Culture of Health News and views from the Robert Wood Johnson Foundation Thu, 16 Oct 2014 06:00:00 -0400 en-us Copyright 2000- 2014 RWJF (RWJF) <![CDATA[Data for Health—Coming to a Town Near You]]>
Listen Image by Ky Olsen (CCBY)

We have some questions for you—questions, that is, about health information. What is it?  Can you get it when you need it? What if your community needed important information to make your town or city safe or keep it healthy? How about information about your health care? Can your doctors and nurses get health care information about you or your family members when they need it quickly?

I came across a recent Wall Street Journal article about a remarkable story of health, resilience and survival in the face of an unimaginable health crisis—a Liberian community facing the advancing Ebola infections in their country got health information and used it to protect themselves. When the community first learned of the rapidly advancing Ebola cases coming toward them, the leaders in that Firestone company town in Liberia jumped on the Internet and performed a Google search for “Ebola”. From that Internet search they learned how to protect themselves. Then those brave people acted on that new information—that new knowledge. They did a number of things like use the information to build quarantine and care facilities as well as map the advancing illness cases in their town—so they could be smart about identifying, quarantining and caring for those infected with the virus—and then stop it. Months later, this town is now essentially a lone bright spot of health in a country devastated by death and illness. Why?  Because the leaders of that town used technology to get the critical health information they needed, and then they used it to act.

Across the globe, in a far different place we find a prosperous, safe community in the United States. It’s a place fortunate to have vast resources and great wealth. It’s a place with beautiful health care facilities that have expensive, nearly brand new electronic health record systems with some of the world’s best trained health professionals. Almost everyone living in this community has a smartphone and nearly nonchalant, expected instantaneous access to detailed information about everything from traffic patterns and weather to the latest movies and best restaurants. This place faced its own Ebola crisis, and something different happened.

Sometimes data, in spite of all of the advantages, does not turn into useful information. We all know now about the health care system failure in Dallas that prompted the missed Ebola diagnosis there. The doctors and nurses in that Dallas hospital had  a brief opportunity to put key bits of information about the patient infected with Ebola together so they could make the right care decision —but they couldn’t quite do it. Instead they missed a chance to get a sick man the care he needed and at the same time triggered a community and national health crisis.

Miscommunication in health care is not unusual. That’s sadly not the headline for the Dallas Ebola story, and it’s not my main point here. It is, however, a striking example of the limits of our current health data system. We have potentially helpful health data all around us—but all too often when we need it to help us make smart health decisions for ourselves or our communities we can’t quite put it together.

What if, however, we developed the information capabilities that would help ensure that you, your community leaders, your physicians and nurses and other health professionals could easily, readily, rapidly and reliably get health information when they needed it in order to keep you safe and help you get and stay healthy? What would that system look like? What do you expect from such a heath information system? What worries you about data systems that provide important information about your health and the health of your community?

We at the Robert Wood Johnson Foundation want to know. We work with leaders like you across the country to help build a Culture of Health. None of us can build that health culture without a way to get and use the best health information possible, quickly and efficiently. So, we’re convening a series of meetings across the country in Philadelphia, Des Moines, Phoenix, San Francisco and Charleston this fall to ask you.

Specifically we’ll be inviting 100 community members from each of those places to tell us their hopes, aspirations, worries and fears about digital collection, access and use of data for health. National Coordinator, Karen DeSalvo is interested in these RWJF meetings as well. She will be at all five events listening in person.

Although creating a reliable data system is a tough technical problem—that’s not really the hard part. The really hard data system challenge will be deciding what we want as a country—what we expect—what worries us—and what we will ultimately demand.

As you can see, we have a lot of questions about health information. 

Mostly, though, we’ll be listening as hard as we can to you this fall for some answers.




Thu, 16 Oct 2014 06:00:00 -0400 Mike Painter Data Healthy communities <![CDATA[New School Year Means New Opportunities to Build Healthy Campuses ]]> RWJF Philadelphia Child Obesity

September always brings the promise of a fresh start, especially for school age kids and their parents. New teachers, new books, new supplies, new shoes. And hopefully, a renewed emphasis on healthy choices. This week is National School Lunch Week, a time to highlight the importance of serving healthy school meals to students throughout the U.S.

Making sure all children have access to healthy food and drinks is a key priority for RWJF. Schools are where kids spend the most amount of time outside of their homes, so it’s an ideal place to instill lessons about the importance of eating healthy and being active. That’s why we are leading a number of initiatives to highlight how healthy school food, as well as recess and physical education (PE), contribute to nationwide efforts to reduce the prevalence of childhood obesity.

Last month, we hosted a ‘back-to-school’ Google Hangout focusing on how schools can ensure that students eat better and move more. One of my fellow panelists, Principal Mickey Komins from Philadelphia’s Anne Frank Elementary School, shared how his school completely transformed its campus. In order to get kids to eat healthier foods, the Anne Frank school started serving salads at lunch and replaced cupcakes and other sugar and salt-laden snacks, often served at school celebrations, with healthier options like fruit salad. To complement the nutrition improvements, the school offered physical activity programs such as yoga sessions and walking clubs, in addition to PE class and recess. Komins stressed that his school’s incredible story was possible because he engaged the entire school community—students, staff, and parents.

Parents are crucial allies in the quest for healthy school lunch, as underscored by national poll results we released with The Pew Charitable Trusts and the American Heart Association. The poll found that 72 percent of parents favor national standards for both school meals and snacks, while even larger majorities expressed concern about the state of children’s health and childhood obesity. The survey reinforces that parents want us to keep moving forward on making schools the healthiest places they can be.

That’s why we were so pleased to help celebrate 250 of the healthiest schools in the country at the Alliance for a Healthier Generation’s Leaders’ Summit. Representatives from the schools shared their stories on Capitol Hill and in interviews broadcast across America. President Bill Clinton offered his personal congratulations to the inspiring group of educators. At the official awards ceremony, USDA’S Under Secretary for Food, Nutrition, and Consumer Services, Kevin Concannon, shared some great examples of innovative solutions that schools are implementing to encourage students to make healthier choices. He also hit on a crucial, if sometimes overlooked point: healthy food and physical activity aren’t just good for kids’ health—they have also been shown to improve their academic achievement.

The drive to make schools as healthy as possible can’t be limited to a certain week or month on the calendar. It requires a year-round effort, and it takes everyone to make a difference. I encourage teachers, administrators, students, parents and community members to look for ways to help their local schools make the healthy choice the easy choice before, during and after school. And please share any ideas and successes you’ve had in the comments. Whether it’s in the cafeteria, classroom, hallway, or gymnasium, schools have powerful opportunities to help all children grow up healthy and build a Culture of Health across the country.

Tue, 14 Oct 2014 17:14:00 -0400 Ginny Ehrlich School foods School snacks Nutrition Childhood obesity RWJF Staff Views <![CDATA[Reflecting on the Great Challenges at TEDMED]]> TEDMED 2014 photo w/Ramanan Laxminarayan Photo courtesy of TEDMED

Here at RWJF, we are working to build a Culture of Health for all. This is an audacious goal, and one that we clearly cannot accomplish alone. We need to collaborate with thinkers and tinkerers and doers from all sectors–which is why we sponsored TEDMED’s exploration of the Great Challenges of Health and Medicine at its 2014 events.

Specifically, RWJF representatives helped facilitate conversations around six Great Challenges: childhood obesity, engaging patients, medical innovation, health care costs, the impact that poverty has on health, and prevention. We spoke with hundreds of people in person and online (Get a glimpse of the conversation here).

We asked three TEDMED speakers from RWJF's network to reflect on their experience at TEDMED and share some of the stimulating ideas they heard. We hope you'll add your ideas in the comments. 

Ramanan Laxminarayan, of the Center for Disease Dynamics, Economics & Policy

Several of the TEDMED talks offered solutions for patients to play a more informed and active role in their care. Dr. Leana Wen’s work at and Elizabeth Holmes’ company Theranos both focus on getting patients the information that they want to inform their personal care decisions. Empowering patients to make decisions based on accurate information can also play a role in reducing hospital-associated infections (HAIs). Patients need better information on the risks of HAIs, and they need to feel comfortable asking questions.

Thomas Goetz, former RWJF entrepreneur in residence

I came away from the Great Challenges and TEDMED event with a sense that there is yet another challenge: How to turn data into something more useful. There’s a persistent gulf between the promise of data to address these challenges and the real-life, logistically complicated, compatibility-challenged, resource-starved, doing of it. In previous years I think many people in the TEDMED constellation expected the data gods to come along and make it happen. This year I think there was an epiphany that the promise of data won’t be fulfilled by IT departments but by those at the top, and those in the trenches.

Consider Ted Kaptchuk’s presentation about research into placebos: On the face of it, he’s not a typical big data acolyte but a philosopher, an expert in Eastern medicine. But by recognizing that placebos can have clinical value, he’s applied statistical rigor toward a new paradigm of understanding. Or look at the audacious vision of Marc Koska, who wants to attack the status quo by re-designing the way we immunize people, , and leverage data in a relentless pursuit of that vision. Or Carl Hart’s data-driven debunking of the conventional wisdom around drug abuse. Or Jill Vialet, founder of Playworks, and the way she took a pragmatic idea about improving recess and brought it to community after community, armed with evidence and passion in equal measure.

My takeaway from TEDMED 2014: that passion and pragmatism mesh, and that data and dedication can be equal allies. I witnessed a new way to tackle the Great Challenges, an inspired approach that doesn’t accept the way things are, and that makes a compelling argument for the way things must be. Data is part of that argument. It’s also part of the solution.

Ted Kaptchuk, of Harvard's Program in Placebo Studies and the Therapeutic Encounter

Innovation is critical, yet new ideas are disruptive–so understandably resisted. Intelligence requires a critical attitude, but it is difficult to know if one is too skeptical, or not enough. We need our previous knowledge to make judgments, yet these judgments can involve biases that resist valuable new ideas. Only hindsight can tell us whether we avoided ridiculous propositions, or obstructed positive innovations.

Many of the TEDMED speakers wrestled with this issue. Elizabeth Nabel, president of Brigham and Women’s Hospital in Boston, framed the issue in terms of humility. She understands that being “certain” about knowledge is not necessarily a positive for science, and instead can be a way to flatter ourselves. For her, humility means openness to the new and an awareness that today’s “truths” can become tomorrow’s discarded beliefs. She reminded me of Max Planck’s warning that “a new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.”

We want to always reflect on what unexpected innovations the next generation will generate, and remember–they will be smarter than us.



Mon, 6 Oct 2014 11:19:00 -0400 Paul Tarini Conferences Patients Data <![CDATA[Let’s Talk About Stress]]>
Mike Painter Mike Painter speaking at Health 2.0.

I recently returned from the Health 2.0 conference in California, which drew 2,000 health care innovators. One of the most popular Health 2.0 sessions was called “The Unmentionables”—where speakers discussed those important things that affect our health but we are often afraid to address. I participated in this year’s session where we talked stress—what it is and how it’s making us sick.

