Culture of Health News and views from the Robert Wood Johnson Foundation Tue, 31 Mar 2015 10:22:00 -0400 en-us Copyright 2000- 2015 RWJF (RWJF) <![CDATA[Let's Keep the Payment Reform Momentum Going]]>

Recent advancements in payment reform have been massive and exciting. It's time to sustain the momentum and transform how we pay for and deliver care.

Hundred Dollar Bill Modified image. Original photo by Ervins Strauhmanis.

When it comes to how health care providers are paid, change is in the air. I’m probably more excited than most people about trying to make sure our financial incentives are flowing the right way within the health care system. Here’s why.

First, as a bit of context: most doctors and hospitals in the United States are paid on what’s known as a “fee-for-service” basis. Historically, the health care payment system has been designed to reward the volume of services rather than the value of services that are provided to patients. Additionally, in traditional fee-for-service arrangements, doctors often lose money when they spend time doing things that might matter to a patient’s health but that they cannot bill for. For example, a patient might be having a hard time managing their diabetes because they have no way to store their insulin. A doctor might know the best way to address that patient’s true need is to help them procure a refrigerator or by connecting them to income support services. The time and effort associated with either of those activities, under our traditional payment system, would typically mean lost productivity, and a loss of income, to providers. In sum, the fee-for-service payment system can be constraining and lead to higher expenditures than necessary.

Lately, advancements in the field to reform the way we pay for and deliver care have been massive and exciting. The most prominent models, Accountable Care Organizations (ACOs), are designed to disrupt the traditional fee-for-service system by holding providers accountable for the costs and quality of care for whole populations of people, and by providing clinicians with more financial flexibility when it comes to how they treat patients. In four short years, we’ve moved from a nation with 50 Accountable Care Organizations to more than 700 operational ACOs across the country. According to Catalyst for Payment Reform, nearly 40% of all health care payments are now tied to value, or improved health outcomes and/or lower cost. In January, the Centers for Medicare and Medicaid Services (CMS) put a historic stake in the ground, announcing that by 2018, 50% of its Medicare payments would flow through alternative payment models. And the very next day, a private sector taskforce of commercial health care payers and their partners announced their own ambitious goal of placing 75% of their business into value-based payment arrangements by 2020. On top of those announcements, last year CMS launched an $840 billion initiative designed to help health care providers prepare to operate under new payment models.  

It’s clear the time for investing in incremental change has passed. So what’s next? As my colleague Michael Bailit and I discussed a recent blog post, there remains a need for funders to continue addressing the very real on-the-ground challenges involved in working through reformed payment systems. To avoid losing momentum, we also need to rapidly share that experience with others to ensure the successful implementation and refinement of new models. It is also important and necessary to address challenges unique to safety net providers. The Robert Wood Johnson Foundation recognizes these critical needs—last month we released a call for proposals to create a technical assistance and resource center that could serve as that source of help and expertise.

For me, this new world raises a set of compelling questions.

  • What will all of these new changes mean for the practice culture that exists in doctors’ offices and in hospitals across the country?
  • How will our sense of who is accountable for what in health care change?
  • How will we determine where the money potentially saved from these new models goes?
  • Moreover, how will we ensure everyone has the information and data they need to be making different and better choices about delivering and receiving care? 

All of this will start to unfold in the coming months—and we look forward to playing a role in answering these questions.

Tue, 31 Mar 2015 10:22:00 -0400 Andrea Ducas Health Care Payment Reform Health Care Quality <![CDATA[The 2015 Rankings and Philadelphia’s Power of ‘Brotherly Love’]]>

Rather than taking poverty and its ravaging effects on health as a given, Philly leaders and citizens came together to usher in change that would make the city a healthier and better place to live for everyone.

Philadelphia skyline

If you want to understand the texture of a large city, drive from its downtown and make your way out to the suburbs. With few exceptions, you’ll encounter pockets of poverty transitioning into mixed income neighborhoods and, finally, wealth and privilege in the suburbs.

I have lived in Philadelphia—the nation’s 5th most-populous city and 21st most populous county—for most of my adult life, and that is her reality. As a former public health official, I can tell you that such income gradients have a profound impact on the health of our populations.

The 2015 County Health Rankings released today are unique in their ability to arm government agencies, health care providers, community organizations, business leaders, policymakers, and the public with local data that can be applied to strengthen communities and build a true Culture of Health.

The Rankings examine four types of factors that influence a county’s health: health behaviors, clinical care, social and economic, and physical environment. Among these factors, the interplay of income, education and housing are particularly important, and I have seen this up close during my many years in Philadelphia.

Though I was the city’s Deputy Mayor for Health and Opportunity, as well as Philadelphia’s Health Commissioner, I also saw firsthand how poverty impacted patients’ health during my 25 years as a pediatrician here.

In a case that still pains me today, a young mother sought treatment for her teenage son in my clinic. The child was suffering from sickle cell anemia, a rare heredity blood disorder that has many serious complications, some preventable and some that are treatable. Here’s the thing: This family didn’t receive regular care in my office because they couldn’t afford transportation to and from our clinic.  Something most Americans take for granted eluded this family, to the detriment of this young man’s health.

Imagine that mother’s pain knowing that she couldn’t help her suffering son.

It’s a wrenching story that plays out across the nation every day, and a powerful illustration of how income—or a lack thereof—touches most everything related to health.

Income provides economic resources that shape choices about housing, education, child care, food, medical care, and more. Wealth also helps cushion and protect us during times of economic distress, which is why those in poverty and even many middle-income families suffered during the Great Recession.

To put it succinctly—and the data back this up—on average, as income and wealth increase or decrease, so does health.

Poor families and individuals are most likely to live in unsafe neighborhoods, often with limited access to healthy foods, fewer employment options and schools that don’t measure up. Housing is also inadequate in many of these neighborhoods.

The Rankings show how this reality plays out in big places like Philadelphia and even the smallest enclaves in every state in the country. Children in poverty are particularly vulnerable, and the rates of children in poverty are more than twice as high in the unhealthiest counties in each state as they are in the healthiest counties.

We added a new measure this year on income inequality to help us better understand the dynamics of these disparities. Though those with less income have fewer opportunities, the entire community suffers when inequality reigns. Social connections, or how we relate to one another, are frayed, and the sense of community is often lost.

The good news is that we know how to usher in change. The Roadmaps show what we can do to create healthier places to live, learn, work and play.  

In Philadelphia, we knew that heart disease was ravaging the community. For African-American men in particular, the toll was devastating, and the disparity started early, fed by unhealthful food and cloaked by the stresses of everyday life. We knew that obesity, smoking and hypertension needed to be addressed. So we brought the community together and embarked upon an aggressive multiyear mission to change this trajectory. Some of the results:

  • 1 in 4 corner stores and bodegas now sell healthier foods.  We have more supermarkets and farmers markets in poor neighborhoods.
  • Schools are healthier. They have gotten rid of their fryers, flavored milk, and sodas; and have built in physical exercise breaks during the day.
  • Smoking is waning.  Smoke-free laws catalyzed the change and awareness of the dangers fed a rapid decline in smoking.  Within just a year, we were seeing results. We estimated that there were 40,000 fewer smokers, meaning 20,000 fewer smoking-related deaths.  A new tax on cigarettes is a game-changer and will save many more lives.

Philadelphia is emblematic of the nation’s 10 largest cities, and as the poorest on that list, had an even more daunting challenges than some. But when the challenges are identified and a path is laid out, great things happen that can change—and even save—lives.

That’s the power and opportunity at the heart of today’s Rankings.

Join a panel of experts for a conversation on what we've learned from the County Health Rankings in an upcoming First Friday Google+ Hangout on April 3rd. Register for the Hangout >

County Health Rankings 2015
Wed, 25 Mar 2015 00:15:00 -0400 Donald F. Schwarz Social Determinants of Health Public and Community Health <![CDATA[Imagining the Future of Health Data]]>

The possibilities to use data for health feel endless when you allow communities to dream out loud. Those dreams may soon become reality with upcoming recommendations from the Data4Health Advisory Committee.


I have found that the only way to understand an emerging field is to listen, to set aside assumptions, and to let people’s own hopes and fears guide the discussion. That is the genius of the Data4Health project, which recently completed a five-city listening tour and returned with a set of insights that will benefit everyone who cares about the future of health and health care.

On April 2nd, during an event in Washington, D.C., the Data4Health Advisory Committee will release a report based on these insights with a set of comprehensive recommendations for how data can be collected, shared, protected and translated in ways that benefit individuals and communities.

My favorite quote in the report captures the importance of staying humble in the face of all that we do not know:

The complexities of people’s lives don’t always fit well in a drop down box.

We can make educated guesses about people’s interests in collecting and sharing health data, but until we give them a chance to dream out loud, we don’t know what is possible.

For example one listening session participant talked about how, if given the chance, families might be willing to track a child’s asthma attacks if they know that the data will be used to inform their wider communities about the effects of air quality.

Or what if physical activity patterns could be used to not only track individuals’ cardiac health but also to inform decisions about where to place a public park, where it is needed most?

We know that younger adults are more likely than older ones to embrace digital technology, but that does not necessarily mean that older adults are less likely to track their health. In fact, people ages 65 and older are the most likely group to track some aspect of their health. They just use offline tools to do so instead of an app, like a journal or a notebook.

And even that could change if digital tools become as easy to use as paper and pencil.  And we learned on the listening tour that the more adept people become with digital technologies; the more likely they are to find value in sharing their health information digitally.

One indication of people’s enthusiasm for health data was revealed when, in the first 5 days after Apple announced its new ResearchKit initiative, an opensource software framework that matches researchers to personal health data through apps, over 41,000 people registered to be part of the first five studies, which cover asthma, diabetes, breast cancer, Parkinson’s, and heart disease. Prior to that, researchers had only been able to recruit a few hundred participants for each study.

During the April 2nd release event, Stephen Friend, co-founder of Sage Bionetworks, a nonprofit research institution that created two of the apps for ResearchKit, will speak to how Apple’s initiative can revolutionize medical studies and lead to a better understanding for how to prevent and treat diseases.

That’s the imagined, possible future that Data4Health can bring—wider participation in building a culture of health—if we can keep listening and learning from people.

Join national health leaders in a live conversation on Thursday, April 2nd from 11:45 am to 2:00 pm EST for the release event for the Data4Health report.

Register for the live webcast and follow the conversation on twitter at #Data4Health.

Mon, 23 Mar 2015 15:15:00 -0400 Susannah Fox Health Data and IT <![CDATA[A TED Dare: Here’s Reality. Now Do Something About it. ]]>
TED Ensure Healthy Communities

Everyone in America deserves a chance to live the healthiest life possible. The reality is a bit more complicated: A person’s ZIP code, after all, can be as important as their genetic code when it comes to determining health. A true Culture of Health in the United States won’t be possible unless we address the inequities that allow some full access to a healthier life, while others are left to struggle.

This week, RWJF arrived at the TED conference in Vancouver, British Columbia, with a challenge for attendees: Try to understand what millions of people face in their pursuit of a healthy life. And in the spirit of the conference’s “Truth & Dare” theme, we dared the TED participants to envision a future in which everyone had access and a path to a healthier life. How might that happen? So far we’re hearing incredible ideas: let’s get to a place where we can celebrate justice rather than seek justice. Let’s make smarter choices about where we spend our health care.

We’ve enlisted five talented—brilliant, really—young filmmakers to help us. We asked each of them to tell the stories of their lives and to document the challenges that sometimes seem distant, but that are all too real for the people in their worlds. Check out their remarkable stories:

Jasmine Barclay, 19, of New York City, is in her junior year at CUNY’s Medgar Evers College studying social work and already has been recognized by the White House as a “Champion of Change.” She has also lived in nine different homes since the age of 2. Barclay is the child of an incarcerated parent—as are 1 in 28 children in America. It’s an all-too-common “adverse childhood experience” that can lead to poor health outcomes in adulthood. “I have no evidence that I ever was a child,” Barclay says. “Or perhaps I never was one.”

Ricardo Amparo, 17, is a senior at Edmondson Westside High School in Baltimore, an aspiring filmmaker and photographer, and a member of Wide Angle Youth Media's Mentoring Video Project. Amparo took up mixed martial arts to stay healthy, build self-confidence and just to have a supportive place to go to connect with peers and mentors. Young men of color face more obstacles in education, employment and health than do their white peers, and policies that support them in their teen years can help put them on the path to healthy and productive lives. “As a young black man in Baltimore, I am trying to be a positive person,” says Amparo. “But I have often been trapped in a negative environment.”

Lily Yu, 19, joined the Bay Area Video Coalition's film program during high school and is now a first-year student at the California Institute of the Arts, where she studies filmmaking and art. She grew up in West Oakland, fenced in by freeways that make shopping for healthful food difficult for people without cars. “Getting groceries is a chore when the closest supermarket is a 30-minute bus ride away,” Yu says. The places we live can have powerful effects on the choices we make, exacerbating preventable conditions such as obesity and even contributing to the prevalence of ailments like asthma.

Julia Retzlaff, 18, graduated from San Francisco’s Independence High School last year and has been making short films for the past four years with the Bay Area Video Coalition’s “The Factory” film program. She was a ninth-grader when she first witnessed a sexual assault—her friend roughly grabbed by a stranger on a San Francisco bus. Street harassment is embedded in a culture of violence, and unsafe neighborhoods contribute to health inequities among women. “With limited access to proper health care,” Retzlaff points out, “the anxiety and stress become lifelong afflictions.”

Tyson Sanford-Griffin, 18, has passion for free-running—an aerobatic way of darting through urban spaces — that has revealed to him the best and worst of Baltimore, a city wracked by crime. His window on this world leaves him wondering how his life might be different if his city was safer: “Can you imagine waking up every morning knowing that nothing bad will happen around you when you walk outside the front door?” Violence is a tremendous impediment to improving public health, hurting both those who suffer directly and the community that surrounds them.

Thu, 19 Mar 2015 00:31:00 -0400 Jessica Mark Health Disparities National <![CDATA[Research Designed Through the Eyes of Youth]]>

There's power in giving youth the means to document what they see as the barriers to their community's health. This project from Charlotte, N.C. shows us how this innovative research design can be a step to addressing local disparities.

Last year, we at the Robert Wood Johnson Foundation asked our community a bold question: What was considered the most influential research around identifying and eliminating disparities? In our first-ever Culture of Health reader poll, a winning research paper emerged in Por Nuestros Ojos: Understanding Social Determinants of Health through the Eyes of Youth, published in the Summer 2014 edition of Progress in Community Health Partnerships. The research project equipped young people in Charlotte, N. C., with cameras to identify and document environmental factors that impact health in their Latino immigrant community. What really makes this paper resonate for us—and, it seems, for many of you—is that it provides a clear example of how community-based participatory research (CBPR) is an important approach to understanding the multiple factors underlying health disparities.

