improving health equity on the West Side and what the effect has been on the health system’s bottom line. Hightower responded that the map in Figure 4-1 showing the differ- ences in life expectancy between Chicago neighborhoods was a catalyst. In addition, David Ansell, Rush’s former chief medical officer and current head of community health equity, had worked in safety net institutions on Chicago’s West Side and had been focused on these disparities. With respect to the financial results, Hightower noted that Rush executives are excited about social impact investing because Rush will get a return on PREPUBLICATION COPY—Uncorrected Proofs

32 MODELS FOR POPULATION HEALTH IMPROVEMENT the approximately $4.5 million that has been invested to date, including reductions in emergency room visits by people on the West Side. Ray Baxter of the Blue Shield of California Foundation asked about hospital labor unions’ engagement in and support for the health equity work. Hightower responded that Rush has worked with the labor unions on affected employee pathways. Wilkins also commented on Rush’s talent acquisition strategy, high- lighting the importance of changing the culture by creating job descrip- tions that remove nonessential qualifications, such as a certain degree or a clean criminal record. Hightower added that pairing Rush’s health equity work with its diversity and inclusion training could help to change the culture internally and build support for these changes in hiring practices. Jaco added that West Side United has helped to bring together hiring managers across the six participating institutions to consider ways to change policies. Sanne Magnan of the HealthPartners Institute asked Hightower and Jaco what the most significant challenges are they have faced in their work to date and what they see as future challenges. Jaco responded that a future challenge is community members’ concern that they will not be able to afford to live in their neighborhood once improvements are made. She noted that the success to date has partly been attributable to the health institutions’ intentionality and honesty about the role they have played in historically perpetuating—and more recently addressing—the disparities. She also emphasized the importance of having a well-known and well-respected champion such as Ansell, leveraging the power of the community, and bringing in resources from different sectors. Hightower added that she thinks the greatest future challenge is sustainably chang- ing the culture to incorporate health equity in the long term. She is also concerned about how to lay the groundwork for continued funding for the work. Implementing the strategy in conjunction with institutional partners who were previously competitors and maintaining ongoing com- munity relationships and support are also challenges. PREPUBLICATION COPY—Uncorrected Proofs

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The Roundtable on Population Health Improvement of the National Academies of Sciences, Engineering, and Medicine hosted a public workshop on September 19, 2019 titled Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream. The term upstream refers to the higher levels of action to improve health. Medical services act downstream (i.e., at the patient level) in improving population health, while such activities as screening and referring to social and human services (e.g., for housing, food assistance) are situated midstream, and the work of changing laws, policies, and regulations (e.g., toward affordable housing, expanding healthy food access) to improve the community conditions for health represents upstream action.

The workshop explored the growing attention on population health, from health care delivery and health insurance organizations to the social determinants of health and their individual-level manifestation as health-related social needs, such as patients' needs. The workshop showcased collaborative population health improvement efforts, each of which included one or more health systems. This publication summarizes the presentations and discussions from the workshop.

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