I’m an avid cyclist. That means I train a lot. Training on a bike means purposefully and intensely stressing your body—sometimes ridiculously hard—in order to make your body stronger, fitter and faster. In that sense stress can be really good. You can’t get stronger without it.

But here’s the key: as you ratchet up that stress—the miles, the hours on the bike, the intensity—you must work just as hard on the flipside, the buffering. The more you train, the more you have to focus on the rest, the sleep, your social supports, the yoga, the nutrition—whatever it takes.

If you don’t buffer you will burn out, get injured or sick, or all of the above. Without buffers, the stress will crush you.

The Robert Wood Johnson Foundation has been thinking about stress and its connection to health for quite some time. We’re finding that in many ways we have a culture of stress rather than a Culture of Health. We need to understand that and work together to fix it.

I’m a family doctor and used to practice at a community health center in Seattle. I recently came across a story that reminded me of many of my former patients. Jeanette is a young mother living in Connecticut, experiencing major stress in her life: she had just had a baby, was suffering postpartum depression, lost her job, was facing eviction, and her relationship was in trouble. Not surprisingly, her stress also affected her baby, Shiloh—just weeks old. Shiloh wasn’t smiling, didn’t play, and didn’t communicate.

When we’re under stress, our bodies produce an increased amount of cortisol. A certain amount is healthy, but too much over a long period of time can have very negative effects—especially in a developing brain. That is likely what was happening to Shiloh. Stress can exacerbate or cause lifelong illness like diabetes, depression and heart disease.

At RWJF we wanted to understand how the public perceives and manages stress, so we conducted a public opinion survey on stress with NPR and Harvard’s School of Public Health.

Here’s some of what we found:

  • Half of those we surveyed had a stressful experience in the past year.
  • Most who reported high stress were already in poor health—including many who have chronic conditions or illness.
  • The vast majority said that stress negatively affects their family and social lives, how they perform at work—as well as their health.
  • Over half of those with a great deal of stress and a chronic illness or disability said stress made their symptoms worse and their condition harder to manage.
  • Over 90 percent said they manage or buffer stress by spending time with family and friends, exercising, eating well, or doing outdoor activities.
  • Unfortunately, only 50 percent said they do things to buffer their stress.

The numbers, of course, are important, but the stories are even more powerful. Jeanette and Shiloh did get help from an RWJF-funded initiative, Child First—a home visiting program that helps stabilize families with young children. But that’s just one story; there are many, many more. When NPR asked people to share stories about the stress in their lives, they received an overwhelming number—6,000 responses, when they typically only get about 500.

Why? Americans are stressed; they know it, and they want to talk about it.

Health isn’t just a lack of illness. It’s so much more—it’s enjoying and embracing life—that includes successfully managing life’s stress.

The goal of our work is health and well-being for everyone. We can’t get there unless we address the stress in our lives. (See our infographic about how to move from a culture of stress to a Culture of Health.) That means we must try to reduce it where we can and learn to directly manage it where we can’t.

What we’re finding: Stress is making us sick.

The good news: We don’t have to let it.

Thu, 2 Oct 2014 09:52:00 -0400 Mike Painter Health promotion and disease prevention Behavioral/mental health Social determinants of health National RWJF Staff Views <![CDATA[The 21st Century Medical School and the “Flipped” Classroom]]> Flip the classroom video still

Pity the poor medical student...or at least many students now slogging away in medical schools across the nation.  

Most spend the first two years of medical school cramming their heads with facts about the functions of cells, organ systems, and other aspects of the human body. Having contact with real patients—the reason most students went to medical school in the first place—is quite limited until the third year, when clinical clerkships begin.

Meanwhile, medical knowledge is exploding, doubling every five years, and taxing the human brain’s capacity for processing and recall. Today’s medical students know that one day, they’ll be most likely to practice medicine with the aid of “cognitive computing” systems like IBM’s Watson, which has already “learned” as much as a second-year med student, and is helping clinicians at the Mayo Clinic, Memorial Sloan-Kettering Cancer Center, and other institutions process reams of medical information to make clinical decisions. 

So in this brave new world of medicine, what sense is there in making medical students cram down many facts that may already be in flux—or spend hours listening to lectures from the proverbial “sage on the stage?”  Why not “flip” the medical school classroom, by packaging much basic content in online form, and then creating richer pedagogical experiences for students that better equip them with critical thinking skills truly required for good doctoring?

Those are the goals of projects sponsored by the Robert Wood Johnson Foundation, and now under way at Khan Academy, Stanford Medical School and four other institutions. With RWJF’s support, for example, Khan Academy has developed dozens of online videos explaining everything from diseases of the heart and circulatory system to how to interpret blood lab test. And for the past two years, the foundation has collaborated with the Association of American Medical Colleges and Khan Academy to sponsor national contests encouraging medical school students to create video and online content for those preparing to take the revised Medical College Admission Test®, or  MCAT®, scheduled to debut in the spring of 2015.

Michael Painter, MD, JD, senior program officer at RWJF, says such efforts aren’t just intended for current or aspiring medical students. “Technology enables us to spread knowledge for free to anyone who is a curious learner,” and also to transmit it to others who may need it, including patients. He notes that video and other online content developed by Khan Academy is playing a growing role in educating people across the health professions—for example, nursing students preparing for the National Council Licensing Examination for Registered Nurses  (NYCLEX-RN).

Working with the Khan Academy, and building on its “flipped classroom” model, Stanford now leads an effort to “create educational products that are more valuable than individual medical schools are able to create on their own,” says Charles Prober, MD, professor of pediatrics, microbiology and immunology and senior associate dean for medical educations at the university’s medical school. Together with medical school faculty and students at the University of Washington, Duke, the University of California at San Francisco, and the University of Michigan, Prober and colleagues are creating a prototype online course on microbiology and immunology–in effect, about viruses, bacteria, and other bugs, and the body systems that fight them–that can be used across all medical schools.

“Right now, in North America, more than 140 medical schools each have their own idea of what a true core course in microbiology and immunology should be,” says Prober. Considering that all US students will ultimately take the same exam to get a medical license, “we’ve been doing them a disservice” not to come to a common agreement on core components of knowledge that students should acquire.

It took much discussion, but the five schools have now agreed on core content for at least the one course, on microbiology and immunology. It will be piloted beginning in October at UCSF, and roll out across the other four schools beginning next January. The course’s online videos feature compelling stories focused on fictional patients, scripted by medical content experts and artfully drawn by another Stanford educator, Maya Adam. One segment features a young Haitian boy, Philippe, who develops cholera after drinking from a local water tap. His fictional elder brother, a medical school student, tracks down the culprit: the bacterium Vibrio cholera, which is endemic in Philippe’s neighborhood.

The videos, which students can watch from home, are intended to serve as “springboards” into deeper, more interactive classroom discussions based on materials somewhat like classic business school case studies. Such sessions, guided by a facilitator, “focus us more on forming us as clinical decision makers, because they force us to interact more with the material,” says Jennifer DeCoste-Lopez, a Stanford medical student who leads a student group working on the project.

The prototype will be evaluated and undoubtedly tweaked—and, if ultimately deemed successful, used as a model for other courses for first- and second-year med students. And it may help to set the stage for similar innovations in educating tomorrow’s health professionals throughout their lifetimes.

Join an RWJF “First Friday” Google+Hangout on Flipping the Medical School Classroom, on Friday, October 3, from 12 pm to 1 pm ET.

Tue, 30 Sep 2014 09:30:00 -0400 Susan Dentzer Medical schools Education and training Medical students and residents <![CDATA[Helping Physicians Do What They Got Into Medicine to Do]]> Two women are at a desk, one is counting money

“Health care was never intended to be the behemoth it's become. It was intended to be the place where people could get help for medical problems so they can return to living a healthy life.”

For me, this statement—from an internist I met last month—is a refreshing take on the value of the health care system in a Culture of Health. It’s an inspiring vision for those of us focused on the usual litany of problems: Our health care system costs too much, and delivers outcomes that lag behind other countries to such a degree that it threatens our economic health and social fabric.

Last year, the Robert Wood Johnson Foundation (RWJF) invested in five markets—Maine, Minnesota, Oregon, Colorado, and the St. Louis region—where there is the will and ability to measure health care costs and quality, and use that information to drive change. In each of these markets, we’re working with multi-stakeholder organizations who are members of the Network for Regional Health Improvement (NHRI). Each organization will produce reports that compare the cost of treating patients in each primary care practice in their market. (You can learn more about this project here.)

At RWJF, we believe working at community level, with many different people and organizations, can help build a Culture of Health. But when it comes to our health care system, physicians are still perhaps the most influential force, in part because they hold the power of the pen to order services. They (along with nurses) also are among the strongest political and moral voices for or against change. Granted, we can't ask our doctors to heal a broken health care system the way they treat a broken bone; on the other hand, I don’t think we can fix the health care system without having physicians on board.

I met that internist quoted above during NHRI’s two-day workshop with 16 primary care physician champions from the five pioneering regions. Our goal was to prepare them to help their physician colleagues back home to use the cost comparison reports to find ways to reduce costs and improve quality—in other words, to deliver high-value care. Some of these physicians had been nominated by community leaders; others were selected by competitive application. Some were veteran health care value champions; some were newbies. All willingly plunged into the complex details of cost measurement.

The physician leaders I met recognize that the current American health care system is financially unsustainable, and that health care is only one component of a Culture of Health.

They understand that our national overinvestment in health care is making it impossible for American industry to be competitive, crowding out investments in things such as education and infrastructure. I didn’t hear anyone say, “That’s not our problem as health care providers to fix.” These physicians know that big changes are coming in the way health care is paid for and delivered, and they seemed anxious for a forum in which they can talk with their peers about how to get ready for those changes. Most of the time was spent helping them think about how cost and quality data will help them lead change in their communities.

One very inspiring session brought together the hard evidence about what we’ve learned from neuroscience and other disciplines about how people use (and don’t use) information to make decisions, with a deeply empathetic framing of how physicians, especially, may respond to reports that compare their performance to their peers. I came away understanding more than ever that when you want people to change, it won’t help—and it may hurt—if you just show people (especially physicians) a pile of data and charts, or just offer to pay them more.

Physicians need to believe that the cost of care comparisons will help them do the work they hoped to do when they entered medical school, and that working with the comparisons “feels” like the right thing to do. It made me think about how I want the doctors who treat my family and me to escape from what was referred to as a “soul-crushing” system.

I also came away understanding much more clearly how the ground is shifting under physicians’ feet; as one participant put it, now that we are better able to measure outcomes, and now that those data are cheap, physicians no longer have infinite power and infinite responsibility.

One of our physician champions challenged us: “Show me something I can change tomorrow.” They all wanted concrete, actionable steps they can take, whether it’s changing their prescribing practices, when they order tests, or where they refer their patients for specialty care. I especially enjoyed a presentation from Sutter Health’s Mike Von Duren, who called himself the “midwife of the ‘aha” moment.” He brings data on variation—in prescribing practices, or diagnostic test ordering, or procedure rates—to community physicians. Mike described the way physicians digest the data, then turn away from the screen and toward each other; they begin to talk to each other and trade best practices—and they have fun doing it!