We wanted to learn more about this interesting example of participatory research and how the Por Nuestros Ojos project is helping advance health equity in Charlotte. Recently, our blog team had a conversation with three of the study’s authors to find out how employing a participatory research model can help enormously in understanding and eliminating disparities in marginalized communities. Below is an interview with Johanna (Claire) Schuch, research assistant and doctoral candidate at the University of North Carolina at Charlotte (UNCC); Brisa Urquieta de Hernandez, project manager at the Carolinas HealthCare System and doctoral student at UNCC; and Heather Smith PhD, professor, also at UNCC.

Tell us about Charlotte and the background of MAPPR.

The Mecklenburg Area Partnership for Primary care Research (MAPPR) is a practice-based research network founded and directed by Michael Dulin, a physician and past RWJF Physician Scholar who came to Carolinas HealthCare System in 2006. Dr. Dulin was surprised to see that there were almost no Latino patients coming to one of the health system’s primary care safety net clinics, even though it was located in an area with high number of Latino residents and Charlotte had experienced a 1,000 percent increase in Latinos over the past 20 years. Dr. Dulin reached out to the Latin American Coalition, a community advocacy group, and found out that the group didn’t even know the clinic existed. Language, culture and being uninsured prevented many of Charlotte’s newest residents from accessing primary care, leading to health disparities. Since then, MAPPR has been conducting research on ways to improve access to healthcare for underserved populations in Charlotte and Mecklenburg County and to identify and address social determinants of health.

How did you identify neighborhoods with the greatest health disparities?

We used census and other quantitative databases to map out where areas with the most needs were located. Since our network includes a large health care system we also had the opportunity to evaluate health data at a neighborhood level. Additionally, we put together a community advisory board that met with providers and key stakeholders to raise their awareness about particular community needs. Once we developed a mapping model that identified neighborhoods with the largest Latino immigrant population and greatest health disparities, we conducted interviews with community focus groups to drill down further and gain insight into specific concerns of this population.

One of the most intriguing aspects of this paper is that student researchers were integral to the project. What did these college and high school students bring to the table?

When we were learning about the Photovoice technique we thought it would be a great idea to involve college students and high school youth in our research. One of our MAPPR network members was teaching an undergraduate neighborhood planning class at UNCC and thought this would be a good opportunity for her students to have a hands-on experience. The youth group [United 4 The Dream] members were already very involved in the community and brought a really unique perspective to the project. Most of them have immigrant parents but were raised in U.S. so they understand both cultures. They were very open and honest throughout the project, and didn’t tell us only what we wanted to hear. The students already had a social justice perspective; we just provided them with the opportunity to look at disparities from a health point of view.

How did the student researchers choose what to take pictures of?

Before the students went out with their cameras we talked about what they see as a healthy community and how physical features of the built environment can impact health and our lives. We talked a bit about being cautious of taking pictures of people, especially without their consent. I think we underestimate what people already know about health and the environment and that you don’t necessarily need to be an academic to understand the connection. In fact, sometimes the connections are not what researchers think. For example, we looked at a community playground as a positive feature, yet the students who live in the neighborhood showed it in a less positive light by taking pictures of a homeless man drinking there and graffiti on the playground equipment. The track would be a great place to run, but someone was raped there and local residents are scared to take advantage of it. You wouldn’t know any of that if you didn’t have these students to provide context of their lived experience in the neighborhood.

Your research was chosen as the most influential research of 2014 that highlights the identification and elimination of disparities in health care. How do you think it achieved those goals?

A: First of all, one of main strengths is that we have such an interdisciplinary team. In addition to the academic and clinical side we have voices from the community because, at the end of day, if you’re not involving the people you are targeting how do you know you’ve got it right? The ability to use photos and narratives to show how community features impact health was important; you just can’t get that through text and quantitative information. That ties into a more comprehensive view of health; how does the environment you live in affect your health? Yes, it’s about your personal and physical characteristics but also the environment you live in. Crime, language and cultural barriers, transportation issues and lack of insurance, all affect your health and well-being. The Photovoice project gave us a better understanding of this community, and for Carolinas HealthCare System, we are better able to engage residents in coming up with effective ways to eliminate disparities.

The student research teams provided photo evidence of unsafe street crossings, dilapidated housing, water and air pollution and evidence of criminal activity. Have any of these problems been addressed?

After collecting this photo information we held presentations at neighborhood forums that included community members and stakeholders. The community decided to hold a series of wellness fairs where residents could have their blood pressure and glucose levels checked and talk to providers about their health and available services. Social service providers were also present at these fairs to address non-medical issues that impact wellness on a broader level. For example, housing code enforcers were present, offering guidance to residents on how to report their landlord for not fixing a roof or leaky plumbing. Representatives from the city’s public transit system came with maps to help residents plan how they can get to free or low-cost clinics or access social services. Our research findings didn’t lead to specific changes being made to the built environment, but community members learned how to access help and are becoming more empowered to overcome barriers to a better health.

Your paper also notes several positive factors contributing to community health, including Women, Infant and Children Offices, a grocery store, a new fire station and schools. Why is it important to include these positive factors in an evaluation of the social determinants of health?

We can’t work with a community and just have it all be negative. You’re already dealing with a community that’s under stress; pointing out only the negative will add to that stress. You want to make sure that residents are aware of the positive aspects of their community and their potential. If there is a park or playground in the neighborhood maybe it should be salvaged and be available for families and kids to use. We have to recognize that people bring strengths to their community as do local businesses, they may just be undiscovered. When we conduct our focus groups and neighborhood forums we always want to end on a positive note.

What comes next for MAPPR?

One of our immediate next steps is to analyze data from interventions like the wellness fairs and community forums that took place after the Photovoice project. We are also interested in engaging local youth and families in another project that looks at the impact of social determinants of health and the built environment on obesity. In addition, we plan to look at the mental health and well-being in the Latino immigrant community as this has been something that has been coming up as an issue for a long time. Lastly, Claire was inspired by this Photovoice project to continue participatory research with Latino immigrant youth for her dissertation.

Tue, 17 Mar 2015 12:30:00 -0400 Dwayne Proctor Social Determinants of Health Built Environment and Health <![CDATA[Wellness in a Networked World: Pioneering Ideas Podcast Episode 8]]>

RWJF’s Pioneering Ideas Podcast explores cutting-edge ideas with the potential to build a Culture of Health. Subscribe on iTunes.

I’m speaking at SXSW this week, the annual festival in Austin, Texas, that brings together creative people from a range of fields to share ideas, many of them related to technical innovation. As I mingle with these innovators, it feels appropriate to be sharing the latest episode of our podcast, which explores how technology can promote well-being by connecting us to our essential self, what our knowledge of social relationships—and social media—can mean for how we design our communities, and how institutions can create organizational cultures where health and socially conscious innovation thrive.

I hope you’ll give it a listen, then join the conversation using the comments below or on Twitter at #RWJFPodcast. And if you’re also at SXSW and have ideas to share about building a Culture of Health, I hope you’ll reach out to me at @lori_melichar.

Here’s what you’ll find in this episode:

Learn about the people and topics in past episodes.

(Please note that this podcast player might not work in some versions of Internet Explorer. Please view this page in another browser, such as Chrome, Firefox or Safari. You may also access the episode via SoundCloud.)

Mon, 16 Mar 2015 10:28:00 -0400 Lori Melichar <![CDATA[How Childhood Experiences Shape Our Nation's Health]]>

New findings strongly suggest that Americans are ready for new approaches to address early childhood trauma and stress. To do that in a big way, we need more than science—we need a movement.

I remember when I first learned about research showing that what happens to a person as a child impacts their health later in life. It was 2007, and I was pregnant with my first child. My boss and mentor, Jim Marks, brought the Adverse Childhood Experience’s (ACE) study to my attention. The Centers for Disease Control and Kaiser Permanente had surveyed 17,000 Kaiser members about their childhood experiences and compared the answers to those members’ medical records.

The ACE researchers found that the more trauma and stress you experienced as a child, the more likely you were to have cancer, heart disease, and diabetes as an adult. The more likely you were to suffer from chronic depression, be addicted to drugs and alcohol, or attempt suicide. And the more likely you were to drop out of school, be incarcerated, or chronically unemployed.

As a new mom, this research completely changed the way I thought about my role as a parent and what I wanted for my kids. As a health professional, it also changed my focus at work. It prompted me to focus more on violence and trauma—which is especially toxic to children—and to help RWJF launch Start Strong, a groundbreaking initiative to prevent dating violence and teach teenagers healthy relationship skills. I also worked with my colleagues to learn everything we could from experts on childhood trauma and adversity. Those lessons led to a new portfolio of RWJF investments focused on promoting the social and emotional wellbeing of families and children and preventing childhood trauma in homes and communities.

It turns out that what took scientists a long time to understand is relatively intuitive to most Americans. Last week, RWJF, NPR and Harvard University’s School of Public Health released a new survey, which found that Americans overwhelmingly believe that our health as adults is shaped by what we experience as children. The following are just some of the highlights of that study:

  • 9 out of 10 Americans (89%) believe that being abused or neglected as a child has an extremely or very important impact on health as an adult. 
  • 2 out of 3 Americans (66%) believe that living in poverty as a child has an extremely or very important impact on health as an adult.
  • 4 out of 10 Americans (39%) report that they have had one or more childhood experiences they believe had a harmful effect on their health as an adult.

These findings strongly suggest that Americans are ready for new approaches that strengthen families with young children from the start and provide protection and healing to those who are most likely to experience childhood trauma. To do that in a big way, we need more than science. We need a movement.

One of the movement’s most promising leaders is a San Francisco pediatrician named Dr. Nadine Burke Harris. Around the same time that I first learned about the ACE study, Dr. Burke Harris experienced the same revelation. At the time, she was primarily seeing kids who grew up in homes and neighborhoods where violence and poverty were common. She started administering the ACE survey to her patients, saw the same pattern emerge, and reinvented her practice to treat root causes rather than symptoms of illness. Today, Dr. Burke Harris is bringing the science of early childhood to a national audience.

Those of us in the health sector have a hugely important role to play in this movement, but we cannot do it alone. We need additional partners who can accelerate progress for children and families.

Recently, RWJF began partnering with the National Governors Association’s Center for Best Practices to help states promote child development, social and emotional skill building, and health within early care and school settings. They will work directly with governors and their staff to share research and innovation, develop model policies, promote interagency collaboration, and provide technical assistance.

We are also now working with the Council for a Strong America to enlist and elevate unexpected messengers who can make the case for investments in early childhood. With their leadership, we will expand the movement to include unlikely allies from business, law enforcement, the military, the faith community and professional sports. Scientists and doctors are now telling us that early experiences are tied to a person’s health. But we also need these other voices to make the broader case that the experiences of the next generation of children will determine our nation’s health and prosperity.

In the coming months, we will continue to share news of even more opportunities to broaden and deepen this movement to strengthen children and families. In the meantime, we encourage you to help us spread the knowledge that childhood experiences matter. Because anyone with that knowledge can be a spark for change.

Thu, 12 Mar 2015 15:36:00 -0400 Kristin Schubert Early Childhood Development Mental and Emotional Well-Being <![CDATA[Investing in Systems Changes to Transform Lives]]>

We know that in order to address health disparities head on, we'll have to implement changes to the systems that influence where we live, learn, work, and play. Oscar and Jose's stories show us that it's possible.   

I was looking at somebody who could be a great person...who could do something great in his future. I also knew that if I sent him to prison, I’d knock him off of that road to success.

In the quote above, Steven Teske, a Juvenile Chief Judge in Clayton County, Georgia is describing the first time he encountered 15-year-old Oscar Mayes as he entered the courtroom in handcuffs. Judge Teske noticed that Oscar was an extremely bright young man and that he had no prior run-ins with the law. Yet Oscar was facing five years in the state’s long term lock up—five years that could have ruined his future.

Fortunately, Oscar literally got a Second Chance. This Clayton County initiative gives youth facing prison an opportunity to redeem themselves through intensive supervision, participation in evidence-based treatment programs, and weekly check-ins with the court. Judge Teske and others in his community had realized that too many of their students were falling out of school and heading into the criminal justice system. To address this, the Juvenile Court partnered with local schools and law enforcement to find ways of disciplining youth while keeping them “in school, out of court, and onto a positive, healthy future.”

Interventions like this have yielded impressive statistics in Clayton County: School arrests have gone down 83% and school attendance has gone up 86%. Clayton County’s approach to juvenile justice reflects the transformational impact that changing a system can have.

What are systems changes and how is the Robert Wood Johnson Foundation (RWJF) investing in them?

Systems are the practices, policies and procedures of institutions, corporations, agencies and other organizations that influence the determinants of health. Improving systems—and the way they work together—is our approach to eliminating health disparities.

It’s only when we critically examine these systems—be they access to quality health care, income, public safety, community environment, employment, housing, education—that we can find approaches to improve lives and reduce health disparities. We want everyone in our country to have an equal opportunity to live a healthier life which is vital to building a Culture of Health.

It’s frustrating to acknowledge that currently, this is not always the case. As RWJF’s own Dwayne Proctor noted, if you’re black you’re 21% more likely to die from heart disease than if you’re white. If you live in the “Deep South” your life is an average of three years shorter than if you live in other parts of the country. Health disparities like these affect individuals but they also threaten the prosperity of entire communities. We want to change this.

To do so, we are launching the RWJF Awards for Eliminating Health Disparities to recognize and celebrate those who have successfully implemented systems changes to eliminate health disparities. In doing so, we’re delving deeper into the determinants that impact health—the neighborhoods we live in, the schools our children attend, the jobs we work and the resources inside our communities. And we’re hoping to heighten awareness around the power of systems change.

Jose’s story: From school suspension to college

There’s one more powerful example that illustrates the impact that changing the system can have. Last year our colleague Maisha Simmons met Jose, a bright student from Chicago who used art as an outlet to express love, fear, joy and pain. He spread his art everywhere—on notebooks, text books and eventually the walls and fences of his community. Despite efforts of a relative to channel Jose’s passion into a community art program, one day Jose found himself in the principal’s office when teachers and staff wrongfully implicated him for vandalizing school property.

Unable to prove his innocence, Jose was suspended from school and found himself falling behind classwork—threatening his chance to graduate. Since art now reminded Jose of his struggles at school, he withdrew from his passion.

Fortunately for Jose, Chicago houses the Safe Schools Consortium, a coalition that offers less disruptive approaches to school discipline. A nonprofit partner of Safe Schools—VOYCE—offered him a chance to share his story and resume using art to positively impact his community. Thanks to this partnership, rather than dropping out of school, Jose is now in college.

Oscar and Jose are only two of a myriad of people who have benefitted immensely from systems changes. What we realize, and now want to promote, is how systems that may have previously tracked them into potentially less healthy lives may be reworked into systems that guide them and others towards a Culture of Health.

Tue, 10 Mar 2015 10:00:00 -0400 Catherine Malone Health Disparities <![CDATA[It’s Not Just the Watch: Apple Also Helping Cancer Patients]]>
Laurie Becklund Laurie Becklund (photo by Bob Barry)

“I am dying literally, at my home in Hollywood, of metastatic breast cancer ... For six years I’ve known I was going to die, I just don’t know when.”

That was written by renowned journalist Laurie Becklund, a former Los Angeles Times correspondent, shortly before she died on Feb. 8 at age 66. Her powerful Los Angeles Times essay was not a lament, however, but a fierce call to action for better cancer research; informed by much, much better data.

As she noted, each cancer patient’s disease is unique, yet there is no system in place to gather data on these tens of thousands of individual diseases. If there were, the data would enable both lab research and clinical trials to be far more efficient, and effective. “The knowledge generated from our disease will die with us because there is no comprehensive database of metastatic breast cancer patients, their characteristics, and what treatments did and didn’t help them,” Becklund wrote. “In the big data era, this void is criminal.”

I agree. But such a database may finally be in the offing, thanks to the rapid proliferation of mobile devices. Apple Computer’s watch will likely add to that proliferation, but that’s not why we at the Robert Wood Johnson Foundation (RWJF) are excited about the company’s big announcement today. Apple also announced ResearchKit, a software framework it developed that helps doctors and scientists conduct medical research by collecting data more frequently and more accurately from people who are using mobile apps. In addition, Apple shared news of a suite of five free mobile apps for ResearchKit—two of which were developed by Sage Bionetworks with RWJF support.

The Sage Bionetworks apps, mPower and Share the Journey, gather personal data on Parkinson’s disease and breast cancer, respectively, and provide patients with a key safeguard—the ability to use their mobile devices to provide informed consent for use of their data. By ensuring that patients can choose how and when their personal health data is shared, more people should feel encouraged to participate in the kinds of databases Becklund was calling for.

The other three apps released with ResearchKit focus on cardiovascular disease, diabetes, and asthma, respectively.

Data from all five apps will be collected and aggregated via BRIDGE, a Sage Bionetworks platform also developed with RWJF funding that allows people to easily contribute their health data to research studies, with appropriate privacy safeguards.

People who live with all of these diseases are untapped experts, and ResearchKit gives them the opportunity to share their expertise with biomedical researchers. Although the apps announced today focus on specific diseases, it is just the start. We believe that data collected via apps will help researchers and policymakers gain all kinds of insights into population health and the actions needed to improve health for all.

The Sage Bionetworks apps are not RWJF’s first health IT rodeo. We’ve been working in this space for more than a decade, supporting a broad range of projects that are exploring the ways technology and data can transform health. A few examples:

  • MIT Media Lab—In September RWJF supported the launch of a Wellness Initiative to address the role of technology in shaping our health.
  • PatientsLikeMe—With support from RWJF, this network of patients is building a platform, the Open Research Exchange, to develop new measures for capturing and reporting different aspects of health.
  • Open mHealth—To make digital health data as useful as possible, it is building products designed to bolster collaborative, connected, personalized care.
  • Quantified Self Labs—The Quantified Self-Access Program is convening stakeholders, highlighting innovative solutions to patient data access, and fostering awareness and collaboration among developers, health care providers, and patients.
  • Genetic Alliance—In December RWJF supported the creation and evaluation of the effectiveness of a simplified version of its Platform for Engaging Everyone Responsibly (PEER), which enables people to share health information with researchers and each other on their own terms.
  • Health Data Exploration Project—The project is creating a network of innovators in personal health data to catalyze the use of personal data for the public good.

We encourage others to join in this effort to make patient data accessible and useful. As Laurie Becklund wrote, “patients shouldn’t have to climb up ladders and fall down chutes.” It’s time to end this game.




Mon, 9 Mar 2015 11:21:00 -0400 Catherine Arnst Health Data and IT <![CDATA[What Will it Take to Help All Kids Grow Up at a Healthy Weight?]]>

We can all play a role in helping children grow up at a healthy weight, including the U.S. Soccer Foundation. Their work is helping make strides in reducing childhood obesity rates. Here's how.

A group of teens playing soccer.

Washington, D.C.’s Shaw neighborhood is named after Colonel Robert Gould Shaw, who commanded the famed 54th Massachusetts Volunteer Infantry, the all-black regiment that fought for the Union during the Civil War. Today, the multi-ethnic neighborhood is home to the U Street Corridor, a revived commercial district known in the early 1900s as “Black Broadway"; Ben’s Chili Bowl, a celebrated city landmark; and Seaton Elementary, a public school whose students are mainly Hispanic, African-American, and Asian.  

It’s also home to the young goalie of Seaton’s soccer team, sixth grader Kevin Alvarez.

Like many kids in his neighborhood, Kevin, age 13, never played sports until recently, and was seriously overweight. Then his school was fortunate to become home to Soccer for Success®, a program managed locally by DC SCORES, a Washington, D.C., nonprofit.

Today, Kevin is one of thousands of children nationwide who’ve lost weight, and seen marked improvements in health and fitness, as a result of the physical activity and nutrition components that make up Soccer for Success. 

Soccer for Success, a program of the U.S. Soccer Foundation (an RWJF grantee), now serves approximately 30,000 youth in 34 cities. It focuses especially on communities where obesity rates exceed the national average. “One of the good things about soccer is that boys and girls play equally, so you can have one program in an after-school setting,” says Ed Foster-Simeon, president and CEO of the U.S. Soccer Foundation. “It’s also low cost, because all you need is a little bit of space, and a ball.”

Besides advancing physical activity and healthy lifestyle choices, Soccer for Success also emphasizes coaches’ mentorship of kids, and engagement of entire families in the benefits of sports and nutrition—in locations around the country where those factors may be in short supply. As such, Soccer for Success is a prime example of fighting broad national health problems like childhood obesity through approaches specifically tailored to the needs of communities most affected by them.

"As RWJF launches its efforts to ensure that all kids grow up at a healthy weight—no matter who they are or where they live—there will be a broadened and intensified focus on closing health disparity gaps that currently exist", says Ginny Ehrlich, director of the Foundation’s efforts to reduce child obesity.

“There’s a lot of buzz around the notion” that rates of child obesity are leveling off or falling in many states, especially among the nation’s youngest children, says Ehrlich. “But we still have a lot of work to do, and we can’t claim victory until all kids have the opportunity to be healthy.”

Kids, that is, like Kevin Alvarez, whose soccer career—and path to lifelong health and fitness—now seem unstoppable.

Live Discussion: Helping All Kids Grow Up at a Healthy Weight

On Friday, March 6, the Foundation hosted a discussion on its renewed commitment to help all children in the United States grow up at a healthy weight. The conversation touched on strategies to eliminate the health disparities that contribute to higher obesity rates among children of color and children living in poverty.

Watch the video, below.

Wed, 4 Mar 2015 11:16:00 -0500 Susan Dentzer Childhood Obesity <![CDATA[Poll: People Worry about Far More than Disease When it Comes to Health]]>

Q&A with Robert Blendon, Harvard T.H. Chan School of Public Health


This week a public opinion poll was released by NPR, the Robert Wood Johnson Foundation, and Harvard T.H. Chan School of Public Health asking people to list the factors most likely to cause ill health in adults. The top five included lack of access to high-quality medical care (42%), and viruses or bacteria (40%)—not a surprise—but also such socio-economic factors as personal behavior (40%), high stress (37%), and exposure to air, water, or chemical pollution (35%). And a majority (54%) said that being abused or neglected in childhood is an extremely important risk factor for ill health later in life.

Robert J. Blendon, Richard L. Menschel Professor of Health Policy and Political Analysis at Harvard T.H. Chan School of Public Health, led the poll and recently talked to RWJF Media Director Catherine Arnst about some of the key results. (Both questions and answers were edited for clarity)  

Robert J. Blendon Q&A with Robert Blendon, Harvard T.H. Chan School of Public Health

What do you think is most significant about this poll?

Most polls about health attitudes tend to focus on the problems of health care, or on specific diseases. This poll is one of the very few that asked people broadly about what they think shapes the future of their own health. The thing that is surprising is that when you focus on overall health people see a number of very broad- based issues, not one single issue. They have a much more nuanced view of health than might have been expected --and that’s very important. People are concerned not just about the quality of their medical care but also about personal behavior, stress, lots of factors. There was a great deal of conversation about pollution as a health risk, for example.

Did you see a difference in the answers based on peoples’ income?

Yes, especially in terms of the order of the factors affecting health. For lots of higher income people access to medical care didn’t rank as high as it did in the poll overall. Higher income people are less concerned about economic issues, and more concerned about stressful work situations, or pollution.

What are some of the specific factors that ranked higher than you might have expected?

The connection made between housing and health surprised me. A good deal of lower income people are more aware than I would have thought that neighborhoods with pollution and poor safety and poor housing create risks that threaten health.

Do you think the recession may have had an impact on the responses?  Would the results have been different in a stronger economic environment?

When you are in the worst part of an economic downturn, job issues are always the number one concern. However, this poll also surfaced concerns about housing, the health of neighborhoods, and the environment, that are not connected to the economy. For example, people have truly gotten the message about pollution’s impact on health—that wouldn’t have been true two decades ago.

Do you think the implementation of the Affordable Care Act a year ago had an impact on the poll results?

In almost every (demographic) sector, access to health care ranked high. That’s a little surprising, and it may be that the rollout of the ACA raised awareness of this issue. But the poll also sends a signal that if you get people to focus on health, they are willing to listen to a broad discussion about improving a variety of social and environmental conditions.

What is your big takeaway from this survey?

That there are a lot of factors that must be addressed to improve health beyond access to health insurance. And that a lot of the things that affect the health of adults could be eliminated if we improved the lives of children—abuse and neglect, poor diet, living in polluted communities, for example.

We found it interesting that only four in ten people thought that their health is better than their parents’ health. Of course, parents want their children to be better off. So health policies have to address these broad factors in order to make that happen.

Read through the full poll results in the report.  NPR’s stories related to the poll results can be found here.

Tue, 3 Mar 2015 09:52:00 -0500 Catherine Arnst Social Determinants of Health <![CDATA[A Warrior for a Healthier, More Equitable America]]> Andy Hyman / RWJF Andrew D. Hyman, JD

Andy Hyman was a warrior for a healthier, more equitable America.

He dedicated his life and career to social justice and progress for the most vulnerable people among us. As a government official, advocate, and philanthropic leader, Andy was tenacious in his pursuit of a singular vision: that everyone in America would have the coverage necessary to access high quality health care—physical, behavioral, or both.

And what incredible success he had.

A few years ago, Andy noted: “Sadly, 50 million of our fellow Americans—nearly one in six of us—are uninsured.” He was determined to change that, and his efforts to ensure that people enrolled in coverage—whether it be Medicaid, the Children’s Health Insurance Program, or marketplace plans under the Affordable Care Act—have paid off.

Today, millions of low- and middle-income families are able to enjoy a level of improved health, financial stability, and peace of mind they never have before.

Former U.S. Congressman Patrick Kennedy told me today, “Andy had a profound effect on the movement.”

“Every fiber of his body was genuinely and fully committed to the achievement of high quality, affordable health coverage and care for everyone,” said Ron Pollack, the founding executive director of Families USA. “For those of us engaged in this noble cause, Andy was a soul brother.”

Andy was a giant in the field of health reform. He was trusted, admired, and loved by the many people who shared his vision.

Chris Jennings, who served as a senior health policy adviser in the Clinton and Obama White Houses, lauded Andy’s “indisputable legacy of achievement that has and will continue to improve the lives and health of millions of people.”

Jack Ebeler, a former Department of Health and Human Services official and a long-time health policy leader remembers Andy’s critically important efforts “to stimulate attention to and solutions for the uninsured at a time when it was easier to be skeptical because the political environment was not receptive.”

Andy worked tirelessly to create the State Health Reform Assistance Network to help states implement the coverage provisions of the health care law. The program’s director, Heather Howard, recalled that Andy “uniquely understood the perils in implementation, and embraced the challenge.” In doing so, “he helped states achieve the biggest expansion of health coverage since the 1960s.”

But Andy didn’t only focus on how state governments would implement the law. He also made sure that consumer advocates had a seat at the tables where decisions are made. To that aim, he helped establish Consumer Voices for Coverage, a national program designed to strengthen the role consumer advocates play in state health reform efforts.

Community Catalyst’s Susan Sherry, who leads the Consumer Voices for Coverage program, praised Andy for creating “incredibly vibrant, smart, and effective permanent consumer health advocacy on the ground—where it matters most to real people.“

Lynn Blewett, of the University of Minnesota’s State Health Access Data Assistance Center said, “Andy believed in the power of data and information to transform debate, in effective communication to influence policy, and in not accepting the status quo.“

“Andy was a visionary risk taker who worked tirelessly to support research and policies aimed at improving the lives of the vulnerable people around the country about whom he cared so deeply and wanted to help,” said Genevieve Kenney, co-director of the Health Policy Center at the Urban Institute. “He was not afraid to find ways to work around the rules to get things done and was willing to stick his neck out to try new things if he thought it would help achieve important goals.”

Sabrina Corlette, project director at Georgetown University's Center on Health Insurance Reforms, called Andy “the best of all possible partners. He asked the tough questions, made us do our due diligence and held us to the highest of high standards. When it was time to start work, he placed his total trust and confidence in us.”

Bruce Lesley, head of First Focus, a national children’s advocacy group, praised Andy’s talent for connecting people across divides, “whether they were Democrats, Republicans, and Independents; or consumers, insurers, advocates, and business leaders—toward the goal of finding common ground and solutions to our nation’s health care problems. He just knew that if he could get the right people to talk to each other that magic might happen.”

“He had a rare combination of wisdom and compassion, not to mention a wicked sense of humor,” said Karen Pollitz, a senior fellow with the Kaiser Family Foundation. Reflecting on their time as colleagues at the Department of Health and Human Services, Pollitz recalled, “We were young then, and determined to work for change so people could live securely and with dignity. For the rest of his life, Andy did that in so many profoundly important ways.”

Personally, I always appreciated and admired Andy’s passion for social change. He was brilliant, creative, charismatic, and funny. He was not beyond relentlessly pushing anyone—including me—out of the comfort zone, or even being a bit stubborn if he thought it would advance the cause of the disenfranchised.

At the Foundation, and among his social circles, Andy was known for going the extra mile to help colleagues and friends who were trying to navigate the health care maze. He always was willing to give of his personal knowledge and time when he knew it would benefit others.

Underneath it all beat the heart of a man with the highest principles, determined to improve the lives of the most disadvantaged people among us. He challenged us to uphold those same principles and to weave them into everything we do, just as he did.

At RWJF, we will not forget the lessons Andy taught us as we pursue his legacy of a healthier, more equitable society—one where a Culture of Health flourishes for everyone.

The nation lost a great man this week. All of us at the Robert Wood Johnson Foundation are truly heartbroken, and our thoughts and prayers are with his family and beloved children.

As you think about Andy, recall Helen Keller’s words:  “What we have once enjoyed deeply we can never lose. All that we love deeply becomes a part of us.”