I was inspired and energized by the 16 physician leaders I met at the workshop, but on the way home, I couldn’t help wondering: Are they enough to change the health care system? Medical education is beginning to incorporate important concepts of health care performance and value but the problems facing us are too urgent to wait for a new generation of leaders. The question is how to extend the efforts of 16 physician leaders in five communities, across the nation. What will it take to get us there? I’d love it if you shared any ideas you might have in the comments section below.

Thu, 25 Sep 2014 10:02:00 -0400 Anne Weiss Health care delivery system Cost of care Quality of care Performance standards and measurement RWJF Staff Views <![CDATA[Bringing in Diverse Perspectives to Build a Culture of Health]]>
Susannah Fox Susannah Fox, RWJF Entrepreneur in Residence

Entrepreneurs start from a place of passion, then work tirelessly to make others see their vision. I'm excited to announce that Susannah Fox will be pushing all of us at the Foundation to behave more like entrepreneurs.

This month, Fox began a new role as the Foundation's next entrepreneur in residence. She was previously an associate director at the Pew Research Center’s Internet & American Life Project, where she combined traditional survey research with field work in online patient communities. She excels at using data and storytelling to compel policymakers, consumers, and entrepreneurs to understand and discuss key health care issues.

To build a Culture of Health in the United States, we have to consider new approaches and ways of thinking. We need the creativity, imagination, and efforts of people from a range of backgrounds and industries to develop innovative solutions to our most pressing health and health care challenges. A health and technology researcher and trend spotter, Fox will be a valuable asset to these efforts.

Fox will collaborate with staff across the Foundation to initiate key projects, some of which will draw on her unique expertise in online patient communities and the social impact of technology. Even more important, we hope that she will challenge us, question our philanthropic processes, force us to consider new ways of doing things, and help us overcome the constraints we often place on ourselves. A master networker, Fox will help scan for new opportunities for the Foundation and will help us partner with entrepreneurs and other leaders to build a Culture of Health.

The entrepreneur in residence role, though successful in its first year, is still an experiment for RWJF. Our first entrepreneur in residence, former WIRED executive editor and Iodine Founder Thomas Goetz, brought his expertise on the design and the communication of health data and information to the Foundation, helping us to consider new approaches to challenges in health and health care. Goetz worked with us to develop two key initiatives: Flip the Clinic, a project to reimagine the encounter between patients and care providers, and Visualizing Health, a partnership with the University of Michigan to explore and share best practices for visualizing data to communicate health and risk information.

We're excited to see where this next phase in our experiment takes us, and we hope you'll stay tuned for updates about Fox's work with RWJF.

Wed, 24 Sep 2014 09:00:00 -0400 Lori Melichar Leadership development Mentoring E-health Disruptive innovations RWJF Staff Views <![CDATA[I’m RWJF’s Newest Entrepreneur in Residence]]>
Susannah Fox offers office hours at RWJF. Susannah Fox offers office hours at RWJF.

I am thrilled to begin my job as the entrepreneur in residence (EIR) at the Robert Wood Johnson Foundation.

You might think that the EIR role is traditionally associated with venture capital firms, not foundations. But scratch the surface and you’ll find commonalities between the two industries. Both VCs and philanthropists have daring ambitions, place lots of bets, and hope for a big pay-off every once in a while. The difference is that a philanthropy like the Robert Wood Johnson Foundation places a priority on societal dividends, such as greater access to health care or a reduction in childhood obesity.

I also like this definition of entrepreneurship: “The pursuit of opportunity without regard to resources currently controlled.” That fits the Foundation to a T as we pursue the audacious goal of building a Culture of Health in the United States.

But how will we measure success? How will we know if our bets ever pay off, especially when we are talking about culture change? I have a story to tell that I think illustrates how a small grant can make a big difference in the world.

In 2002, Robin Mockenhaupt, now chief of staff at the Foundation, oversaw a grant to Tom Ferguson, MD, to write a white paper about what he called “the first generation of e-patients.” In one bold stroke, Tom coined the word e-patients to describe people who are equipped, enabled, empowered, and engaged in their health and health care decisions. It was an almost outlandish idea a decade ago. But Robin believed there was something there and she wanted Tom to chronicle it.

The initial grant was for a six-month project. Tom worked on it for four years, continually improving on and expanding the white paper with the help of a close circle of advisors. I think the Foundation may have given up on seeing any result from the grant. And indeed, when Tom died unexpectedly in April 2006, it seemed that his work would go unpublished and unshared.

Instead, Tom’s friends and advisors (including me) finished the white paper and published it as free PDF on It sparked a conversation that continues today in policy circles, clinical settings, board rooms, and – just as important – around the kitchen table of anyone who finds themselves dropped into the maze of health care without a map.

Meantime, the word “e-patient” has become part of our lexicon. The equipped, enabled, empowered, engaged – and yes, entrepreneurial – patient has a seat at the health care table. That’s a cultural change that benefits us all. And it’s a ripple effect from a pebble dropped into the pond of the public conversation in 2002.

How might we measure the effects of small grants like the one that supported Tom’s work? How might we recognize the opportunities that seem outlandish today but will resonate far into the future?

As a researcher, I documented the online landscape and followed the trail blazed by people living with chronic and rare conditions – the alpha geeks of health care. Now, as an Entrepreneur in Residence, I hope to drop a few pebbles into the pond of culture change.

Please join us in dreaming big, setting audacious goals, and co-creating the future of health and health care. Let us know what opportunities you see and where you are placing your bets.

Tue, 23 Sep 2014 13:54:00 -0400 Susannah Fox Leadership development Mentoring Disruptive innovations E-health Patient-centered care National Leadership Views <![CDATA[Stress: Withstanding the Waves]]>
Infographic: stress_section
Infographic: stress_section

Infographic: How Do We Move From a Culture of Stress to a Culture of Health?

View the full infographic

As a kid, when you went to the beach, did you ever play that game where you’d wade into the ocean and test your strength against the waves? You'd stand your ground or get knocked over, and after a few minutes, you'd head back to shore.

We didn’t realize it at the time, but as we felt those waves roll by, we were getting an early glimpse of the stresses of everyday life. The difference is, as adults we can't choose to stand up to just the small ones. And for the most part, going back to shore is not an option.

In a survey RWJF conducted with the Harvard School of Public Health and NPR, about half of the public reported experiencing a major stressful event in the past year. In more than four in 10 instances, people reported events related specifically to health. Many also reported feeling a lot of stress connected with jobs and finances, family situations, and responsibility in general.

Over time, those waves can take their toll. And when they become overwhelming, they can truly wear us down, seriously affecting our both our physical and emotional health.

So how can we deal with these waves of stress? Certainly, there are proactive things we can all do help manage its effect on our lives—exercise, for example. At the same time, we’ve probably all experienced instances when we’d love nothing more than to get up early for a run or brisk walk—but don’t have the energy because stress kept us up at night. Or we may just be too tapped out from long hours, relationship struggles, caring for loved ones, etc., to spare the energy or the time.

If this sounds familiar, consider yourself human. Right next to you, whether at work, on the train, in your grocery store, is probably someone whose waves are similar to or bigger than your own. So at the same time as you try to manage your stress, ask yourself: What could be done to help others achieve a solid footing? In this ocean of ours, there’s never a shortage of opportunity to lend a helping hand.

Have an idea to help move from a culture of stress to a Culture of Health in the home, workplace or community? Please share below—we’d love to hear from you.

Tue, 23 Sep 2014 11:42:00 -0400 Ari Kramer Behavioral/mental health Health promotion and disease prevention Social determinants of health National RWJF Staff Views <![CDATA[Cutting Calories: Good for Health, Good for Business]]> 90307108

Four years ago, 16 companies, acting together as part of the Healthy Weight Commitment Foundation (HWCF), announced an ambitious pledge—to remove 1.5 trillion calories from the U.S. marketplace by 2015. They wanted to help reduce obesity in America, especially childhood obesity. Research published today in the American Journal of Preventive Medicine confirms that the companies far exceeded their pledge, and are making a difference that’s helping families buy fewer calories.

Collectively, these companies sold 6.4 trillion fewer calories in 2012 than they did in 2007, which we announced in early 2014. What’s new in these studies tells us that, during that same pledge period, families with children bought fewer calories from packaged foods and beverages—and the biggest cuts were from major sources of excess calories in kids’ diets, such as sweets, snacks, and soft drinks.

Why is this pledge so important, and what’s the next step for industry leaders who want to help reverse the childhood obesity epidemic? RWJF senior vice president Jim Marks and lead study author Barry Popkin, PhD, of the School of Public Health at the University of North Carolina at Chapel Hill, share their views.

RWJF: What’s the most important finding in these studies?

Barry Popkin: People are buying fewer calories from HWCF brands, and many of those calorie cuts came from foods and drinks that are key sources of excess calories in kids’ diets—products that are highest in fats and added sugars, like sweets, snacks and sugary drinks. These are meaningful changes.

But we must remember that this is only one part of broader national efforts needed to help all families and children have healthier diets. To make progress on this very ambitious goal, we must collaborate beyond the HWCF pledge to encourage industry leaders to shift to product lines and marketing practices that make it easier for kids to consume more vegetables, fruits, whole grains, and other nutritious foods and drinks.

RWJF: The 6.4 trillion calorie cut translates into a reduction of 78 calories per person per day. Is this enough to make an impact?

Jim Marks: The calorie cuts achieved by these companies have the potential to be quite important. Together, the 16 companies account for about a third of all the calories from packaged foods and beverages sold in America, so they can have a big influence on the market.

But it’s true that this measurement of calories per person per day is a limited picture. The 78 calorie number does not take into account other sources of calories, the purchased food that is wasted, the impact of physical activity, or how healthy those calories are. It’s a good start, but it’s not enough.

That’s why we must continue to do all we can to make sure that the foods and beverages available to children and families are healthy and affordable. The HWCF companies need to further their commitments, and other companies need to step up to the plate as well. We also need to ensure that these changes are benefiting everyone, especially those at higher risk for obesity.

RWJF: The study on households with children notes that the decline in the number of calories families purchased from HWCF brands was less than expected. What does that mean?

Barry Popkin: We looked at shifts in what families were buying both before and after the HWCF companies made their commitment. We found that before these 16 companies started their pledge, families were already buying fewer calories from packaged goods sold by HWCF companies. If those trends had continued at exactly the same pace, we would have expected the calories purchased from HWCF companies to go down more than they did from 2007 to 2012, during HWCF’s pledge period.

Overall, we found that American families with children bought 101 fewer calories from packaged goods per person per day during the pledge period. We also found that HWCF brands contributed to the decline more than other brands—families bought 66 fewer calories from HWCF brands—and that the largest calorie cuts came from sweets and snacks, carbonated soft drinks, and cereals and other grain products. These are extremely encouraging accomplishments and they had a real impact on families.