I hope you’ll take a moment to share a story or reflect on a memory about Andy in the comments section below.

Fri, 27 Feb 2015 16:23:00 -0500 Risa Lavizzo-Mourey From the President <![CDATA[The Secret to Successful Health Partnerships]]> raising hands graphic

Across the country, there is growing awareness that restraining the increase in health costs and improving the health outcomes will require approaches that address the full array of factors that affect health. Greater attention and resources must be devoted to promoting a safer environment, healthy lifestyles, prevention of illnesses and injuries, and early detection and treatment of health problems, as well as dealing with the underlying determinants of health. Improving access to outpatient and inpatient medical services and the quality of those services, while vitally important, are not enough.

To effectively design, implement, and sustain a comprehensive approach to promoting the overall health of communities, we need meaningful collaboration among healthcare delivery organizations, governmental public health departments, and other community stakeholders. Unfortunately, while there is evidence of some increase in recent years, decades of limited communications, lack of mutual understanding, and incongruent goals have inhibited collaboration among these groups across the country. The University of Kentucky College of Public Health recently conducted a study intended to accelerate change, encourage collaboration, and contribute to building a Culture of Health in America. The purpose of the study is to identify successful partnerships involving hospitals, public health departments, and other stakeholders in improving the health of communities they serve and elevate key lessons learned.

The 12 partnerships in the study have involved hundreds of public and private organizations and thousands of community volunteers from various corners of the country. From New Orleans, Louisiana to New Ulm, Minnesota, these efforts have successfully informed broad cross-sections of their communities around the determinants of health, local issues that need to be addressed, and the long-term value of improving the overall health of their communities. Through engaging community organizations and citizens in their programs and activities, these partnerships are generating collective interest and action, building community spirit and social capital, and helping to build a Culture of Health within the communities they serve.

Formal partnerships involving hospitals and/or health systems, public health departments, and other stakeholders who share a commitment to improving the health of the community they serve have an important social role. These partnerships can serve as effective vehicles for collective action. But this is difficult work with substantial challenges, so our team formulated eleven recommendations for community leaders and policy makers to consider when developing effective and durable partnerships:

  • To have enduring impact, partnerships focused on improving community health should include hospitals and public health departments as core partners but, over time, engage a broad range of other parties from the private and public sectors.
  • Whenever possible, partnerships should be built on a foundation of pre-existing, trust-based relationships among some, if not all, of the principal founding partners. Other partners can and should be added as the organization becomes operational, but building and maintaining trust among all members is essential.
  • In the context of their particular community’s health needs, the capabilities of existing organizations, and resource constraints, those who decide to establish a new partnership devoted to improving community health should adopt a statement of mission and goals that focuses on clearly-defined, high priority needs and will inspire community-wide interest, engagement, and support.
  • For long-term success, partnerships need to have one or more “anchor institutions” with deep dedication to the partnership’s mission and commitment to provide on-going financial support.
  • Partnerships focused on improving community health should have a designated body with a clearly-defined charter that is empowered by the principal partners to set policy and provide strategic leadership for the partnership.
  • Partnership leaders should strive to build a clear, mutual understanding of “population health” concepts, definitions, and principles among the partners, participants, and, in so far as possible, the community at large.
  • To enable evidence-based evaluation of a partnership’s progress in achieving its mission and goals and fulfill its accountability to key stakeholders, the partnership’s leadership must specify the community health measures they want to address, the particular objectives and targets they intend to achieve, and the metrics they will use to track and monitor progress.
  • All partnerships focused on improving community health should place priority on developing and disseminating “impact statements” that present an evidence-based picture of the effects the partnership’s efforts are having in relation to the direct and indirect costs it is incurring.
  • To enhance sustainability, all partnerships focused on community health improvement should develop a deliberate strategy for broadening and diversifying their sources of funding support.
  • If they have not already done so, the governing boards of nonprofit hospitals and health systems and the boards of local health departments should establish standing committees with oversight responsibility for their organization’s engagement in examining community health needs, establishing priorities, and developing strategies for addressing them including multi-sector collaboration focused on community health improvement.
  • If they have not already done so, local, state, and federal agencies with responsibilities related to population health improvement and hospital and public health associations should adopt policy positions that promote the development of collaborative partnerships involving hospitals, public health departments, and other stakeholders focused on assessing and improving the health of the communities they serve.

We think a paradigm shift is occurring in America: there is growing realization that controlling the increase in health expenditures and improving the health of our nation’s population will require major changes in traditional policies, practices, and organizational models. These partnerships are bold pioneers and, we hope, as harbingers of a new era of innovation and multi-sector collaboration focused on building a robust Culture of Health throughout America.

Have you built effective health partnerships? Share your story in the comments below.

Thu, 26 Feb 2015 10:58:00 -0500 Robert Pestronk Public and Community Health <![CDATA[Setting Our Sights on Healthy Media Consumption]]>

Alonzo Plough, PhD, MPH, is vice president, Research-Evaluation-Learning and chief science officer for the Robert Wood Johnson Foundation. Read more from his series.


Childhood obesity is a tremendous threat to the current and future health of our young people. Compared with their healthy-weight peers, obese children face a higher risk for serious health problems, miss more school, have greater psychological stress, and are more likely to become obese as adults. If we don’t do something to reverse this epidemic, the nation’s current generation could be the first in history to live sicker and die younger than their parents’ generation. This is why RWJF recently pledged $500 million over the next 10 years to support strategies aimed at helping all children in the United States grow up at a healthy weight. This new funding increases our investment in preventing childhood obesity to more than $1 billion—the largest commitment we have ever made on a single issue.

We are in it for the long haul, and we have already seen signs of progress. Research published last year showed obesity prevalence among 2 to 5 years old dropped by approximately 40 percent in eight years. But nearly one-third of children and adolescents in the U.S. are still obese or overweight, and more than 25 million are at risk for high blood pressure or Type 2 diabetes because of their weight.

Improving the nutrition of children’s foods is an essential step in helping to reduce obesity rates, but marketing of unhealthy foods also plays a powerful role in shaping young people’s food preferences and consumption. To address this, part of the Foundation’s research strategy is to monitor the marketing of unhealthy foods and beverages and to measure its impact on childhood obesity. To build evidence around what is working in reducing childhood obesity and identify where progress is needed, RWJF is funding research at the University of Connecticut Rudd Center for Food Policy and Obesity. Here is what Rudd researchers have found:

  • While many companies have reduced their advertising of unhealthy foods on children’s television, children’s media tastes expand far beyond kid-oriented programming. The Better Business Bureau's Children’s Food and Beverage Advertising Initiative (CFBAI), a voluntary program that includes industry leaders such as McDonalds, General Mills and Pepsico, pledges to advertise only healthier options to children. The CFBAI pledge applies to all media (television, magazines, websites) whose audiences are made up of at least 35 percent of children age 11 and under. By using detailed media data from Nielsen, Rudd researchers found that the CFBAI parameters capture less than one-half of the TV ads viewed by children under the age of 12 and none of the websites they regularly visit. In fact, even though the CFBAI companies scaled back on their television advertising, they placed 46 million ads for their products on children’s websites in 2013. The CFBAI measures also don’t factor in marketing that reaches children on mobile devices and social media sites that include Facebook, Twitter and YouTube.
  • Companies extensively market fast food to older children and teens. In the Fast Food Marketing 360 Brief, researchers explain that a 50 percent decrease in display ads on youth websites has almost completely been replaced by an increase in ads and videos on social media sites that include Facebook (viewed by an average of 18 million 2-18 year olds every month), Twitter and YouTube. Marketing on mobile devices is also on the rise, with most fast food restaurants offering free apps available for download that provide nearby locations and menu choices.

As the media universe expands, it’s clear that more remains to be done to ensure that industry self-regulation and government guidelines adequately protect children from exposure to unhealthy food and beverage marketing.

RWJF-supported research is helping to jumpstart the dialogue about expanding the current definitions and approaches used to advertise and market foods and beverages to children.  For example, the Healthy Eating Research national program convened a panel of national experts who developed recommendations for responsible food marketing practices directed at children. They offer model definitions for food marketing practices, such as:

  • The child audience is defined as birth to 14 years of age.
  • Media and venues are considered child-directed if children constitute 25 percent or more of the audience or if an assessment of the marketing strategies, techniques, characteristics, and venue suggests that children are the target demographic for the advertising or marketing message.
  • Any marketing that is especially appealing to kids is child-directed.
  • Brands marketed to children contain only products that meet nutrition criteria.

When paired with strong nutrition criteria already in place, these recommendations may help leaders across many sectors find common ground to create healthy food environments for all children.

Adopting such approaches need not be onerous for food and beverage companies. In fact, Better-For-You Foods: It’s Just Good Business, another research effort supported by RWJF, found that between 2006 and 2011, companies that committed to growing their lower-calorie/better-for-you foods and beverages enjoyed superior operating profit growth. The healthier items also drove more than 70 percent of companies’ sales growth.

How does this all relate back to curbing childhood obesity? It’s simple; companies are advertising across an increasing range of media platforms to reach children and influence their choices around food and beverages. This marketing must encourage nutritious, healthy foods and beverages if we really want to reduce childhood obesity. Producing, pricing, and promoting healthy products to make them the easy and everyday choice for kids and families could be a win-win. There is solid evidence that an emphasis on healthier products and responsible marketing is good not only for consumers, but also for the bottom line.

Mon, 23 Feb 2015 16:27:00 -0500 Alonzo L. Plough Childhood Obesity Children (6-10 years) <![CDATA[A Portrait of Women with Health Insurance]]> 2015 Health Care Coverage Billboard Woman Image

For the second year running, more women than men have signed up for coverage in health insurance marketplaces during open enrollment under the Affordable Care Act. According to the Department of Health and Human Services, enrollment ran 56 percent female, 44 percent male, during last year’s open enrollment season; preliminary data from this year shows enrollment at 55 percent female, 45 percent male—a 10 percentage point difference.

What gives? An HHS spokeswoman says the department can’t explain most of the differential. Females make up about 51 percent of the U.S. population, but there is no real evidence that, prior to ACA implementation, they were disproportionately more likely to be uninsured than men—and in fact, some evidence indicates that they were less likely to be uninsured than males.

What is clear that many women were highly motivated to obtain coverage under the health reform law—most likely because they want it, and need it.

Women Health Insurance

It’s widely accepted that women tend to be highly concerned about health and health care; they use more of it than men, in part due to reproductive services, and make 80 percent of health care decisions for their families. The early evidence also suggests that women who obtained coverage during open enrollment season last year actively used it.

According to Inovalon, a company that tracks and analyzes data for health plans and providers, people who used the coverage they bought through the marketplaces last year tended to be older, sicker, and more female than the general commercially insured population. As of June 2014, 41 percent of females who purchased coverage through exchanges had face-to-face visits with health care professionals, versus 32 percent of males.

Those numbers are consistent with the notion that many women who signed up for coverage under the ACA had preexisting conditions or other health issues that led them to seek treatment. In some cases, their pre-ACA insurance may have excluded those conditions, or the preexisting conditions may have prevented them from obtaining coverage at all.

What’s more, as HHS points out in a recent report, there are plenty of benefits in the ACA’s qualified health plans that are especially attractive to women. These include coverage at no out of pocket cost for many preventive measures, such as mammograms or screening for gestational diabetes. An estimated 48.5 million are benefitting from that provision of the law alone.

Other data support the notion that many U.S. women are in disproportionately higher medical need, relative to men—even adjusting for the fact that they typically live longer. According to an analysis of Medical Expenditure Panel Survey data from the Agency for Healthcare Research and Quality, women constitute nearly 60 percent of people in the top tenth of medical expenditures in 2011 and 2012. Most of those in the top tenth of spending are either ages 45 to 64, or 65 and older.

One obvious conclusion is that many, and perhaps most, of those who’ve benefited from coverage under the Affordable Care Act are female—and especially women in middle age and beyond. Another is that, if the Supreme Court rules in King v. Burwell that subsidized coverage can’t be obtained through the federal marketplace, women will be disproportionately harmed.

A case in point: Rosemary Forrest, 63, who lives in Augusta, Georgia. Laid off from her job at a university science lab at age 55, she spent five years unemployed and without health insurance.  She now works as a contractor to a small nonprofit agency; battling painful osteoporosis, she sometimes earns less than $400 a month. Last year, when the federal health insurance marketplace went live, she signed up for coverage. This year, she re-enrolled, and after federal tax credits, pays $86 per month in premiums.

Forrest says the subsidized coverage has been a godsend. “I am very nervous” about losing it, she adds.

Thu, 19 Feb 2015 14:21:00 -0500 Susan Dentzer Women and girls <![CDATA[Looking Back, Looking Ahead: Banding Together to Fight for Health Care Value]]> L1032033_JHW Key health care stakeholders have joined forces to work toward improved quality of health care available to the rural, low-income population of Humboldt and Del Norte Counties, Calif. (AF4Q)

Sometimes it feels like we take one step forward, two steps back when it comes to making sure that we are getting the best quality health care for the tremendous amount our society invests in it. Maybe sometimes it’s one step forward, three steps back.

But then I think about Aligning Forces for Quality—RWJF’s signature initiative to lift the quality and equality of care in 16 regions around the country—and my hope returns. While progress is slow, it is still progress.

More than 10 years ago, RWJF’s leadership suggested to me that we change course in our health care quality improvement strategy. Instead of testing single interventions in widely scattered sites, they asked, why not focus on a limited number of target communities where we could go deep with multiple approaches? We knew health care is essentially local, though shaped by state and federal policy.

We also knew no single “silver bullet” role or organization or intervention could fix our troubled health care system. What would happen if we brought together the people who give care, get care and pay for care together around shared information about the performance of their local health care systems? At the time, there were really no other public or private initiatives taking this kind of community-level, comprehensive approach; we were very lucky to have the support of our Board of Trustees and senior leadership to explore it.

In 2015, we will see the end of Aligning Forces for Quality. This past November, the friends and family of Aligning Forces came together at ALIGN, a two-day summit to celebrate the program’s achievements and to reflect on how its lessons will help RWJF and our partners build a national Culture of Health.

It’s hard to summarize the accomplishments of a decade-long, $300 million initiative. Our communities’ story, and the lessons that can be drawn from them, have been documented in our Quality Field Notes and Journalists on Quality series. Sometimes I wish our lessons learned could be easily captured with a single statistic or a headline. Instead, I offer you a glimpse of our results, and the lessons we have learned.

Our first order of business was transparency. Our Alliances were required to bring together health care data from different sources and turn it into useful information on the quality of care local physicians and hospitals provided. This wasn’t only a daunting task technically, but also a real leadership test for our local Alliances to earn provider and consumer support. These early efforts paid off, with many of our Alliances now positioned as national leaders in measurement and reporting of health care quality and cost; seven of the first 10 Medicare Qualified Entities were from our communities.

I’d have liked to see our Alliances come together around a tightly defined set of common measures, and that didn’t happen, which taught me a lesson about how using just the right measure locally can be critical to engaging providers. There’s more work to be done, but I’m proud of how Aligning Forces Alliances overcame daunting barriers in order to publish those very first reports, and am equally proud of the fact that many communities now have a series of these annual reports available.

We had other struggles, too. From the start, we were fiercely committed to engaging consumers in every aspect of health care system improvement, and when people objected to the word “consumer” or told us consumers couldn’t really be partners in health care transformation, we didn’t let it stop us. Looking back, I’m proud that our Alliances have engaged consumers at every level—from governance to being more active partners in managing their own health.

Employers in many communities were not as fully engaged as I’d expected, teaching us that in many markets, purchasers still look to brokers or consultants to advise them on health care decisions. We were surprised it was often public employers—schools and counties—who led the way toward higher-value health care.

Another lesson: By setting specific expectations early on, as we did for public reporting, we pushed our young AF4Q projects to develop new partnerships and hone their data skills. But as time went on, RWJF had to start letting each Alliance develop its own strengths. Some excel at engaging consumers in community-wide health improvement. Others are first-class health care measurement and data organizations. I’m proud that at least half our Alliances have created strong organizations that will have impact long after the grant funds have been spent. Some are new organizations, some already existed, and others are a small organization in the context of a bigger network of local organizations aligned around common goals. There’s no one model for success.

We also learned that there are so many good things about making a long-term commitment to our Alliances. It allowed them (and us) to try new things, learn and adapt to changing circumstances. For example, we knew financial incentives were important to health care transformation, but it was not until 2009 that we were ready to give a few early adopter Alliances the chance to experiment with payment reform. By 2011, we were requiring every community to wade into payment reform; some didn’t get much farther than meetings to explain to community stakeholders why it’s necessary to move away from fee-for-service medicine, while others have become national leaders in implementing patient-centered medical homes or bundled payments.

So what’s next for Aligning Forces communities and RWJF? The Foundation remains committed to taking on the challenge of improving health care value—improving quality at an affordable cost.

We believe that bringing different stakeholders together around shared goals is an essential building-block for a Culture of Health. Some Aligning Forces communities have already moved beyond a focus on health care to create healthier communities. We’ve supporting the Collaborative Health Network to connect local leaders throughout the country who are working to accelerate health improvement.

Many challenges still lie ahead. One is greater consolidation of health care providers. These changes may improve efficiency, but they may also create market power that drive up prices without improving value. Some Aligning Forces communities have found that, as competition among the remaining mega-systems gets fiercer, people are less likely to collaborate around shared data, because data is a strategic competitive asset.

But I think the greatest challenge facing us, really, is the tendency to substitute more study for action. From these 16 regions and others, we know what works in very different circumstances, to create the conditions for high-value health care. We have a network of committed leaders ready to offer a hand to those who come next and who can help others, as one ALIGN attendee reminded us, avoid “reinventing the bleeping wheel.”  

The ALIGN summit was full of wilderness metaphors and images. But my favorite makes me incredibly optimistic about fixing what is broken and building a true Culture of Health for everyone:  “The pace of change may feel glacial, but a glacier changes the landscape behind it.”

Fri, 13 Feb 2015 17:06:00 -0500 Anne Weiss Health Care Quality <![CDATA[A New Approach to Eliminating Health Disparities]]> Spokane Adverse Childhood Experiences Last year, Spokane County received the Foundation's Culture of Health Prize for improving community health by addressing the critical link between poverty, education, and poor health. Here, children play at St. Anne's Center in Spokane, where teachers are trained to catch and address early warning signs that may indicate future problems in school.

I, like many others, have made a commitment to living healthier this year. I am resolved to find and eat a new fruit and vegetable each month, decrease my consumption of meat to a few times a week, and drink at least a half-gallon of water each day. I also plan to laugh more and spend more time outdoors. My personal goals aside, I also find myself more hopeful than at the start of many past years about the state of health in our nation as a whole.

  • More Americans than ever before have access to the health care they need because of the Affordable Care Act;
  • States throughout the nation are making significant progress in helping kids achieve a healthy weight;
  • The disparities gap between black and white Americans’ life expectancies is narrowing.

These bright spots indicate that America is heading down the road to better health—but they only begin to address the challenges many Americans continue to face in accessing good health. As highlighted in a recent article in the New England Journal of Medicine, significant gaps and unmet needs remain.

Authored by Marshall Chin, director of RWJF’s $8 million national program Finding Answers: Disparities Research for Change, which seeks and evaluates projects aimed at reducing racial and ethnic health care disparities, the piece points out that while differences in processes of care—such as administering shots and prescribing medicine—are becoming more equitable between racial and ethnic groups, the health outcomes are far from even. Black enrollees in Medicare plans still fare worse on control of blood pressure, cholesterol, and glucose than white enrollees, even though the care they receive has improved, writes Chin.

Unfortunately, this is a reality we at the Robert Wood Johnson Foundation understand all too well. We know that if you are black, you are 21 percent more likely to die from heart disease than if you are white. If you live in the “Deep South,” your life is an average of three years shorter than if you live in other parts of the U.S. And if you live below the poverty line, you are 25 percent more likely than higher-income Americans to develop hypertension.

Health disparities like these not only affect the day-to-day experiences of individuals, but also threaten the prosperity and well-being of entire communities. They can be experienced between ethnic groups, income groups, and regions of our nation. And while the greatest impact of health disparities unquestionably falls on those directly affected, no one is immune: these inequities hurt all of us.

It is through this lens that RWJF will approach its work this year. We are specifically targeting the elimination of these pervasive gaps in health to give everyone in our country an equal opportunity to live a healthier life.

Fortunately, we are not starting from scratch. Since 2010, RWJF has invested more than $600 million to address disparities across the health landscape. And last year, we introduced a new goal for RWJF and the nation: to build a strong, vibrant Culture of Health, enabling all in our diverse society to lead healthier lives, now and for generations to come.

Going forward, RWJF plans to take a broader approach, and focus on the systems that drive health outcomes. Eliminating health disparities is a bold and ambitious goal, but we believe it is both achievable and necessary to ensure the health and prosperity of our nation. Our new efforts will embed the disparities lens in all that we do, and connect the dots between investments so that our work—and the work of our allies—go further to strengthen the programs, institutions, and resources that improve the well-being of all people.

As Chin discusses in his piece, our country has made significant progress in improving health, but addressing long-term health disparities is more complicated than “standardizing the care provided to patients.” Instead, we must make connections between a person’s health problems and other life circumstances to yield truly transformative change.

“Eliminating disparities requires truly patient-centered care—that is, individualized care by caregivers who acknowledge that patients’ beliefs, behaviors, social and economic challenges, and environments dictate their health outcomes,” he writes. Then, by either providing incentives and/or assistance, we can help those key institutions and other stakeholders work together to eliminate them.

Through our new approach, RWJF will do just that. We will go beyond quality and access to health care to dig deeper into the factors and social determinants that research proves impact a person’s health—the neighborhoods we live in, the schools our children attend, the jobs we work, and the resources inside our communities.

We will then reach out to youth leaders, parents, and community advocates who have long supported health equity to identify new opportunities to tackle the systemic issues that impact a person’s well-being. We will also seek out business leaders, government officials, and organizations who can help us leverage these existing systems and institutions so we can help improve overall health for all.

An example of where we have seen great success is with Spokane County, Wash., where nearly 1 in 5 children lives below the federal poverty level. Spokane County received our Culture of Health Prize in 2014 for realizing, and addressing, the critical link between lack of education, poor health, and poverty. Within seven years, the local school system, government officials, and business leaders worked together to help raise high school graduation rates by 20 percentage points and build career pathways for students to support economic sustainability in Spokane. With greater academic and workplace success, also comes more positive health outcomes.

Most of all, our efforts will help build awareness among all the systems that impact health to provide people the tools and resources they need to be healthy. This work will be an integral part of our mission to build a Culture of Health that enables everyone to make healthy choices where they live, work, and play, no matter their demographic or social status.

In the next five years, we hope to take significant steps toward achieving our vision by helping make the movement for health equity broader than it is today. With greater participation from private industry, policymakers, and individuals whose life experiences reflect the disparities we aim to eliminate, we expect the nation to achieve even greater accomplishments in the next decade.

There's a quick and easy way to keep informed of our work and progress. Sign up for our weekly e-newsletter, Advances. We hope you will join us on this journey.

Tue, 10 Feb 2015 14:13:00 -0500 Dwayne Proctor Health Disparities <![CDATA[We Must All Play a Role in Ending Childhood Obesity]]> A mother walking with her daughters on sidewalk

We all want our kids and grandkids to grow up happier and healthier than we did. Instead, today’s children are the first generation of young Americans to face the prospect of living their entire lives in poorer health and dying younger than previous generations.

The reason is no mystery. Too many of our children – one in three, according to studies – are overweight. We are allowing, and in some ways encouraging, our kids to consume more calories, more sugar, more fat, more sodium. At the same time we’re enabling a more sedentary lifestyle. Running, jumping, skipping, dancing, biking – today’s children simply don’t move as much as they once did, making it that much harder to keep off the pounds.

The childhood obesity epidemic is having a devastating affect on too many families. Obese and overweight children are sick more often. They too often endure prejudice and bullying at school, leaving them embarrassed and depressed. They miss more school. When they grow up, they have more difficulty leading productive work lives. And they are more likely to suffer from chronic illnesses directly linked to obesity, such as diabetes and heart disease. 

William Frist Sen. Bill Frist, MD

All of society pays a stiff price for childhood obesity. Twenty percent of the United States’ total expenditures on health care can be linked to conditions associated with obesity. Obesity costs our society more than smoking or drinking.

But there is reason for hope. Parents, educators, business leaders, government officials, health care professionals, and nonprofits have launched remarkable initiatives to end this epidemic. The Robert Wood Johnson Foundation has been a leader in these efforts, ever since its dramatic $500 million initiative in 2007 to reverse trends in childhood obesity. And there are signs that we are already creating a brighter future for our children.

In the last two years the Centers for Disease Control and Prevention (CDC) have reported small but significant downward trends in the percentage of preschool-aged children who are obese. Those kids are less likely to be obese when they are in middle school, high school, and beyond.

How did we begin to alter a movement that once seemed impossible to stop? I like to think of it as a good old-fashioned American mix of families, educators, policy makers and businesses pulling together to bring about change. Parents are getting out and doing things with their kids – hiking, jogging, cycling, swimming, throwing a ball or Frisbee around – and both parents and kids find themselves feeling better. Schools are offering healthy lunch choices, and making good food, including breakfast, available for students who might otherwise be able to afford only junk food, or no food at all. Cities and states are requiring fast-food outlets to post nutrition information. Large retail chains are building fresh-food grocery stores that represent oases of healthy nutrition in “food deserts.” Hospitals and clinics are emphasizing preventive care programs. Foundations such as RWJF, with its efforts to build a Culture of Health, are promoting innovative pilot programs and partnerships. All these efforts, taken together, are truly making a difference.

But there’s no question that we have a long way to go. We can all do more, and we must do more, both individually, through our organizations, and in partnership with others. That’s why RWJF is pledging another $500 million over the next ten years to expand efforts to ensure that all children in the United States―no matter who they are or where they live―can grow up at a healthy weight. Watch the video of RWJF President and CEO Risa Lavizzo-Mourey, MD, renewing the Foundation's commitment.

What can you do? Take a kid bowling, or for a hike. Suggest alternatives to fried foods at the next covered-dish supper held at your church. Write your elected representatives expressing your support for programs to fight childhood obesity. Present a petition to the school board asking that physical education be reinstated or expanded, and that unhealthy snacks and drinks be removed. Ask the city council to ensure that all kids and families have access to safe parks and playgrounds. Donate money or volunteer your time to programs fighting childhood obesity. Buy and serve healthy foods for yourself and your family, and do your best to let everyone in the food chain know – from the local grocery manager to the big brand-name food companies to the farmer at the local greenmarket – that you want healthy, fresh food.

It’s been shown time and again, all across the country: If we make healthy food and exercise options easy and affordable, those are the choices that most families will make for their children. Please do your part to help America’s kids. Here at the Foundation, we’ll be supporting you all the way.

Bill Frist, a heart surgeon, is a former U. S. senator (R-Tenn) who has long been involved in promoting good health across America. He is a member of the Board of Trustees of the Robert Wood Johnson Foundation.

Working in partnership with other funders and leaders in a variety of sectors, key initiatives enabled schools nationwide to transform their campuses into healthier places for kids and helped communities expand access to nutritious foods and safe places to be active. States and cities ranging from California to Mississippi, and New York City to Anchorage, Alaska, have begun reporting declining childhood obesity rates.
Thu, 5 Feb 2015 13:00:00 -0500 Sen. Bill Frist, MD Childhood Obesity <![CDATA[When It Comes to What Consumers Value in Health Care, One Size Does Not Fit All]]>
Pioneering the Use of Personal Health Data - Banner

My husband and I recently bought our first house in Princeton, N.J. We had looked at several houses, all within a similar price range. But price wasn’t the only factor, and simply having a roof over our heads wasn’t our only goal. We wanted a place that allowed us to walk to town and had a yard for the kids to play in, as well as a garage and storage space. We didn’t care so much about some things that might be important to other people, such as the size of the bedrooms or any particular architectural style. Figuring out what was most important to us, what would be a high-value house for us—the people who would be living in the house—was just part of the process.

Just as people have widely varying preferences when it comes to a home purchase, they also have very different preferences and priorities when it comes to their health care. For example, I might prefer a primary care doctor who has weekend and evening hours, whereas my mom might prefer one who has a reputation for spending more time with patients. At least right now, Mom and I just care about different things.

What does “value” in health care mean to consumers generally—and not just consumers overall, but consumers of many different backgrounds and perspectives? What matters to people when they are choosing their health plan, which doctor to go to, or whether to go to a retail clinic, and what might make for a high-value experience in different health care settings? It’s hard to know, because today value is typically measured more from the perspective of payers and providers.

So that is why, this week, the Robert Wood Johnson Foundation and AcademyHealth, released a call for proposals to better understand what factors are most important to consumers when they make health care decisions.  

In building a Culture of Health, we realize “value” won’t mean the same thing for everyone, any more than it does when you’re buying a house. But unlike in home buying, we don’t have many tools and supports in place to help people make their own high value decisions. In health care, we don’t have enough information about what people care most about. This is what we want to find out.

Thu, 5 Feb 2015 09:00:00 -0500 Tara Oakman <![CDATA[Entering the Final Stretch]]> 2015 Affordable Care Act ACA Enrollment Website Screen

As we head into the final weeks of this year’s open enrollment season, we can all be proud of the progress that’s been made. New numbers released last week show 9.5 million Americans signed up for health coverage through marketplaces across the country. Behind each number is someone who now has quality, affordable health coverage with access to health care when they need it and protection from financial ruin if they get sick.