RWJF: To evaluate HWCF’s pledge, the research team developed a way to track the flow of food and beverage products across America. Are there other ways to leverage this system?

Barry Popkin: These results are part of a pioneering evaluation that, for the first time, tracks foods and beverages from factory to fork. It tells us what companies are selling and what Americans are buying and eating. It also opens new opportunities to work with industry leaders to find far-reaching solutions that benefit both the health of Americans and the companies’ bottom lines.

We are continuing to monitor trends that show what people are buying. Future studies supported by RWJF will go beyond examining the HWCF pledge to assess how changes in the marketplace influence children’s diets and their risk for obesity. Other studies also supported by RWJF will examine how these changes have affected the foods and beverages purchased by those at greatest risk for obesity, including minority and lower-income families.

RWJF: Why did RWJF evaluate this pledge and what’s RWJF’s goal going forward?

Jim Marks: I was in the room with these companies when they announced their original commitment and volunteered for it to be evaluated. I know these leaders recognize the severity of the childhood obesity epidemic and are committed to addressing it. That’s why we agreed to fund the evaluation, and I’m so pleased with what we’ve learned so far. This is a remarkable accomplishment. It shows that industry can be part of the solution for reversing the nation’s obesity epidemic.

At RWJF we recognize that our vision—to build a Culture of Health that offers everyone opportunities to make healthy choices, no matter where we live or how well off we are—cannot be realized without cooperation from the business community. So we’ll move forward by encouraging HWCF and other industry leaders to do even more to ensure that healthy changes are a priority. This includes companies that shape our nation’s food supply—food and beverage manufacturers, restaurants, grocery stores, and other retailers. But also health care providers, childcare facilities, hotels, sports organizations, major media and entertainment companies, and other businesses that influence how we live, learn, work and play.

We’d encourage anyone who’s interested in learning more about how the food and beverage industry can help address childhood obesity to join the live webcast here for a special conversation between RWJF CEO Risa Lavizzo-Mourey and Indra Nooyi, chairman and CEO of PepsiCo and chair of HWCF. The discussion will take place Wednesday, September 24, and will be moderated by Judy Woodruff of PBS NewsHour.

RWJF: How are people responding to these types of changes? Does "healthy" sell?

Jim Marks: Yes. Making the shift to lower-calorie products is not just the right thing for customers, it also makes solid business sense because consumers are demanding healthier choices. In fact, for some food and beverage companies, it’s the “better for you” lower-calorie products that are driving sales and profits.

A report by the Hudson Institute found that 99 percent of the almost $1/2 billion in sales growth for leading consumer packaged goods came from lower-calorie foods from 2007 to 2012. There also has been a 96 percent increase in the availability of lower-calorie products. Food and beverage manufacturers are responding to shifting consumer demand for lower-calorie, healthier products, which is an encouraging trend. This is an important piece of the puzzle when it comes to helping all kids and families make the healthy choice the easy, affordable, everyday choice.


Healthy Weight Commitment Infographic Social Graphic
Healthy Weight Commitment Infographic Social Graphic

How Food and Beverage Companies Met the Challenge

The 16 companies, working together as part of the Healthy Weight Commitment Foundation, pledged to cut 1.5 trillion calories from the marketplace by 2015. They did better than that. They sold 6.4 trillion fewer calories in 2012 than in 2007.

View the full infographic

Tue, 16 Sep 2014 12:58:00 -0400 RWJF Blog Team Obesity policy Nutrition <![CDATA[Tackling Great Challenges at TEDMED]]>

TEDMED calls them the “Great Challenges:” Knotty issues that can’t be solved with a simple cure. Reducing childhood obesity. Determining how to engage patients more effectively. Accelerating the pace—and lowering the cost—of medical innovation. Eliminating poverty as a hurdle to good health. Cutting health care costs. Embracing prevention as the most effective medicine of all.

All of these great challenges call for new ways of thinking, new approaches, and a shift in society’s values if we are to conquer them. That’s why the Robert Wood Johnson Foundation is supporting TEDMED, taking place this month in Washington, D.C., and San Francisco—to bring together innovative thinkers, keep the dialogue flowing, and hopefully facilitate some great solutions to these great challenges.

We have a bold vision to build a Culture of Health in the United States, where being healthy is a social value that is reflected in our public and private policies, in the way we live, in the ways communities are developed, and in the way health care is provided. We believe that only when we TRULY value health will we be able to overcome these and other challenges facing our country.

My colleagues and I will be at this year’s TEDMED conferences, happening simultaneously in Washington, D.C., and San Francisco, September 10-12. Walk up to us. Talk to us when we walk up to you. Tell us what you are going to do to overcome these Great Challenges. Tell us what you can do to help us build a strong, inclusive Culture of Health.

TedMed Logo

We need ways to give individuals the means and the opportunities to make choices that lead to healthy lifestyles, so they will be more empowered and committed to engaging as active partners in their health. To make sure all of us, regardless of race, geography, ethnicity, or socioeconomics, live in a society where our kids can walk or bike to school safely, and have healthy, affordable foods within easy striking distance, so we can continue to reduce childhood obesity.

If we work with academia, government, industry and citizen scientists to reconsider how medical knowledge is created and distributed, we can make major leaps in medical innovation. And find ways to ensure that health providers serve as an active partner with patients, openly discussing the price and value of treatment, it could contribute to cutting health care costs.

If we can design approaches and knit systems together in ways that bridge care delivery with the non-medical factors that shape people’s well-being—where they live, learn, work, and play—we can help alleviate the impact of poverty on health.  Furthermore, if we redefine what it means to be healthy to mean so much more than simply not being sick, we can help change how the nation values and invests in prevention.

If you’re not able to be there, tell us—and the TEDMED community—your ideas and visions by using the hashtags #GreatChallenges and #TEDMED. Follow us at @RWJF_Live and our president, Risa Lavizzo-Mourey—who will be on site in San Francisco—at @risalavizzo. You can also follow me at @susanpromislo. We’re listening and can’t wait to move this exploration forward.

RWJF is also a proud supporter of several of the innovative thinkers who are sharing their ideas on the TEDMED stage this year, including Jill Vialet, Ted Kaptchuk, and Ramanan Laxminarayan, as well as former RWJF entrepreneur in residence Thomas Goetz. If you are a teaching hospital, nonprofit, medical school or government agency, you may apply to watch the live stream from the event and see their talks.

In the meantime, watch previous TEDMED talks from current and past RWJF grantees and leaders.

Wed, 10 Sep 2014 07:00:00 -0400 Susan Promislo Disruptive innovations Behavior change Community benefit RWJF Staff Views <![CDATA[Expanding Horizons for Rural Young Men of Color]]> Forward Promise - Oakland

When we first began the Forward Promise initiative, we envisioned building the capacity and impact of organizations across the country working with boys and young men of color from every type of community and background. We wanted to identify and support a cohort of grantees that were diverse in their approach, in their geography, and in the racial, ethnic and cultural experiences of the young people that they supported. Once we began doing this work, it didn’t take long to realize we were falling short.

The simple truth is that the majority of organizations who applied for Forward Promise that had demonstrated success and were ready to expand were located in major cities. Few applicants were in the rural beltway that stretches across the Southern United States, from Alabama to Arizona. It would be easy to assume that there weren’t many young men of color there or that there was not much innovation or capacity to support young men of color in that region. But you know what they say about assumptions ...

To me, good grantmaking means asking ourselves hard questions. It means making sure we are not setting up barriers that inadvertently exclude whole categories of communities and organizations that have the potential to do amazing and transformative work. In this case, when we realized that we were leaving out a major region of our nation, we had to ask ourselves, how could we adapt Forward Promise to build a Culture of Health there? What would we need to do differently to be effective in the rural South and Southwest?

In answering those questions, three insights stood out:

Place matters in the health of young people, families and communities. Where you live, where you go to school, and where you play profoundly influences your opportunities for health and success. We would have to design an approach that reflected the rural realities of the communities we wanted to reach.

Partnership is essential. The only way we could make a difference for the young men in this region would be if we found the right regional partners to work with us. And they would need to be able to partner with local organizations, who in turn would work together with schools, social services, local government, and health providers in their own communities.

There is no one-size-fits-all approach. What a young, black teenager in Mississippi experiences is different from a Native American boy living in Indian Country in rural Arizona. Because their experiences vary so much, our approach across the South and Southwest would have to vary as well.

These insights drove and shaped the design of our new Forward Promise Catalyst Grants, the third and final cohort of grantees to join the initiative. The Robert Wood Johnson Foundation together with Public Interest Projects have chosen four primary grantees in the South and Southwest. These regional grantees will regrant funds to community organizations working to build a Culture of Health for young men of color. We believe this approach gives us the best opportunity to build new capacity for change across a region that traditionally has lacked the philanthropic resources. And it gives us the best chance to empower local communities to help their own young men of color live healthy and productive lives.

The four primary Catalyst grantees are:

  • Black Belt Community Foundation will focus in 12 largely rural counties of Alabama, where more than a third of the population lives below the poverty line;
  • The Foundation for the Mid South will focus on rural communities of Louisiana, Mississippi and Arkansas;
  • First Nations Development Institute will focus on rural Native American communities of New Mexico, Texas and Arizona; and
  • Hispanics in Philanthropy will focus on rural Hispanic communities in the Southwest.  

Over the next 18 months, as each grantee redistributes funds to promising solutions in their regions, we will also be documenting the project and using the stories and lessons we capture to boost investment more broadly in the South and in rural areas. Our investment is the largest private investment in rural young men of color to date, but we hope it will be the spark for something even bigger.

All of this is a reminder that responsive grantmaking can be game-changing for investors as much as grantees. I look forward to sharing the transformative stories to come and seeing how they help to build a Culture of Health that includes all communities.

Mon, 8 Sep 2014 13:55:00 -0400 Maisha Simmons Youth development Risky behavior Poor and economically disadvantaged At-risk and vulnerable people Behavior change Mentoring Underserved populations Early intervention Education and training Men and boys Rural American Indian (incl. Alaska Native) Asian/Pacific Islander Black (incl. African American) Latino or Hispanic Arizona (AZ) M New Mexico (NM) M Texas (TX) WSC Mississippi (MS) ESC Louisiana (LA) WSC Arkansas (AR) WSC Alabama (AL) ESC RWJF Staff Views <![CDATA[Obesity in America: Are We Turning the Corner?]]> Childhood Obesity West Virginia

What word describes the current state of obesity in the United States?

How about the unexpected: Optimistic.

You might think that would be the least likely descriptor. After all, the annual report The State of Obesity: Better Policies for a Healthier America, released today by Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF), says adult obesity rates went up in six states over last year.

The obesity rate is now at or above 30 percent in 20 states (as high as 35 percent in Mississippi and West Virginia), and not below 21 percent in any. Colorado has the lowest rate at 21.3 percent, which still puts it higher than today’s highest state—Mississippi—was 20 years ago.  The childhood obesity headlines are difficult to swallow as well. As of 2011-2012, nearly one out of three children and teens ages 2 to 19 is overweight or obese. Similar to adults, racial and ethnic disparities persist. And rates are higher still among Black and Latino communities.