But there are still millions more who are eligible for coverage this open enrollment period. RWJF and our partners are doing all we can to get as many people enrolled as possible before the February 15 deadline. These collective efforts focus on breaking down the biggest enrollment barriers for people to get covered. Our research shows that consumers are more motivated to enroll when they understand the benefits of coverage, believe they can afford the cost, and know they can find enrollment support to complete the process.

Enroll America, an RWJF grantee, is addressing the need for in-person help head on—operating grassroots efforts in 11 states and connecting consumers to enrollment tools and help nationwide. Their connector tool, allows consumers to schedule appointments for in-person help right away. Drawing from lessons learned from the first open enrollment period we know this one-on-one support will be critical for many consumers during these final weeks.

Consumer Voices for Coverage (CVC), a longstanding program funded by RWJF, coordinates local enrollment activities in states. By organizing statewide coalitions, CVC identifies gaps in enrollment work, reaches out to communities who might otherwise be missed, and provides critical feedback to state and local officials on how to improve enrollment.

Many of our partner organizations are trusted messengers for consumers who are eligible for coverage. These organizations provide answers to specific questions about insurance options. For example, groups like the National Council of La Raza and the Asian Pacific Islander American Health Forum are helping consumers who may have particular questions about immigration status and coverage or who need help in a language other than English. As state laws around same-sex marriage continue to change, lesbian, gay, bisexual and transgender consumers may have questions about eligibility and coverage. Recently, Out2Enroll, created a platform to connect consumers to assisters who can help answer these questions. And the NAACP is working to engage faith leaders to help spread the message of the importance of coverage.

The Foundation’s own Talk Health Insurance to Me digital campaign is using humorous ads, social and earned media outreach and organizational partnerships to promote the availability of low-cost health plans and financial help to lower the cost of monthly premiums. Through the campaign, we’ve created resources in English and Spanish for organizations conducting outreach to motivate consumers to enroll.

Getting people covered is essential to our vision for a Culture of Health helping everyone live the healthiest life possible. Thankfully, this is a growing reality for millions of people in America. In these final weeks leading up to the February 15th deadline let’s exert an extra push in our work together so millions more can enjoy the peace of mind that comes from knowing they’re covered.

Tue, 3 Feb 2015 18:15:00 -0500 David Adler <![CDATA[Journey Towards Becoming a Mindful Leader]]> Mindfulness zen garden

In our fast-paced, overcommitted world, our typical automatic first response—to be better multitaskers and problem solvers—often leads to increased stress and reduced satisfaction. As leaders—especially in the high-stakes, quickly changing health care sector, we focus our attention outwardly on the well-being of others. We’re faced with a number of competing priorities, interruptions, and distractions that too often get the best of us. It seems that, for many, the noisy world has taken up residence within us.

As a nurse focusing on gerontology and oncology, I learned to help others find what was most important during times of bittersweet transition, prioritizing where and how their energy was spent. Through my clinical research experiences, I learned that the perception of stress, rather than a specific circumstance, could just as easily lead to physiologic consequences. I also observed how some people used their challenges to become more resilient, while others weakened.

Because of these experiences, the ideas of resiliency, mindfulness, and caring began shaping my research questions and investigations. My research and my work with my nursing colleagues showed me that teaching self-awareness, compassion and attention-focusing practices can reduce stress, build resilience and extend the positive impact of nurses and other leaders, including their ability to care for patients, strengthen communication, mentor others and lead successful organizations.

Dr. Teri Pipe Teri Pipe, dean of the College of Nursing & Health Innovation at Arizona State University, a Robert Wood Johnson Foundation Executive Nurse Fellow

Mindfulness has since become the quiet center of my leadership journey. How do we make compassion a regenerative force for our patients, colleagues, organizations, students and ourselves? How can we identify and learn to appreciate our sources of strength so that they are available to serve us and others? How do we develop the skills that will help us become more conscious of our thoughts and choices in the present moment—allowing us to put that noisy world into perspective?

We start with ourselves. We need to give ourselves permission to reflect and find better, more restorative, less reactive ways to care for ourselves and the world around us. One of the first things I share during my workshops is the importance of making the practice a habit. We cannot know the benefits of mindfulness, or recognize our sources of strength, until we’ve committed to the practice. I also emphasize that we are always in practice—to internalize and share these gifts rather than master them.

Attention-focusing practices, while quite beneficial in high-demand situations, can be easily transferred to such ordinary activities as walking, eating, sitting, preparing for a meeting, answering a phone, and even breathing. We bring our practice with us everywhere and it can be felt by everyone. Here are six foundational attitudes of a mindfulness practice that I try to remember and use every day and encourage you to explore in your personal and professional lives.

  1. Non-judging: be an impartial witness to your own experience
  2. Patience: sometimes things must emerge on their own time
  3. Beginner’s mind: be willing to see everything as though you’re seeing it for the first time
  4. Trust: listen to your inner self
  5. Acceptance: seeing things as they actually are at the present time
  6. Letting go: our minds want to hold on to thoughts; release them.

When we approach our daily lives through a lens of non-judgment and self-awareness, we experience our world in a whole new way. Becoming more mindful and in the moment provides us with the skills of authentic presence and compassion. These are sorely-needed skills to lead at any level. “Beginner’s mind,” as it’s been called, allows us to experience each moment of our day with great clarity, empathy and renewal. Good leaders are good beginners.

What do you think?  In a future blog post, I’ll explore the different foundational attitudes of mindfulness and how they relate to leadership.  I hope you’ll join me.

Teri Pipe is the dean of the College of Nursing & Health Innovation at Arizona State University and is a Robert Wood Johnson Foundation Executive Nurse Fellow. She is an expert on nursing leadership, interprofessionalism and mindfulness.

Mon, 2 Feb 2015 11:35:00 -0500 Teri Pipe, PhD, RN Health Leadership, Education, and Training <![CDATA[Roadmaps Out of Fantasyland: RWJF’s Outbreaks Report and the National Health Preparedness Security Index]]> Outbreaks 2014

“When you hear hoofbeats, think of horses, not zebras,” the late Theodore Woodward, a professor at the University of Maryland School of Medicine, cautioned his students in the 1940s. Woodward’s warning is still invoked to discourage doctors from making rare medical diagnoses for sick patients, when more common ones are usually the cause.

And while many Americans have worried about contracting Ebola—in viral terms, a kind of “zebra”—more commonplace microbial “horses,” such as influenza and measles viruses, continue to pose far greater threats. For instance, a large multistate measles outbreak has been traced to Disneyland theme parks in California—while this year’s strain of seasonal flu has turned out to be severe and widespread.

One obvious conclusion is that many microbes remain a harmful health menace, expected to kill hundreds of thousands of Americans this year. Another—speaking of Disneyland—is that much of America appears to live in a kind of fantasyland, thinking that it is protected against infectious disease.

That’s the grim subtext of the 2014 edition of Outbreaks: Protecting Americans from Infectious Diseases, the annual report released last month by Trust for America’s Health and the Robert Wood Johnson Foundation. “Millions of Americans could be spared and billions of dollars spent on healthcare could be saved with better infectious disease prevention and control,” the report concludes. Consider:

  • One in five Americans gets the flu annually, and up to 49,000 a year die from it. Flu costs the country $10 billion a year in health care spending, and $16 billion in lost earnings. Even though this year’s flu vaccine is less effective than normal due to unanticipated changes in the H3N2 virus, in most years the flu is largely preventable. Yet Outbreaks notes that half of the population was vaccinated against seasonal flu only in 14 states during last year’s flu season—and only about one in four health care workers got a flu shot.
  • The failure to vaccinate all pre-school children on time leaves 2 million U.S. children a year “unnecessarily vulnerable to preventable illnesses,” the report says. According to the CDC, many of those who contracted measles in the current outbreak weren’t vaccinated. And with a growing number of so many unvaccinated children around, the goal of achieving herd immunity is imperiled. Even the best vaccines aren’t 100 percent effective—and the CDC has noted with concern that six people previously vaccinated against measles still fell ill amid the current outbreak.

The report drives home that “we are only as prepared for these threats as the community that is least prepared among us,” observes Paul Kuehnert, DNP, RN, director of the Bridging Health and Health Care portfolio at RWJF. And Outbreaks identifies scores of other risks beyond common communicable diseases, including food-borne illnesses like salmonella and hospital-acquired infections like MRSA.

The report advances a series of recommendations, including modernizing surveillance to allow for better real-time disease tracking, and boosting so-called medical countermeasures—including research on new vaccines, diagnostics, antiviral medications, and antibiotics. (Note that, with 2 million Americans falling ill and 23,000 dying each year from antibiotic-resistant infections, President Obama has called for nearly doubling federal spending on fighting antibiotic resistance to $1.2 billion in fiscal 2016.)           

Vulnerability to infectious disease outbreaks is just one aspect of the nation’s health defenses captured in another RWJF-sponsored effort: the National Health Security Preparedness Index. A composite of 194 measures, the index depicts the capabilities of the 50 states in six areas: health security surveillance; community planning and engagement; incident and information management; healthcare delivery; countermeasures management; and environmental and occupational health.

Thomas V. Inglesby, MD, who directs the UPMC Center for Health Security, and who chaired the steering committee behind the preparedness index, describes it as “the first really comprehensive attempt to measure preparedness in all its dimensions and improve quality over time.” An interactive map on the index’s web site illustrates which states rank highest, including Virginia, New York, and Utah. At the low end are Alaska, Georgia, and Arkansas. Overall, the country scores 7.4 out of 10. The index didn’t label it as such, but that’s  about a C grade.

Not surprisingly, a number of states aren’t happy with the rankings, or their place in them. But the results shed light on what states must do to boost their preparedness, while future installments of the index will also help policy-makers gauge progress, Inglesby says.  

In other words, think of the preparedness index as a road map for helping us get out of fantasyland, and confront reality on the critical topic of health security.

Discussion with Preparedness Experts

What have we learned from recent infectious disease outbreaks, like Ebola and H1N1? On Friday, February 6, the Foundation hosted an online chat with notable disease prevention experts, Tom Inglesby, MD, chief executive officer and director, UPMC Center for Health Security and Suzet McKinney, DrPH, MPH, deputy commissioner, Bureau of Public Health Preparedness and Emergency Response and Division of Women & Children’s Health, Chicago Department of Public Healthon the state of preparedness in America, including a discussion about the new National Health Security Preparedness Index.


Fri, 30 Jan 2015 17:47:00 -0500 Susan Dentzer Disease Prevention and Health Promotion Susan Dentzer: Toward a Healthy America <![CDATA[Some Unconventional Approaches to Stress: Pioneering Ideas Podcast Episode 7]]>

(Please note that this podcast player might not work in some versions of Internet Explorer. Please view this page in another browser, such as Chrome, Firefox or Safari. You may also access the episode via SoundCloud.)

A man asking for money on the subway this week told me how Hurricane Sandy led to a series of events that left him stressed out by the challenges of putting food on the table for his children.

Recessions, hurricanes, violence—how many ways can we count that add stress to our lives? Whether dealing with economic stress, the stress of caring for an aging parent, or even the stress of keeping up with email, research shows that all of it affects our health. As Alexandra Drane, a guest in the latest episode of RWJF’s Pioneering Ideas podcast, puts it: “When life goes wrong, health goes wrong.”

This episode of the Pioneering Ideas podcast explores unconventional approaches to tackling stress­—and other health problems—with energizing possibilities that could also transform health and health care. From monitoring electricity use as a way of helping the elderly stay in their homes, to measuring the indirect health effects of social services (what if heating assistance led to greater medication adherence?), these conversations offer cutting-edge ideas for building a Culture of Health.

In this episode:

  • Cutting-Edge Approaches to Helping the Elderly Age in Place: How can tracking electricity usage help senior citizens age in place—and reduce stress for caregivers? Listen in as my colleague Paul Tarini and Paul Tang, MD, MS, of the Palo Alto Medical Foundation talk about innovations coming out of the linkAges Connect program, which RWJF supports.
  • How Understanding Scarcity Can Help Build a Culture of Health: Harvard economist and TED speaker Sendhil Mullainathan chats with me about how the ideas in his book with co-author Eldar Shafir, Scarcity: Why Having Too Little Means So Much, apply to transforming health and health care.
  • Personal Essay: When Life Goes Wrong, Health Goes Wrong: “We need to formally acknowledge that helping someone survive a divorce is just as important as helping someone with their diabetes,” argues entrepreneur and speaker Alexandra Drane in her personal vision for building a Culture of Health.

Let me know what you think about the ideas in this episode. How do they relate to pioneering work you’re doing? What possibilities do they suggest to you? What questions do they inspire? Let’s keep the conversation going. Leave a comment below, or tweet me at @lorimelichar—you can use the hashtag #RWJFPodcast.

And if you’ve got a pioneering idea for building a Culture of Health, I encourage you to learn more and submit a proposal.

Thu, 29 Jan 2015 19:00:00 -0500 Lori Melichar Mental and Emotional Well-Being <![CDATA[Field Notes: What Cuba Can Teach Us about Building a Culture of Health]]> MaryJoan Ladden and Susan Mende Trip to Cuba

Ever since President Obama announced the restoration of diplomatic ties between the United States and Cuba, there’s been growing excitement over the potential for new opportunities for tourism, as well as technology and business exchanges. Most people assume that the flow will be one-sided, with the United States providing expertise and investment to help Cuba’s struggling economy and decaying infrastructure.

That assumption would be wrong. America can—and already has—learned a lot from Cuba. At RWJF, we support MEDICC, an organization that strives to use lessons gleaned from Cuba’s health care system to improve outcomes in four medically underserved communities in the United States—South Los Angeles; Oakland, Calif.; Albuquerque, N.M.; and the Bronx, N.Y. Even with very limited resources, Cuba has universal medical and dental care and provides preventive strategies and primary care at the neighborhood level, resulting in enviable health outcomes. Cuba has a low infant mortality rate and the lowest HIV rate in the Americas, for example—with a fraction of the budget spent in the United States.

This past October we traveled to Cuba to see for ourselves how health and well-being are integrated into daily life. We wanted to learn firsthand about best practices that might be adapted to improve the health of residents in our own low-income communities. It’s important to recognize, though, that all is not ideal in Cuba. Poverty is widespread, the government is restrictive and many freedoms and access to information that we take for granted are not available to Cubans.

Our trip was focused on the health system, and there was a lot to learn. We visited schools, local health clinics, farms, and senior centers across the Havana area where we spoke with government officials, doctors, nurses, teachers, and Cubans of every age and many occupations. The journey was eye-opening: We saw how concerns about public health are deeply imbued in every aspect of daily life and play a part in every government decision. Staying healthy is considered a national responsibility, a message that consistently comes from the top, originating with Fidel Castro himself. If you keep fit and stay healthy you help your neighbors, your community, and Cuba.