But if we look a little deeper, we see a hint of promise on the horizon.

Adult obesity rates have largely stabilized over the past two years while childhood obesity rates have leveled off over the last decade. Childhood obesity rates have even declined in a number of places in recent years—from Anchorage, Alaska, to Eastern Massachusetts, in California and Mississippi, in big cities like New York and Philadelphia, and in rural areas like Vance and Granville counties in North Carolina.

Plus, for the first time in a decade, data show a downward trend in obesity rates among young children from low-income families in many states. The importance of this development cannot be overstated. These are children at particularly high risk for obesity and whose families have the fewest opportunities to make healthy choices. Preventing obesity early makes it much more likely for a child to maintain a healthy weight into adolescence and adulthood. Research shows that kids who receive a healthy start in life stand a much better chance of graduating college, earning higher-paying jobs, avoiding chronic diseases, and living longer lives.

Over the past few years, RWJF has spotlighted several communities that are working to build a Culture of Health, setting a national example for others to follow. Every school in Mingo County, W.Va., for example—home to Williamson, one of six winners of the 2014 RWJF Culture of Health Prize—has joined the Alliance for a Healthier Generation’s Healthy Schools Program to promote healthy eating and physical activity for all students. A new farmers’ market and unique “Prescription Vegetables” program incentivizes healthy eating for all residents, particular seniors and those who are low-income.

In Santa Cruz County, Calif.—one of the inaugural RWJF Culture of Health Prize winners in 2013—the youth-led advocacy group Jóvenes SANOS is on a mission to encourage healthier eating for all county residents. After noticing that there were almost no healthy food options around the high school, its members worked with the city council to pass a new restaurant ordinance that requires new restaurants to offer and highlight healthy options. They’re also working to bring healthy vending machine options to the county’s metro bus stations.

Or consider the Midwest city “Mighty” Manistique, Mich., whose local farmers’ market placed second nationally in the America’s Favorite Farmers’ Market contest in the boutique-size market category. In Manistique, city leaders turned a former dumping ground into a 40-acre park complete with sledding hill, archery range, nature trails, baseball field, basketball and tennis courts, and swimming beach.

Now, let me be clear: when it comes to obesity, there’s still too much bad news and too few success stories.  We’re starting to tip the scale in the right direction but much more work is needed to keep the momentum going. It will take strong and ongoing commitment from policy, industry, and community leaders across the nation to create policies and environments that make healthy choices the easy and everyday choices for all of us, no matter where we live.

When the description of obesity in America turns from “optimistic” to “reversed,” I believe the Williamsons, Santa Cruzes, and Manistiques, and hundreds of other communities like those, will be the reasons we won the fight. 

John R. Lumpkin, MD, MPH, is RWJF senior vice president and director, targeted teams.

Thu, 4 Sep 2014 09:18:00 -0400 John R. Lumpkin Obesity policy Childhood obesity Health policy <![CDATA[No More Tobacco Behind the Counter at CVS]]> CVS Tobacco Stopping Starts Here in Store Sign

You can pick up a prescription. You can get your blood pressure checked. You can buy a bottle of pain reliever, a package of bandages, a tube of toothpaste.

Here's what you can't do at CVS: buy cigarettes or any other tobacco product.

Last February, CVS (now CVS Health) announced its decision to remove all tobacco products from its 7,700 pharmacies nationwide. One month ahead of the deadline the company set for itself, CVS has declared all of its stores free of tobacco products.

Back when CVS made its announcement, RWJF President and CEO Risa Lavizzo-Mourey, MD, praised the pharmacy chain’s decision to go tobacco-free, saying, “In eliminating the sale of tobacco products, CVS recognizes that pharmacies and pharmacists are responsible for far more than filling prescriptions and selling sundries; they have become a key partner for better health in neighborhoods across the nation.”

At the time, some raised questions about the business impact of that decision, Lavizzo-Mourey acknowledged in a related blog post on the professional social networking site LinkedIn. In snuffing out tobacco sales, she noted, CVS stands to lose about $2 million in revenue. That’s a big hit in the short term, but it could also be a smart move in the long run, many analysts say, as the chain seeks to grow its in-store clinic program and partner with traditional health care providers.

Regardless of business considerations, the decision by CVS to stop selling tobacco in its stores is also the right thing to do for the nation’s health, Lavizzo-Mourey noted in her LinkedIn post. “In today’s interconnected world, corporate policies must take into consideration far more than short term revenues—the health and wellness of a company’s employees, customers, and community are also key determinants of the well-being of its business.”

Read coverage of this week’s announcement:

Wed, 3 Sep 2014 14:40:00 -0400 Jeff Meade Tobacco Tobacco control <![CDATA[Living Out Their Salad Days: Shaping Healthier Environments for Kids in the Nation’s Schools]]>

A school lunchroom full of hundreds of young children, happily slurping up ... salad.

If you’re someone who’s ever struggled to get kids to eat their vegetables, it sounds like an impossible dream.

But this is reality at Anne Frank Elementary School, the largest in Philadelphia, with 1,200 students from kindergarten through fifth grade. Serving salads was the brainchild of Anne Frank principal Mickey Komins, who had the salads brought in from a local high school cafeteria.

Along with the after-school Zumba and kickboxing classes that the school now sponsors for kids, parents, and staff, healthier food offerings are among the innovations that earned Anne Frank an award from the Alliance for a Healthier Generation. The Alliance, a Robert Wood Johnson Foundation grantee, is a nonprofit founded by the American Heart Association and the Clinton Foundation to help stem the tide of childhood obesity. It’s at the vanguard of a growing national movement to turn schools into healthier environments, and offer kids fundamental lifelong lessons about maintaining their health.

The Alliance first sought to enlist Anne Frank Elementary four years ago in its Healthy Schools Program to support healthful eating and physical activity. With nearly 1 in 3 U.S. children overweight or obese—and since many children consume at least a third to one-half of their daily calories at school—it didn’t take much to persuade Komins, a former physical education teacher turned administrator, that combating child obesity would require such “revolutionary” measures as serving more green vegetables to kids.

Following the Alliance’s framework, Komins and his team first sent out a survey to the rest of the staff, soliciting their ideas for building a healthier school. Next came a survey of kids and parents to determine their interests and obtain buy-in for any changes.

 “We started out very small because we didn’t want to overwhelm people,” Komins says. “If you start small, you get small successes and find things you can build on.”

The initial building blocks included two councils created to advise the school on changes: one representing adults and another, students. Besides salad, fruits were added to the school menu. The school sent a letter home to parents asking them not to send in sweets for birthdays, and suggesting an alternate list of food and non-food items, such as stickers. One student arrived at school subsequently with 30 Greek yogurts for his classmates as a birthday treat.

On the activity front, teachers began scheduling a “JAMmin’Minute” in classes to get kids up and moving. A once-a-week exercise class for teachers after school eventually led to multiple classes for kids, teachers, and parents. And an annual 5K “color” run was scheduled to provide a fun-filled event in which the participants—students, parents and school staff—were blasted with colored powder as they passed various stations along the way.

The results are in: Average body mass index scores for Anne Frank’s students have decreased by three points—from 25 to 22—since the changes were initiated, according to an analysis conducted by the school’s nurse. (To put that in perspective, the Centers for Disease Control and Prevention considers a 10-year-old boy with a BMI of 21 overweight; with a BMI of 23, obese.) Komins is now a Healthy School Ambassador for the alliance—one of a group of 30 innovators who’ve adopted program and policy changes to support healthful eating and physical activity in schools.

These voluntary efforts have gained reinforcements at the federal level. Revised federal nutrition standards governing school meals are being phased in from 2012 to 2022, and new standards governing snack foods and beverages sold in schools take effect this school year. Still other public-private partnerships, like First Lady Michelle Obama’s Let’s Move! initiative, have sparked the Salad Bars to Schools program to raise private donations to install such facilities in schools.

Best of all, there’s growing evidence that such measures work. Although a Government Accountability Office study earlier this year reported a 3.7 percent decline in the number of students participating in the National School Lunch Program, a separate study, sponsored by the RWJF Bridging the Gap research program, shows that 7 in 10 U.S. public school administrators surveyed say the majority of students like the meals produced under the new federal standards. Still other RWJF-funded research shows a link between strong school meal standards and lower rates of child obesity.

The bottom line: At Anne Frank Elementary and elsewhere, millions of kids nationwide are returning to healthier schools this fall. That means that they’ll be able to look back on their school days as genuine salad days for many more years to come.

Tue, 2 Sep 2014 10:59:00 -0400 Susan Dentzer School foods Childhood obesity School snacks Children (6-10 years) Urban Pennsylvania (PA) MA <![CDATA[Healthy Communities: The Building Blocks of a Culture of Health]]> Baldwin Park California

What do Corvallis, Ore.; Baldwin Park, Calif.; and Buffalo, N.Y. have in common? It certainly isn’t their weather.

Hint—the commonality is something much more relevant to RWJF’s newly refined mission. These three cities are building a Culture of Health for all their citizens. They are tapping into the skills and resources of a diverse group of partners to ensure everyone has access to healthy choices. It’s their collective efforts, along with dozens of other communities supported by the Foundation’s Healthy Kids, Healthy Communities (HKHC) program, that make me so optimistic about our organizational goal.

My strong belief that environments—physical, social and educational—play a prominent role in our individual health and well-being is what initially drew me to RWJF. So, in 2008, I excitedly embraced the opportunity to be the national program officer for HKHC, which addressed the root causes of childhood obesity by transforming the physical activity and food environments in which children and their families live, learn and play.

Without us necessarily realizing it at the time, HKHC started “planting the seeds of a Culture of Health” and served as an early model for our current work. Its approach to the childhood obesity epidemic is what the movement is all about—addressing health in a way that is more than just the treatment of a disease.

As our HKHC investment wraps up, it’s a perfect time to celebrate those communities that have supported and nurtured healthy places, kids and families.

HKHC’s umbrella organization, Active Living By Design, developed three substantive reports and resources from the program that comprise lessons learned and provide compelling community examples. While the reports contain many great nuggets of information, I want to highlight one of my favorite themes from Growing a Movement: Healthy Kids, Healthy Communities Final Report.