How is this Culture of Health so deeply woven into Cuban society? For starters, the resources for maintaining health are free, universal, and available in every community. The central government views education, housing, public safety, and other national issues all through the lens of health. At a middle school, for example, students learn about nutrition and medicinal herbs along with physics and chemistry. Not far from our hotel in Havana, some streets were unpaved and buildings were in serious disrepair—yet the government had installed new pedestrian and vehicle countdown lights at crossings. When we asked why, we were told that there had been a lot of accidents on the road, so putting a system in place that lets pedestrians know they have 10 seconds left to safely cross the street is considered a good investment in public health.

Cuba’s health care system is not perfect. Medical records are still all paper, medicines are not always easy to come by, and people can wait a long time for dental and other care. But despite having few economic resources, the Cuban government has an effective system in place for offering its residents support at the community level for maintaining and improving their health.

Here then are some lessons we believe could hold the greatest potential for catalyzing innovations in health care and population health, especially in marginalized or poor communities in the United States.

  • Primary Care is local and comprehensive. A physician and nurse live and work in each community, and care for about 1,800 families. They make yearly home visits and keep updated records on each member of a household to see how they are maintaining their health. If a resident needs to see a specialist, his or her records are hand-delivered back to the primary care provider. Local doctors and nurses also understand the social situation of their patients—what their homes are like, their education level, the number of family members, and any particular challenges they face. In Cuba, prevention of such public health threats as tuberculosis, diabetes, hypertension and HIV is a primary goal for the country’s leadership. This kind of continuous, cradle-to-grave medical and social care goes a long way toward helping people stay healthy and avoid hospitalization.
MaryJoan Ladden and Susan Mende Trip to Cuba
  • There is a strong emphasis on healthy aging. Cuba has a rapidly aging population, and by 2025 one-quarter of the nation’s citizens will be over 60. Since almost all of the older people in Cuba live with their families, nursing homes are rare. To better care for older residents, local health workers educate families about how to prevent falls and how to recognize problems that need prompt care. Communities also have vibrant senior centers that offer activities that include visits to museums, dancing at local cabarets, and educational sessions where older people learn new skills and continually expand their knowledge. Since having several generations living in the same home can cause tensions, we heard about seniors taking classes on grandparenting, the challenges of intergenerational relations, elder abuse and gender equity. These senior centers are operated very much peer-to-peer, tapping the talents of the older people themselves to provide social, emotional and intellectual support. Maintaining the health of the body and mind through life-long learning is considered of upmost importance for the oldest residents of communities.
  • Community health is everyone’s concern. Clinical records are used to monitor the health of the entire community. If there is an uptick in the number of skin rashes, authorities will look at water quality. If an outbreak of food poisoning occurs, the community will make sure refrigeration is adequate. When red flags go up, there is a coordinated response and intervention. For example, if residents are concerned about increased use of alcohol among their teens, community members will get together and try to develop a strategy for dealing with the problem—perhaps providing more teen activities and a space for young people to socialize. The community then informs the central public health administration about their experience with teen drinking to help the government devise a national plan for dealing with the issue, likely to be impacting other communities.

In the end, our overall impression is that the government and the people of Cuba truly value health and well-being, and are effectively building a Culture of Health. What is astonishing to us is that they have done this with the scarcest of resources. In 2012 and according to the World Health Organization, life expectancy in Cuba and the U.S. was the same—79 years—yet Cuba spent 1/25th of what the U.S. did on health care per person.

From our firsthand experience, we can see real benefit in identifying best practices in other countries, including poorer or less-developed ones, and adapting them to improve social determinants of health in underserved communities in the United States—part of our strategy for global learning. The Cuban emphasis on primary care, its integration of public health and health care systems, active engagement of families and communities, and building cross-sector alliances for health, are all key elements in RWJF’s own vision.

Thu, 29 Jan 2015 09:54:00 -0500 Maryjoan Ladden Disease Prevention and Health Promotion International RWJF Staff Views <![CDATA[Identifying the Causes of a Persistent Health Disparity: High Blood Pressure Among African-Americans]]>

Jacquelyn Taylor, PhD, PNP-BC, RN, FAAN, is an associate professor of nursing at Yale University and an alumna of the Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholars program (2008-2012). She recently received a $3.4 million grant from the National Institute of Nursing Research, a department of the National Institutes of Health, to conduct a large-scale study on the influence of genetic and psychological factors on high blood pressure in African-American women and children.

Jackie Taylor Jacquelyn Taylor

Human Capital Blog: Congratulations on your new grant from the National Institutes of Health to study blood pressure in African-Americans. What will be your focus?

Jacquelyn Taylor: African-Americans have the highest incidence of hypertension of any racial or ethnic group in our country. Studies show that some medications don’t work very well in reducing blood pressure in this population, and we are convinced that some other underlying mechanisms are at play. My co-principal investigator, Cindy Crusto, PhD, an associate professor in the department of psychology at Yale School of Medicine, and our research team and I will be studying two of those—genetic markers and psychological factors, such as perceived feelings of racism, mental health, and parenting behaviors—in our study. We want to know what effects these variables have on increases in blood pressure among African-American women and children over time.

HCB: Does this study build on your earlier work?

Taylor: In a previous study in Detroit, I looked at gene-environment interactions for high blood pressure in three generations of African-American women and identified hypertension risk alleles in grandmothers and in their daughters and granddaughters. Then I replicated the study in West Africa, where people live the same way as they did in the 1400s—in clay huts, with no running water, no sanitation, and no fast food as in the developed areas such as Detroit. The West African Dogon sample were mostly underweight, participated in large amount of physical activity, and had a limited but healthy diet. But they still had the same genetic markers for hypertension that I had identified in the sample in Detroit.

Then, as an RWJF Nurse Faculty Scholar, I studied the genetic and environmental risks for high blood pressure among African-American women and offspring using the HyperGen dataset, which is part of the Family Blood Pressure Program, a long-standing study of African-American participants who were recruited mainly from Mississippi and North Carolina. That study further enabled me to identify risk alleles for hypertension in children even before they developed the disease. Together, these studies led me to explore the gene-environment interactions I’m now examining at Yale.

HCB: How will your new study work?

Taylor: We will be recruiting 250 African-American children in underserved areas in Connecticut, as well as their mothers, for a total sample of 500 people. We will collect a baseline of genetic information from the mothers and their children through saliva samples, and we will assess psychological factors every six months over two years. In addition to candidate genes for hypertension, we are also taking an epigenome-wide approach to help explain risk for hypertension in this population. During each assessment, we will also collect clinical data, such as blood pressure, height, weight, and body mass index.

HCB: Why are you focusing on this population and this condition?

Taylor: Hypertension among African-Americans is a huge problem. More than 40 percent of African-Americans are diagnosed with hypertension, which can lead to other morbidities such as renal disease, stroke and ultimately death. Other studies have explored the independent effects of genetic factors and psychological stress factors that correlate with hypertension on blood pressure, but our study is the first to look at both the independent and interactive effects genetic and psychological factors have on increases in blood pressure. Another important aspect of our study is that we’re including children as young as three who have not developed hypertension yet.

HCB: What are your goals for the study?

Taylor: By the end of this study, we expect to be able to identify hypertension-related candidate genes, epigenetic factors, and psychological factors that can help explain the high prevalence of hypertension in African-Americans.

HCB: What would be the implications of those findings?

Taylor: With these findings, we hope to study therapeutic treatments for future intervention and translational studies. In other words, we would be studying the effects of individualized, rather than general, standardized treatments for hypertension. Right now, if your blood pressure is at a certain level, the standard of care is to prescribe certain medications and recommend weight loss measures and dietary changes. But if someone has a genetic predisposition or specific type of psychological stress contributing to increases in blood pressure, then anti-hypertensive medications are may not solve the problem. We need to look at the underlying mechanisms that are driving this health disparity and hone in on these individualized factors to guide the clinical practice interventions.

HCB: What do you expect to find at the end of the study?

Taylor: At the completion of this study, we expect to identify intermediate biological pathways influenced by hypertension-related genes that can help explain the high prevalence of hypertension traits in African-Americans. The findings could also highlight therapeutic targets for future interventional and translational studies for clinical prevention and treatment of hypertension secondary to effects of psychological and genetic factors. Based on the results of this study, we will seek additional funds to replicate our findings in comparable samples.

HCB: If your hypothesis pans out, what kinds of treatment do you envision?

Taylor: To treat patients with psychological markers, I envision more referrals to psychologists instead of just treating the disease with anti-hypertensive medications. For individuals with genomic markers I imagine a greater emphasis on prevention. If you already know that your child may have a genetic predisposition for hypertension, you may want to start to initiate healthier lifestyle practices early on. Additionally, for those with both genomic and psychological factors at play, I envision psychologists and nurses working together on care plans for patients that are based on an individuals’ unique profile and needs.

HCB: How did the RWJF Nurse Faculty Scholars program prepare you for your current study?

Taylor: The Nurse Faculty Scholars grant was phenomenal. I can’t say enough great things about it. It opened the door to collaborations with leaders in the field and helped pave the way for access to datasets with larger samples and, consequently, stronger results. In addition to the research component, the program incorporated the leadership training that I need now to oversee my current grant. It’s played a tremendous role in the advancement of my research agenda and role as a leader in nursing science. 

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Thu, 29 Jan 2015 07:31:00 -0500 Jacquelyn Taylor Health Disparities <![CDATA[What Will It Take to Diversify Medicine?]]>

Every few weeks, Dana Todd, MD, does something rare for an American physician:  She makes a house call. The visits are her way of making life easier for a bedridden stroke survivor and her caregiver daughter.

“One afternoon, I looked out into the clinic waiting room and there they were,” Todd recalls. “My patient was laying on a stretcher. Her daughter was by her side. Her family was adamantly against putting her in a nursing home because she is only in her 50s, so coming in was the only way she could get care. I just hated seeing her that way so I said, ‘Next time, I’ll come to you.’”

Todd is one of four primary care physicians who, along with a small group of nurse practitioners, provide care for residents of Greensboro, Ala., population 2,440, in rural Hale County. The little town, though, is a lot more to Todd than a place to work. 

“It’s my hometown. We have four stoplights,” Todd says with a laugh, “I know. I’ve counted every one of them. Friends and family often ask why I came back here after medical school. I explain that this is where I wanted to be, a place where I can make the greatest impact on people’s lives.”

Growing up, Todd did not think that becoming a physician was possible. That all changed when a high school guidance counselor suggested she participate in the University of Alabama’s Rural Health Leaders Pipeline program, a project initially supported by the Robert Wood Johnson Foundation (RWJF).

“That was the first time I thought medicine was something I could do. They also taught us that it was difficult to attract doctors to rural areas. That motivated me to come back to Greensboro and take care of the people I’d known all my life,” Todd says.

Commitment to Community

Research shows that physicians such as Todd — African-Americans, Hispanics, Native Americans, and Alaska Natives — are more likely to specialize in primary care and serve patients who share their backgrounds. The culture connection also produces other benefits. When patients see physicians and nurses  from similar backgrounds, they report greater satisfaction with their care and they are more likely to stick with treatment protocols.

“When a provider understands a patient’s culture, you will see things you might have otherwise missed. It also increases trust between patients and providers,” says Rosa Gonzalez-Guarda, PhD, MPH, RN, an RWJF Nurse Faculty Scholar who works to bring minority students into health disparities research.

Or, as Todd puts it, “when I see one of my diabetes patients putting unhealthy food in the buggy at the grocery store, I can pull up a chair and ‘go there,’ when she visits my office. She will listen because she knows I understand how important food is in Southern black culture.”

While awareness of these important facts has increased, minority students still face significant barriers to attending medical school. A 2014 report from the American Association of Medical Colleges (AAMC), Diversity in the Physician Workforce: Facts and Figures, shows that just 4 percent of physicians are African-American. The 2004 percentage was 3.3 percent.

“The medical school applicant pool has remained steady for some time now, in part because too many talented potential applicants are in poor-performing K-12 schools with limited resources,” explains Marc Nivet, EdD, AAMC’s chief diversity officer. “Unfortunately, there aren’t any initiatives to address this issue at a national level.”

The Power of the Pipeline

Lynne Holden, MD, founder of Mentoring in Medicine (MIM), which prepares underrepresented minority students for medical school, and a 2009 recipient of an RWJF Community Health Leader Award, agrees. “Reaching children in high school is too late. You have to get to them in elementary school as we do in our program, but there are also cultural issues that many academic administrators don’t understand.”

Citing a recent project in one of Washington, D.C.’s poorest schools, Holden says, “We were asked to do an after-school program. A large number of students signed up, but they could not show up after school. The administrators did not realize that these students often had to go home to take care of siblings or work to help support their families. When we switched to a lunch and learn program, the sessions were packed.”

There are other factors that may stop students from becoming physicians. “There’s the notion of stereotype threat. Society sometimes sends the message that minority kids can’t achieve,” says Michael Hernandez, a 2012 participant in RWJF’s Summer Medical and Dental Education Program (SMDEP).

The grandson of a migrant farm worker and the first person in his family to pursue a career in medicine, Hernandez, who is studying at Columbia University College of Physicians and Surgeons, adds: “So many of the minority students who entered school with me gave up on becoming doctors. I’ve heard professors steer kids to other careers because they don’t think they can get into medical school.”

He credits his mentor, Vanessa Rivas-Lopez, MD, and the SMDEP program with showing him that “I cannot be placed in a box based on my race. I can become a doctor.”

To nurture more students such as Todd and Hernandez, Holden, an emergency room physician at the Albert Einstein College of Medicine of Yeshiva University, says, “We must address the social determinants of education. That means taking on the full range of challenges these kids face at home and in school, including dwindling scholarship funds. We are not going to succeed in getting more of these young people into medical school until that occurs.”

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Wed, 28 Jan 2015 15:00:00 -0500 Sheree Crute Social Determinants of Health <![CDATA[‘Good Morning, My Name is Aara’: Building Trust in Health Care]]>

Aara Amidi-Nouri, PhD, RN, is associate professor of nursing and director of diversity at Samuel Merritt University in Oakland, Calif. She is a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow (2014-2017) and has served as a project director for the RWJF New Careers in Nursing scholarship program at Samuel Merritt University since 2009.

Aara Amidi-Nouri

Trust. Our health depends on it, and so do our lives.

Our very first stage of personality development as infants starts with trust, according to renowned developmental psychologist Erik Erikson. A newborn’s basic needs—food, shelter, and clothing—are entirely entrusted to a caregiver, one who hopefully recognizes that he or she does not yet have an ability to shiver, sweat, or shed tears.

When caregivers are attuned to babies’ environments and hunger cues, they are able to meet their needs and build their trust in other human beings. When caregivers hold newborns close, they meet their need for love and affection, building trust with every heartbeat and with every breath. We are social beings, dependent on one another. We must trust one another in order to survive. It’s no coincidence that our pennies—our most basic form of currency—are engraved with that very word.

What happens when, instead of building trust, we createmistrust? What happens when we can’t trust our health care system or our health care providers—our own caregivers, the very people who hold our fate and our lives in their hands? 

Consider the Tuskegee syphilis experiment and the recent revelation about Henrietta Lacks, whose cancer cells, taken without her knowledge, led to critical medical discoveries but with damaging consequences for her family.

Consider the story of the Kennedy Krieger Institute, which in the 1990s allegedly exposed young African-American children to dangerous levels of lead to study its hazardous effects—a study that the Maryland Court of Appeals compared to the Tuskegee study.

Consider long wait times for care for critical medical conditions, and short health encounters with providers that often end with yet another prescription but no real solution.

And think about this story: A grandmother summons the courage to see a health care provider for severe back pain. Her blood work reveals high blood glucose, and a physician diagnoses her with diabetes, largely because of her risk profile: She is over 65, overweight, and African-American. Six months later, her diabetes remains uncontrolled and she gets a new diagnosis: inoperable pancreatic cancer. This woman was an acquaintance of mine, and her death a few months later was a stark reminder to her community that health care providers were not to be trusted.

Think about the ever-widening digital divide and the lack of high speed internet in certain zip codes. This divide grows wider thanks to our health care industry’s incessant desire to move to online scheduling, telehealth visits, and electronic health information. Just try to make an appointment by phone; a human voice is almost impossible to find in a web of endless voicemail loops.

In our quest to ensure that we have the right patient, simple greetings are replaced with scanning a code on a wrist band and a cold request for a date of birth 

As providers, we don’t give our patients warm greetings, the kind that can build trust in us. We let the plastic badges on our white lab coats make our introductions for us.

I visited a health care provider recently, and there were few introductions. My name was simply called out aloud in the waiting room, and I found my way to the hallway chair for the obligatory weight, blood pressure, and temperature measurements—all taken by a person who never told me her name.

How can our very basic human need for trust be met when this is how health care providers provide basic care?  How can we make trust a more important priority when we educate health professionals? How does trust begin to become as important or, dare one hope, more important than the technological imperative?

A Culture of Health is built on trust. As providers, we must take deliberate measures to rebuild trust with every encounter and in every classroom. Sometimes, building trust begins with something as simple as, “Good morning, my name is Aara. How are you today?”

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Wed, 28 Jan 2015 08:00:00 -0500 Aara Amidi-Nouri Patient-Centered Care <![CDATA[How Not to Flip Out: Flip the Clinic]]> Flip the Clinic San Francisco January 2015 Hard at work at the first regional Flip the Clinic meeting in San Francisco

“If you’ve been waiting more than 15 minutes, please see the receptionist.”

That’s the sign that was posted on a bulletin board in the radiology clinic where I was waiting for an MRI earlier this month. The funny thing? It was so lost amid the other postings around it screaming for attention that I only saw it on my way out, as I waited for a copy of the disk with my MRI on it. It struck me as odd, and a little concerning; did that mean I should be worried the clinic staff might have forgotten about me if I’d been waiting more than 15 minutes?

Don’t get me wrong: I understand that unpreventable delays happen. For me, the most frustrating aspect of signs like this is that they take the power away from the patient. 

As a nurse, as a caregiver, and patient, I’ve seen many facets of the interaction between health care providers and patients. I’ve seen it work well, and I’ve seen it at its absolute most dysfunctional.

I thought a lot about that interaction—and that sign—as health care entrepreneurs, physicians, nurse practitioners, and patients gathered for the first regional Flip the Clinic meeting in San Francisco on January 13. Throughout this exhilarating day, we talked together about the “pinch points” in our health care delivery system—the points at which we were most frustrated with how we go about getting—and giving—health care. (Want a snapshot of the conversations in the room? Read the Flip the Clinic Storify from San Francisco.)

Flip the Clinic San Francisco Beth Toner

Every voice in that room was important—and I was humbled by the energy and commitment to change around me—but what left the biggest impression on me was the courage of the patients (all of them struggling with chronic or life-limiting conditions) who had the guts to stand up and say: “The system isn’t working, and I have some ideas about how to fix it.” As I listened to them, I had an epiphany. When it comes to my roles in the system, I have neatly compartmentalized myself. When I’m a nurse, I tell my patients to speak up for themselves, to advocate for themselves, to get the right care, to know their numbers. Yet when I’m a patient, I find myself passive, unwilling to speak up, wanting (and yet unwilling) to force people to slow down and explain what’s happening. (And I’ve never, ever let the receptionist know I’ve been waiting.)

There’s really no excuse for my hypocrisy. Other than knees that seem determined to give me problems, I am very healthy. I’m also assertive by nature, health-literate, and fluent in the language of health care. I understand, from having stood where they stand, why providers are rushed, and I’m grateful for the providers who were rushed, but took time to inform and reassure me anyway.

My epiphany reminded me that the system is broken for all of us, and we won’t fix it without each other; providers, patients, entrepreneurs, caregivers—we must all come together to find solutions, because we each hold a piece of the puzzle. That’s what’s so exciting about Flip the Clinic: It brings us all together, and reminds us that we can all change the way health care works by working with each other—and taking small steps that turn the system on its head every day. For instance, what if you had a health record resume? What if clinicians provided more ways for patients with chronic illnesses to do daily self-reporting on their condition? What if we provided community-based incentives for patients to get routine preventative care?

After 12 intense hours, many folks there agreed with each other on “flips” they would explore together in their communities. Others posted new flips to the Flip the Clinic web site. I’ve decided to bring the “flip” concept to the tiny nurse-run free clinic where I volunteer, and focus more on asking our patients what they need—not on what we think is important to give them.

With five more regional convenings ahead, and a national summit at the end of 2015, we’re just getting started. And you can get involved:

Share your thoughts here: How would you Flip the Clinic—change the way patients and providers interact?

Blog, Facebook or tweet (@fliptheclinic) your ideas. Many of those who attended are trying out the hashtags #iwishmydoc and #iwishmypatient; feel free to use those, or even add #iwishmynurse.   

Tue, 27 Jan 2015 16:38:00 -0500 Beth Toner Health Care Quality RWJF Staff Views <![CDATA[How Data Will Help Me Keep My Resolution]]> Pioneering the Use of Personal Health Data - Banner

It's a brand new year and like many Americans, I'm thinking about New Year’s resolutions—specifically, fitness and exercise resolutions. People who know me well know how I feel about working out (Hint: I don't like it. Or do it). But I have lots of good reasons for wanting to start. I turned 30 this year, so I’m starting to age out of that Young Invincible demographic (#GetCovered), and realizing that I am, in fact, “vincible.” As I get older, and watch my parents age, it's starting to hit home that getting to a particular shape or size really isn't the point. The point is getting my heart and body in the best shape I possibly can.

So this year, New Year’s resolution time feels a little different. And as I start thinking about making some changes, I’m reflecting back over the last two Data for Health listening sessions I attended in Charleston and San Francisco. As a result, I’ve decided that it’s time to think about setting my New Year’s resolutions in an entirely different way--by using data.

I want my New Year’s resolution to be informed by data. Data about me:

  • How many hours did I sit today?
  • What's my resting heart rate?
  • Am I getting enough deep sleep?
  • How many steps did I take today, and how fast?

Of course, I’m in a very privileged position. I can afford to buy a fitness tracker that collects this type of personal data. Imagine if everyone in America had such data at their fingertips? We know from behavioral sciences that having access to data about yourself can lead to self-reflection and motivate change. Of course, we need to think about how our data is shared with us.

At the San Francisco meeting, I heard a very wise participant say:

I would like more data about my environment. I don't just want devices and gadgets thrown at me that tell me to change my behavior. It's condescending—and reinforces an idea of health as being only about personal behavior. It's very much victim-blaming."

She is absolutely right. We have a choice—we can use data to blame individuals for their poor health, or we can use it to help people lead healthier lives. Less information is not the answer, nor is less data sharing.

In San Francisco, I was surprised to hear Gary Wolf, the leader of the Quantified Self movement, passionately challenge the idea that historically disempowered groups are less capable of analyzing and understanding data about themselves. He shared the provocative point that we too often underestimate people’s intelligence, and think that we have to interpret data FOR people. Wolf’s point is that everyone deserves access to data about themselves, in whatever format it is available.

Greater access to data about our personal health could soon be a reality. Prices on wearable fitness trackers are coming down, and the proliferation of mobile technology is reaching every corner of society. In Charleston, Ida Sim of Open mHealth noted a jaw-dropping statistic: globally, more people have access to a cell phone than have access to a toilet.

I love the comparison of personal health data to toilets. At one point, not so long ago, it was preposterous to think that anyone but the very wealthy could afford a toilet. What’s more, toilets are perhaps the greatest public health intervention ever to have been developed. Imagine if the public health revolution in sanitation could one day be matched by a public health revolution in data—that the huge amounts of personal data being generated every day could be used not only to help individuals improve their health, but to improve the health of many.

There’s something very different about the way that we generate and use data today, and there is huge power in thinking about using data in new ways tomorrow—both at the individual level, to personalize health information, as well as at the population level, by aggregating huge troves of individual data being generated. We can rapidly increase the pace of learning about what works to help people live healthier lives.

As we enter a new year, I’m ready to start thinking about the future – my own future, my heart’s future, my data’s future, my community’s future, and the future of using data for health.

Stay tuned for the final report from the Data for Health listening sessions to be released in April, 2015.

Stay connected

Emmy Ganos

Emmy Ganos

Program Associate

Tue, 27 Jan 2015 10:54:00 -0500 Emmy Ganos Health Data and IT RWJF Staff Views <![CDATA[Diabetes: The Case for Considering Context]]>

At Virginia Commonwealth University School of Medicine, Briana Mezuk, PhD, is an assistant professor in the Department of Family Medicine and Population Health, Division of Epidemiology; and Tiffany L. Green, PhD, is an assistant professor in the Department of Healthcare Policy and Research. Both are alumnae of the Robert Wood Johnson Foundation (RWJF) Health & Society Scholars program.

Tiffany Green Tiffany L. Green, PhD
Briana Mezuk Briana Mezuk, PhD

Approximately 30 million U.S. adults currently have diabetes, and an additional 86 million have pre-diabetes. The incidence of diabetes has increased substantially over the past 30 years, including among children. Estimates place the direct and indirect costs of diabetes at a staggering $218 billion annually.1 Like many other diseases, disparities on the basis of race and income are apparent with diabetes. Non-Hispanic blacks, Hispanics, Native Americans, and socioeconomically disadvantaged groups are more likely to develop diabetes than non-Hispanic whites and socioeconomically advantaged groups. 

Despite the enormous economic and social costs associated with diabetes, it remains a struggle to apply what we know about diabetes prevention to communities at the highest risk. We have robust evidence from randomized controlled trials that changing health behaviors, including adopting a healthy diet and regular exercise routine and subsequent weight loss, will significantly lower the risk of diabetes. Unfortunately, these promising findings only appear to apply to the short-term. Even worse, results from community-based translation efforts have been much more modest than expected, and show only limited promise of reducing long-term diabetes risk. In response, leaders at the National Institutes of Health have noted that many efforts at translating clinical findings into community settings are “limited in scope and applicability, underemphasizing the value of context.”2

Health Care in 2015 logo

What do we mean by context? Simply that health inequality does not occur in a vacuum. Where people live and work affects their exposure to stress, their ability to cope with stress—and consequently their mental and physical well-being. Moreover, some researchers have suggested that what appears to be a “race” effect—racial differences in diabetes risk—can be substantially explained by a “place effect.”3  That is, the stress of living in resource-poor neighborhoods is a primary driver of racial and socioeconomic differences in diabetes risk. Despite this evidence that diabetes-related disparities originate at the intersection of physical, psychosocial, and biological context, to date limitations on data have made it extremely challenging for population health researchers to investigate these issues.

On the other end of the spectrum, clinical research related to diabetes prevention often fails to incorporate theoretical perspectives and knowledge from the social sciences, hampering efforts to disseminate and implement interventions in communities at high risk of developing the disease.

To bridge these two important perspectives, we designed the Stress and Sugar Study (SASS), a pilot investigation aimed at understanding the role of context in diabetes risk, particularly among disadvantaged populations. Our target sample was Non-Hispanic Blacks with pre-diabetes living in Richmond, Virginia—a city that, like many in the United States, is racially segregated and has a large safety-net (socioeconomically disadvantaged) population. This target sample is one exemplar of a population at high risk of developing diabetes, and thus understanding the drivers of diabetes risk in this population specifically will inform translation efforts.

In SASS we sought to characterize the context of participants’ lives at three levels: (a) their physical context (i.e., access to healthy affordable food, resources for physical activity, neighborhood crime); (b) their psychosocial context (i.e., exposure to stressors, self-regulatory coping behaviors, mental health); and (c) their biological context (i.e., hypothalamic-pituitary-adrenal axis reactivity, hemoglobin A1c). 

One important innovation of our study is that we both empirically measured stress reactivity using laboratory-based methods and conducted personal interviews to assess stress exposure, coping behaviors, and mental health. Analysis is ongoing, but so far the two most significant findings from the study are that self-reported stress exposure is strongly related to overeating and eating high fat/sugar foods as a means of coping with stress; and that blunted stress reactivity is associated with higher hemoglobin A1c (a marker of diabetes risk). 

SASS is one example of what the physical and psychosocial context of a high-risk population looks like, and we propose that these contexts must become a central organizing theme of diabetes prevention efforts, if they are to be effective. Most SASS respondents were highly interested in improving their health; however, their ability to turn desire into action was hampered on almost a daily basis by stressors (particularly related to financial, employment, and housing instability) and constrained opportunities to cope with these stressors in a healthy way.

Although preliminary, our findings suggest that health-behavior-change programs must begin to address the complex ways in which neighborhood context, stress, and health behaviors intersect in order to be effective among high-risk populations. Without this grounding principle, we fear that implementation of standard diabetes prevention efforts may perversely widen, rather than narrow social disparities—similar to the unintended consequences smoking cessation programs have had on widening socioeconomic disparities in tobacco use. 

While our study is not representative of all populations at risk for diabetes, the experience of SASS participants serves as one exemplar of what we believe is a cross-cutting need to explicitly integrate physical, psychosocial, and biological context into efforts to prevent and eliminate racial disparities in diabetes.

The Stress and Sugar Study was funded by the Virginia Commonwealth University Center for Clinical and Translational Science.


1.      American Diabetes Association. Economic costs of diabetes in the US in 2012. Diabetes Care 2013 36(4): 1033-1046. [Return to text]

2.      Glasgow RE, Vinson C, Chambers D, Khoury MJ, Kaplan M, Hunter C. National Institutes of Health Approaches to Dissemination and Implementation Science: Current and Future Directions. Am J Public Health. 2012;102:1274-1281. [Return to text.]

3.      LaVeist TA, Thorpe RJ, et al. Environmental and socioeconomic factors as contributors to racial disparities in diabetes prevalence. J Gen Intern Med 2009;24:1144-1148. [Return to text.]

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

Tue, 27 Jan 2015 09:00:00 -0500 Tiffany Green Disease Prevention and Health Promotion Health Disparities Social Determinants of Health