Giving locals a real role and voice are key ingredients in establishing a Culture of Health. Here’s how HKHC made it happen:

  • HKHC worked with local governments to make community engagement more of a priority. In many instances, elected leaders and/or departmental officials developed new procedures to accommodate, and even require, greater participation from local residents. This is one place where Corvallis, Ore., excelled. HKHC helped “Creciendo en Salud,” the local partnership, focus on building the capacity of youth and low-income residents to advocate for health opportunities in their neighborhoods. For the first time, in many cases, Latino and low-income residents testified at city council meetings, city advisory groups and school board meetings.
  • HKHC-supported communities also made sure to prepare their residents, so they could engage in civic-planning processes and improvement projects in a meaningful way. Preparation took a variety of forms, ranging from periodic educational sessions addressing healthy eating and active living issues to a year-long curriculum for equipping residents with the skills they needed to participate in city council meetings and, in some cases, even serve on boards. Locals also learned about a range of topics including government services, political processes, land use planning, utilities and economic development. For example, the HKHC project in Baldwin Park, Calif., worked with local partners to launch an initiative solely focused on strengthening resident leadership. It produced results. Resident advocates, armed with cameras and assessment tools, led a grassroots campaign for healthier corner stores and prompted the development of a nationally recognized Complete Streets policy.
  • The best part of HKHC’s work with local residents is that they collaborated with both adult and youth leaders. Kids and teens were able to have a seat at the table and share input that really shaped the changes made in their communities. In Buffalo, N.Y., HKHC helped facilitate the creation of a youth advisory committee that led to youth seats on three different city-wide councils. The youth committee members also participated in the city’s zoning and land use change process, and they hosted a youth training session to educate high school students about land use planning and effective participation in public meetings. Another successful effort resulted in a policy change that will remove the old, unhealthy vending machines throughout the school district.

I am certain that the HKHC local partnerships, especially resident supporters, will continue to serve as leaders and resources to the Culture of Health movement that is occurring in communities across the country. The childhood obesity epidemic didn’t happen overnight, and we’re not going to reverse it overnight. Similarly, realizing our Culture of Health vision is going to take time. It’s also going to take partnerships like the ones HKHC developed. This is an opportune time to leverage the investment we made over a decade ago to reverse the childhood obesity epidemic and to create a Culture of Health everywhere. Corvallis, Baldwin Park and Buffalo are just the tip of the iceberg. How can we replicate their achievements, and the achievements of the 46 other HKHC communities, in cities and towns around the country?

Mon, 25 Aug 2014 09:15:00 -0400 Jamie Bussel Childhood obesity Healthy communities Built environment RWJF Staff Views <![CDATA[Are E-Cigs a Gateway to Smoking for Teens?]]> Vaping Electronic Cigarette

As you step through the door of Beyond Vape, you are enveloped in the warm scent of vanilla, tinged with butterscotch. The sleek glass counters and display cases are reminiscent of a high-end cigar shop, but there are no tobacco leaves on hand here. This popular, high-end “vaping” parlor, on one of Williamsburg Brooklyn’s more popular streets, is one of seven the company owns on the East and West Coasts.

Vaping—or inhaling richly flavored, heated vapor through a slender, battery-powered tube—is the latest trend in “smoking,” without actually lighting a traditional cigarette. Cindy Hsu, the store’s manager, explains that some of her customers “vape" without even adding liquid nicotine to the tube’s cylinder. “They prefer to just enjoy the extensive menu of flavors such as mocha mint, kiwi strawberry and pineapple.”

Tasty flavors are one thing, but there’s another popular incentive to vape: the claim that vaping can help you stop smoking. Another neighborhood shop, Brooklyn Vaper, advertises its wares with a video explaining that vaping is a “greener, cheaper alternative to help you quit smoking effortlessly... while vaping in 40 flavors.”

Is that true? Can vaping or pre-packaged e-cigarettes help smokers quit?

It depends on which research you're reading. One recently published survey of almost 6,000 adult smokers in Britain found that those who used e-cigarettes were 60 percent more likely to quit than those who tried nicotine replacement therapy or willpower alone.

However, many other researchers have come to very different conclusions. For example, an analysis published in the May 2014 JAMA Internal Medicine found no evidence to support the contention that e-cigarettes help conventional smokers quit, and the Center for Tobacco Control, Research & Education at the University of California, San Francisco, has called upon the Food and Drug Administration to "prohibit e-cigarette marketing that promotes false health claims."

And that's not even taking account the potential health risks associated with e-cigarette vapors, which are regarded as toxic.

That's the debate swirling around adult e-cigarette smoking and vaping, but there is an even more worrisome issue: What do we know about the effect of e-cigarettes on adolescent smoking behavior?

The Impact on Teens

Sociologist and demographer Adam Lippert, PhD, a Robert Wood Johnson Foundation (RWJF) Health & Society Scholar (2013-2015), is one of many researchers asking the same question.

“My research was motivated by 2011-2012 data showing that the rate of adolescent e-cigarette use had doubled (from 5 percent to 10 percent) in a single year,” he says. The rate is increasing even though many states, including New York, ban the sale of e-cigarettes to people under 21. (Editor's note: Newly published research by the Centers for Disease Control and Prevention shows a threefold increase in the number of young people who had tried an e-cigarette in 2013, from roughly 79,000 in 2011 to more than 263,000 in 2013.)

Understanding why adolescents begin smoking is critical because almost nine out of 10 smokers pick up the habit by age 18, and 99 percent start before 26, according to the Centers for Disease Control and Prevention (CDC).

“I wanted to know whether adolescents were also using e-cigarettes to quit conventional cigarettes, like adults, or if e-cigarettes were used along with conventional tobacco,” Lippert explains.

His research found that teen smokers in general were most likely to be white and male, and that this group was also most likely to use e-cigarettes. The bad news: Those teen smokers tended to use conventional cigarettes and e-cigarettes together. Lippert reported that for teens, “e-cigarette use does not appear to be part of a [smoking] cessation regimen among conventional cigarette smokers wishing to quit.”

He makes his argument in the article “Do Adolescent Smokers Use E-Cigarettes to Help Them Quit? The Sociodemographic Correlates and Cessation Motivations of U.S. Adolescent E-Cigarette Use,” published online in the American Journal of Health Promotion in June.

Protecting Kids

Not only does Lippert express concern about the possible unknown health effects of e-cigarettes, he also suggests that for some young people, e-cigarettes might serve as an easy introduction to smoking. (A March study published in the journal JAMA Pediatrics makes just that assertion. The CDC research cited above paints an even more distressing picture. It shows that young people who had tried e-cigarettes were about twice as likely to intend to smoke tobacco cigarettes.)

“Other research has shown us that for adolescents, peers are the greatest influence on substance use,” Lippert says. And as every parent knows, even with legal restrictions in place, hot social trends, like vaping and e-cigarette products, transcend legal barriers and easily end up in the hands of teens.

“When smoking is portrayed as a social norm among others who are seen as cool, sophisticated, rebellious, or fun-loving, teens often respond by copying the behavior and trying cigarettes themselves,” according to the CDC report Preventing Tobacco Use Among Youth and Young Adults.

For parents and policy-makers, Lippert advises:

The danger, he adds, is slipping backward in time when it comes to adolescent tobacco use. “Teen smoking is at a historic low now, so we have something to protect. If we do nothing, we risk losing that. We do not want to go back to the days of Joe Camel.”

Learn more about the RWJF Health & Society Scholars

For an overview of RWJF scholar and fellow opportunities, visit

Thu, 21 Aug 2014 15:44:00 -0400 Sheree Crute Tobacco cessation Tobacco control Tobacco <![CDATA[Straight Talk: Black Women, Hair and Exercise]]>

When you're starting to exercise, you look for reasons not to, and sometimes the hair is one of those reasons.—U.S. Surgeon General Regina Benjamin, August 2011

I once wrote about how black women can care for their hair when physically active. It featured the perspectives of women ages 21 to 65 on how we protect our weaved, straightened, and natural styles while exercising. After reading the post, a well-respected public health leader admitted, “I did not know that hair care was an issue that kept black women from exercising.”

I wasn’t surprised that a middle-aged, middle class, white male had missed this not-too-insignificant tidbit. But I was saddened that someone with a prominent role in prevention wasn’t aware of an important factor behind the obesity crisis among black women.

There are many reasons why four out of every five black women in the U.S. are overweight or obese: We live in neighborhoods that make eating cheap, high-calorie foods and beverages very easy, but physical activity very hard. Some wonder if our genes predispose us to excess weight; others say that we are beyond motivation, given data suggesting that too many of us suffer untreated depression.

But hair, for black women, adds a whole other level of complexity, as we struggle with how we can maintain our hairstyles while being physically active. Hair is no small matter for us—it is intimately connected with our life experiences, from whether we get married, to how much money we make, to who we socialize with. Ultimately hair is a powerful mediator for how African-American women feel about themselves.

Many of us struggle with shame around our body image. This includes how we present and care for our hair. In work settings, we feel pressured to have "professional" hair that doesn’t bring too much attention to ourselves. Socially, the rules wax and wane, but overall it is important to be not too far beyond the mean with your tresses. Most black women spend a great deal of time and money finding the right fit. Physical activity, with its attendant sweat and dishevelment, adds another layer of concern.

So what are we, as public health stewards, to do if we are serious about getting more black women active? Any public health initiative targeting physical activity for black women must be culturally responsive, and that means taking hair care into consideration. Rutgers University’s H. Shellae Versey has closely studied how hair influences physical activity among black women, and recommends that public health efforts include strong social networking, social media, and responsiveness to cultural norms and preferences.

I agree. Within the last five years, there has been an upsurge of groups that are promoting physical activity in the black community. In Birmingham, Alabama, where I live, nearly 6,000 black women are moving with GirlTrek and Black Girls RUN! (BGR!). We log thousands of miles monthly even when the temperature is 30 degrees, in the pouring rain, or when the humidity is over 90 percent. You'd best believe that this causes hair stress for black women.

Birmingham trekker, Rukiya, does not let what’s on her head get in the way of what is in her heart. She is resolute about keeping her hair straightened and reaching her health goals. For Rukiya, being physically active means fewer curly styles as well as taking extra time to use protective grooming techniques. She has found the right balance that permits her to walk five miles, three days per week. She also does strength training three times per week and has begun to add interval runs to her routine. Rukiya spreads the word about walking to family members, sorority sisters, and friends in BGR! and GirlTrek.

Her diligence is paying off. Her loved ones have begun to take note of a more toned and active Rukiya. She has dropped two dress sizes over the past three months and continues to explore new ways to be active. After a recent GirlTrek skate party, I asked Rukiya what keeps her moving and committed. She quickly replied “I see what you all are doing or have done, and it's encouraging. The support is amazing. In some things, I'm a loner. But my fitness journey, I believe, is not something I'm meant to do alone. I tried it that way and failed. Thank you all for being such shining stars!”

Rukiya’s story should set a trend for how we tailor physical activity programming in public health—it should be inspirational, culturally responsive, and build community. We have to set the stage for more shining stars to emerge from communities of color and in low-income communities. We must ponder the types of policies and practices that can promote a culture of health and bolster health equity. Ask yourself: “What if more public health programming was framed to be culturally and circumstantially responsive? What policies and funding decisions can build upon the strategies of BGR! and GirlTrek? What role can I play in ushering in this type of change?”

Hair will remain an issue, but the allure of powerful social networks and positive imagery has shifted the dialog for black women’s wellness. Many have transitioned from asking ”can I be active” to “how can I try on more and new activities” in the comfort of a community of other black women.

Our fitness community also includes our daughters. It is not unusual to see Rukiya with her 9-year niece, Garnier, along the walking trail. She is the spitting image of her aunt, and she too wears her hair straightened. Garnier has a powerful role model that lets her know that she can be active and have any hair style she chooses. We need to spread that message to all girls and women of color—they can have great hair and great health as well as public health systems that make it possible.

About the author

Keecha Harris, DrPH, RD is a walking enthusiast who has trekked every day since October 2012.  Her consulting company has provided support to the Robert Wood Johnson Foundation Childhood Obesity Team and the Research, Evaluation and Learning unit.  

Thu, 21 Aug 2014 09:00:00 -0400 Keecha Harris Physical activity Behavior change Cultural competence <![CDATA[Building the Information-Rich Culture of Health]]> Reform by the Numbers Visual

What if your mother wanted to take some ibuprofen for her arthritis, but didn’t know if it would interact adversely with her other medications?

No problem, right?

She could whip out her smartphone and launch an app that connected to her local health information exchange. Within fractions of a second, the exchange would verify her identity, locate the computer storing her electronic health record (EHR), and shoot an answer back to her.

This scenario is just one example of the many ways that having timely access to health information could contribute to health. It could, that is, if the nation had an agreed-upon way to organize data about health and health care in ways that made it easily accessible and usable while still secure and protected.

But for now, we don’t.

There are many more ways in which we could all benefit if things were different. What if a community’s planning department wanted to know where building a new bike path would provide the most benefit and could call up on an app the most common cycling routes that citizens already use? Or a public health department could immediately tap into data about who was showing up in clinics with flu-like symptoms as it sought to pinpoint a local disease outbreak?

You get the picture. Health information—our ability to organize it, access it, and actually use it, is a critical part of building a Culture of Health.

The nation is on its way to building systems that could make all these data uses possible, but it isn’t as far along as it needs to be. Rather than having the data structures in place that would allow the agile uses these examples suggest, it’s as if, at least for the type of clinical data collected on EHRs, the nation had installed a bunch of freestanding fax machines that could somehow send faxes, but never receive them.

That was the conclusion of a Robert Wood Johnson Foundation forum on the nation’s health information infrastructure held in Washington, D.C., on August 7. (See the videos: Part 1 and Part 2.)

On the one hand, the United States has made enormous progress in health information technology (HIT) adoption since enactment of a 2009 federal law aimed at spurring HIT adoption.

The latest RWJF annual HIT adoption report—“Health Information Technology in the United States: Progress and Challenges Ahead, 2014” shows that almost 3 in 5 U.S. hospitals had at least a basic EHR in 2013. In 2012, about 2 in 3 eligible hospitals were receiving incentive payments from the government for meeting initial “meaningful use” criteria of the technology, up from fewer than 1 in 2 hospitals in 2011.

What’s more, nearly half of U.S. physician practices had adopted at least a basic EHR, double the number that had one in 2009. No other large nation has made so much progress in HIT adoption so quickly, one of the authors of the report, Harvard’s Ashish Jha told the forum.

But looked at from another perspective—just how much are health care professionals really exchanging health care information—the accomplishments to date have fallen short. Only one in 10 hospitals are providing patients with access to their health information, for example. Only about half of hospitals use EHRs to identify gaps in care. Important parts of the nation’s health care continuum—particularly small physician practices and medical specialists—are far less likely than hospitals and other providers to have adopted EHRs. And when it comes to exchanging health information among providers—for example, sending lab results from one hospital or health system to another when a patient is transferred—only about 1 in 3 hospitals are actually doing it.

Organizing health and health care information so that those who need it can access and use it, quickly and easily, while still protecting patients’ privacy, is critical. That’s why, in 2013 RWJF collaborated with the Agency for Healthcare Research and Quality and the Office of the National Coordinator for Health Information Technology (ONC), and asked a prestigious group of the nation’s scientists and academicians to tackle the issue. The group, known as the JASONs has been advising governmental agencies, such as DARPA, on science and technology matters for more than 50 years. The report it produced, “A Robust Health Data Infrastructure,” represents one of the first times—if not the first time—that federal agencies have asked the JASONs for assistance with a health-focused question.

The report recommends that ONC prompt the development of an overall software architecture that could make robust health data exchange possible nationwide. The architecture would be based on “open” standards for collecting data. Developers of EHRs would have to publish so-called application program interfaces—the directions for how various software components can connect with each other. Such a system would be similar to the arrangement that allows millions of developers to create apps that connect to proprietary smartphone software developed by an Apple or Samsung.

The JASON vision frames the big technical data infrastructure challenges, but emphasizes that those are surmountable. It does not, however, deal specifically with many of the other barriers to such an effort—including legal, economic, societal and even cultural ones. Those other challenges are likely the most difficult to overcome.

Speaking at the RWJF forum, National Coordinator for Health Information Technology Karen DeSalvo called the JASON report “a gift to the nation” for proposing a pathway to a health information architecture. Arguably, if we cannot find ways to harness the tremendous power of the health and health care data that we are collecting, we will not be able to attain that vision. Now, the nation needs focused, intense work to promote and tend the development of system that can deliver on the promise of an information-rich Culture of Health.

Wed, 20 Aug 2014 10:36:00 -0400 Mike Painter Information technology Data RWJF Staff Views <![CDATA[A Survivor’s Take on Depression: We are the Sad Ones Try to Understand Us]]> Depression Painting to go with blog post Painted in the hospital after suicide attempt

(This post was written by a member of the RWJF family who has asked to remain anonymous.)

Every day I worry that I will be caught. It could happen any time, any place, and by any one person that looks past my smile and into my eyes and knows immediately that I am not like him nor her. He or she will not see the color of my eyes, but rather that I am hiding something.

I have been in and out of therapy since the age of 9, and on and off antidepressants of every color and brand for more than 20 years. Yet I stand here today with the same diagnosis that I had when I was a child, despite the “help” and the “work” that I have devoted to my illness ever since I can remember. I have clinical depression.

I will never be “okay” by conventional standards without medication. I have finally come to realize that this is not my fault, but rather a product of my DNA. Nonetheless, I hide in shame. No one knows of my diagnosis, or the medicines that I take to help control it, or the acting that I perform daily to hide it.

I could be your sister, your friend, your neighbor, your co-worker, your daughter, and you would never know it unless I told you.

The recent passing of beloved actor and cultural icon Robin Williams has spurred an online conversation around depression, shining a light on the disease’s severity, and the millions who suffer from its affliction. The confusion that surrounds his death prompted me to write my story.

So many people have wondered why he didn’t seek help. We (the sad people) know there is help. We just don’t want it. A 1-800 number will not help those who have reached the end, the point of no turning back. When we are sad, the last thing we want is “help.” But what may work is compassion and empathy for our suffering, and a communal acceptance that we are not crazy.

My mother would always ask “what’s wrong with you, you have everything, you have amazing talent and you are so smart, why can’t you snap out of it?” My response was always a calm, steady three words: “I don’t know.”

As a sufferer of mental illness, I cannot control it. It is as scary to me as it is to you. If I could change, I would.

I will forever hold on to the memory of attempting suicide and being held in a mental facility afterwards. My freedom and dignity stripped from me because I had a “bad night” and cut my wrists. Instead of compassion and empathy for my suffering, I was stripped of my clothes, locked in a dirty room with nothing but a stained cot and intense fluorescent lighting that prevented me from resting. I was questioned by very young psychology students who asked me remedial questions that were meant to judge my mental state, but all I could focus on was the thought of losing my entire life (job, children, family, etc.), and being locked away in a mental hospital against my will. I still recall the cries of the patients in holding cells next to mine.

I gathered my strength, stood in a poorly laminated floor hallway, and spoke to the loved ones of those in the adjacent holding cells. Everyone but me was a minor who had attempted to take his or her own life. I tried to sneak a peek at the boy across the hall; his dad just shook his head and said; “the system is broken and it really fails to protect the young. My son is being shipped over 90 miles away because all of the local juvenile mental facilities are full.”

Our society needs to take mental health care seriously, and make sure it is accessible to everyone. Simply asking the mentally ill to reach out for help, reminding us that “suicide is not the answer,” will not save us. Providing us with resources and support systems might. Make sure that health insurance covers the mental health needs of people like me, and that there are community-based mental health resources, so that all who need help can afford it, and find it. So don’t call us crazy, don’t feel sorry for us. Most of all, be patient with us. We did not ask for this affliction and we do not want to be sad. We just are.

Read Brent Thompson's post on bipolar disorder, and the death of a friend

Read Jane Lowe's post on an intervention program to prevent development of severe mental health problems in young people

Fri, 15 Aug 2014 11:22:00 -0400 Culture of Health Behavioral/mental health Chronic illness <![CDATA[Preventing Suicide: If You See Something, Say Something]]> Dave and Brent Dave and Brent

The second week of August is one of the worst weeks of the year for me. At least it has been since 2008.

Six years ago this week, my friend Dave decided he had enough of the daily struggles of this world and took his own life on a trailhead in the desert near Tucson, Ariz.

He was 31 years old and left behind a fiancé, family, and scores of friends who loved him deeply.

Dave was one of the most incredible people I’ve ever known: a generous soul, full of humor, creativity, compassion, and love. He had more friends than anyone I know. Dave elevated everyone who knew him, inspiring them to find joy, open their minds, chase dreams, and see beauty in the world. It is impossible to count the lives Dave changed for the better, including my own.

But, like so many other people, Dave battled mental illness. He wasn’t afraid to talk about his bipolar disorder or his depression. He didn’t care who knew about it. He felt absolutely no social stigma about his conditions. He wasn’t afraid to discuss his challenges, and in fact, often joked playfully about the flawed brain chemistry with which he was born.

Those of us who were close to Dave were lulled into complacency, because even though he had mental illnesses, he understood them and had the appropriate support systems in place to manage them.

Until he didn’t.

Unfortunately, Dave got seriously injured at his job, preventing him from working. His small employer did not support him once he couldn’t physically perform his duties. He lost his health insurance. He lost his prescription coverage, and he went off his medications.

When further financial strain hit, Dave became overwhelmed. He couldn’t see a path out of the problems he faced. Unfortunately, because Dave was such a positive outward presence, it was hard for anyone close to him to understand how much pain he was in, and how much he was suffering inside. He was just too damned joyful, at least to the outside world.

Every year at this time, I feel the deep loss. I think about his pain, what he was going through, and the methodical, deliberate way he ended his life. I usually try to reach out to his mom, to let her know that I haven’t forgotten her wonderful son.

But this year, it feels like sharing Dave’s story might help others who have a heightened awareness of suicide because of the tragic, high-profile death of Robin Williams.

So many things said in the hours following Williams’ death stuck an eerily familiar chord, making me think about Dave and about suicide in a new light.

A quick scan of just my own Twitter feed produces sentiments that are almost exactly the same as things said about Dave when he died. Some excerpts:

"He brought so much joy...” - ‪@ddiamond

"Robin Williams taught us that pain could be subdued with humor. It is only now, in his death, that I realize he couldn't do that for himself”‪@mckinneykelsey

"Robin Williams made everybody around him laugh. But maybe he couldn't hear it.”@CitizenCohn

Those are precisely the sentiments expressed about Dave when he died in 2008. And they still burn my insides today.

"Think tonight about those nearest you. Who is hurting? Reach them.” -@jmsiniff

Every time I think about Dave, I question myself. Why didn’t I pick up on the severity of the trouble he was in? If I had called him that day, could we have talked it out? While Dave was never ashamed of his illness, I believe he felt shame about his situation. Could I have done something to help him find his way through it? Those thoughts haunt me, and I know they haunt others who have lived through the suicide of a loved one.

If someone you care about is struggling, try to help, even if they put up a convincing front. Find a way to connect on a human level, in whatever way is appropriate for them. Don’t be disarmed by their fun-loving personality or their steely defense mechanisms.

Make sure you are within reach when they stumble.

And know that there is always help, even for those who don’t have friends or family they can talk to.

"Important: do not ever feel ashamed of depression. Please, if you ever feel helpless, call the national suicide hotline: 1-800-273-8255.” - @HeyThereJac

Read a first-person post about depression and the best way to support those who are suffering with it

Read a post by Jane Lowe on an intervention program to prevent development of serious mental illness in young adults

Wed, 13 Aug 2014 09:16:00 -0400 Brent Thompson Behavioral/mental health Prevention RWJF Staff Views <![CDATA[To Build a Culture of Health, There Is No Place Like Home]]> 12_03_21_ChildFirst_26041

A century ago, it was normal for a doctor to make a house call to tend to a patient in need. By the time I was a child growing up in New Jersey in the 1970s and 80s, the practice had become virtually obsolete.

The case for bringing health care back into the home is becoming more compelling every day. One place where we see the potential to make a big impact is with new parents and newborns.

Last month, JAMA Pediatrics published new research from on the effects of nurse-home visits on maternal and child health. The randomized, clinical trial followed a group of low-income, primarily African American mothers and children living in disadvantaged, urban neighborhoods of Memphis over a 19-year period. Specifically, they wanted to see whether home visits conducted by the Nurse-Family Partnership before and after a birth influenced whether the mothers and children died prematurely.

The research revealed that “mothers who did not receive nurse-home visits were nearly three times more likely to die from all causes of death than nurse-visited mothers.” It also found that “there were lower rates of preventable child mortality from birth until age 20.” The new findings come on top of other research showing that the same nurse-home visiting model leads to better prenatal health and behavior, reduces risks for child abuse, reduces chances that children would be hospitalized before the age of 2, and improves the mental health and behavior of children at home and in school.

As a mother of two young kids, I know that what happens at home is as important to the health of my family—if not more important—than what happens in the doctor’s office. The interactions my husband and I have with each other and with our children, how we cope with stress, whether we can meet the basic needs of our children for things like food, clothing, or a safe place to live—all of these things matter. In fact, what our children experience in the home in their first years actually affects how their bodies and brains develop. It has a lasting impact on their health over their entire lives. Recent RWJF-supported research bolsters that point of view.

As a society, we ought to be doing much more to help families with young children establish a solid foundation for health from day one. And the best way to strengthen families is to meet them where they are, and help provide them with the tools they need to make healthy choices where they live: at home.

To be clear, the best interventions are ones that empower families to make healthy choices. They don’t preach to parents or do the work for them. They give parents tools and information to help them become the parents they want to be. The nature of the relationship with parents is informal but caring because that’s what it takes to be able to hear what parents need and to offer advice in a way that is heard in return.

Home health professionals also help caregivers overcome the obstacles that make it hard for them to support their children’s well-being and development. That obstacle can be something internal, like depression, or external, like access to healthy food or a safe and stable place to live.

Not all interventions designed to help new parents at home are equal. Research suggests that trained specialists—like nurses, midwives, and mental health professionals—are much more effective at preventing or treating conditions like postpartum depression than models that depend on lay- or peer-based support. Even with the higher bar, there’s no reason why we, as a society, shouldn’t do more to make home health visits a standard practice for all new families and all new babies. It ought to be part of how we build a culture of health for families with young children.

If it sounds far-fetched, consider the fact that every family in the UK gets a visit from a nurse or midwife after the birth of a child. They start with a home visit within two weeks of the birth. After that, they maintain a relationship that combines in-home and in-clinic visits until the child is 5. They monitor and support both the physical and emotional development of children, and help to address the financial or emotional sources of stress that may affect a family’s health. They also have the ability to provide greater support to families who are especially vulnerable or face higher risks. Because home health visits are universal, they can track what is and is not effective and make improvements that can lift the health of entire populations.

For a stateside example, head down to Durham County, North Carolina. A local program, known as Durham Connects “provides in-home nurse visits free of charge to all parents of newborns in Durham County. “Nurses check the baby’s weigh and overall health. They make sure the mother is recovering well after giving birth. If necessary, they assist with breastfeeding and parenting classes. They are trained to spot and address postpartum depression. They help families find options for child care and connect them to financial resources. Research shows that families served by Durham Connects require fewer hospitalizations and emergency medical services, exhibit more positive parenting, and have a safer and healthier home environment.

Even with everything we know, there is still a lot to learn about how to get the most out of home health visits for families with newborns and, especially how to do that at a large scale. We shouldn’t be afraid to do that learning, and to learn by doing. Because home health visits have so much potential to be a home run.

Mon, 11 Aug 2014 15:36:00 -0400 Kristin Schubert Families Home visiting Children (0-5 years) RWJF Staff Views <![CDATA[In a Culture of Health, People Get the Sleep They Need]]> sleep

How can we help people get more sleep?

I asked that question in a blog post back in February. Since then, I’ve been actively exploring the area of sleep health. I’ve talked with researchers, behavioral economists, physicians and mindfulness experts. I’ve talked with people who think they get enough sleep, and people who think they don’t. I’ve talked with anyone I can to discover what we need to know and do in order to help Americans sleep.

Sleep has tremendous ripple effects on our overall health and well-being. Lack of sleep affects your brain. There’s evidence that it affects your working memory. And as any new parent will confirm, we don’t need research to tell us that those who are sleep deprived are less able to control their tempers.

Sleep is important. Research shows that you think better, make better decisions, and recover from colds more quickly. The Centers for Disease Control and Prevention goes so far as to call insufficient sleep a public health epidemic.

And yet, for all the research that exists about the effects of insufficient sleep on health, and all the statistics indicating Americans aren’t getting enough sleep, I’ve discovered that there’s very little research into why. Why can’t more of us get the sleep we need?

Of course, theories about the causes of sleep deprivation abound: We’re stressed out, we’re glued to our devices until the wee hours, or we drank too much (or too little) red wine before bed. Organizations such as the National Sleep Foundation offer tips to fall asleep and stay asleep. But as far as I can tell, there’s no definitive understanding of why many Americans consistently get less than seven hours of sleep.

So I’d like to ask a new question: “Why aren’t Americans getting enough sleep in the first place?”

Are we choosing less sleep? (The coffee shop in the town near my office sells “sleep is for the weak” t-shirts.) Is our physical environment working at cross purposes to a good night’s sleep? Is our sleep health being sabotaged by choices and behaviors in ways we don’t fully understand—or even notice? (For insight into New Yorkers’ sleep habits, check out the very interesting Clock Your Sleep citizen science project from WNYC). Do Americans not know—or not believe—or not care—that good sleep is essential to good health?

We need to understand the full spectrum of reasons for Americans’ sleep deprivation if we are going to imagine and design truly innovative, effective interventions to support better sleep.

Those interventions may be high-tech, such as f.lux, a program that prompts your computer screen to get dimmer as night falls—the idea being that exposure to light sources might overstimulate us and keep us awake past the point of fatigue; or they may be as simple as writing down what’s bothering you on a piece of paper as a way of releasing the anxiety of the day.

For many people, the necessary interventions will almost certainly require resetting cultural norms around work/life balance—when office workers brag about how well rested they are instead of how effectively they can run on fumes, we’ll know we’re making progress.

But I’m getting ahead of myself.  Before we can effectively solve the problem, we need to understand it better.

Here’s where you come in. If you’re a researcher working on this issue, or know of someone with whom I should connect, I’d love to hear from you. If you have a theory or story about why people get or don’t get enough sleep, share that, too.

And if you are a champion sleeper, what are the secrets of your success? We need to understand how good sleep health works, too!

Email me at

You can also follow me on Twitter at @lorimelichar, where I’d love to exchange the latest news and ideas about sleep health.

RWJF’s vision to build a Culture of Health in this country that makes it easy for Americans to be healthy wherever we live, work, learn and play can’t be achieved if we’re bleary-eyed and running on empty. In a Culture of Health, people get the sleep they need.

I look forward to hearing from you.

Listen now: In the latest episode of RWJF’s Pioneering Ideas podcast I talk with Harvard economist Sendhil Mullainathan, author of Scarcity: Why Having Too Little Means So Much, about the ripple effect of sleep on our mental and physical wellbeing—and why this serious health issue doesn’t get more attention.

Mon, 11 Aug 2014 09:52:00 -0400 Lori Melichar Health promotion and disease prevention Behavior change Self-care RWJF Staff Views <![CDATA[An Ounce of Prevention, Even for Serious Mental Illness ]]> An educator works with a student on a hard problem

As we work to build a Culture of Health for all Americans, it is time to end the stigmatizing distinctions between mental and physical health. After all, the brain and the body are in constant contact, and affect the well-being of each other in too many ways to count. A true Culture of Health recognizes the interdependence of mental and physical health, and places a premium on prevention and early detection of illness, regardless of type.

We commonly provide preemptive treatment or suggest early lifestyle changes for people at risk for diabetes before the condition evolves into full-blown disease. Yet, we typically don’t approach care for serious mental illness in the same way. It’s time for that to change.

The results from a recently released national study of the Early Detection and Intervention for the Prevention of Psychosis Program (EDIPPP), a project RWJF funded between 2006 and 2013, demonstrate that early intervention to prevent the onset or progression of psychosis in teenagers and young adults improves health and well-being. By helping family members, pediatricians, teachers, young people, and other community members identify young people experiencing early symptoms of serious mental health problems, EDIPPP was able to engage and treat these young people early. That early intervention in turn helped them stay in school, remain employed, and maintain vital connections to family and friends. These benefits mitigated the effects of mental illness, and allowed these teens and young adults to lead healthier and more productive lives.

This study should shift our thinking about how we best treat young people at high risk of serious mental illness. It should also remind us to look at good health and good health practices through a much broader lens, because building a Culture of Health means finding and sharing solutions, and celebrating signs of progress.

Read a Washington Post article on the program

Read a first-person post about depression and the best way to support those who are suffering with it

Read a post by Brent Thompson on bipolar disorder and the death of a friend

Thu, 7 Aug 2014 01:30:00 -0400 Jane Isaacs Lowe Behavioral/mental health Preventive care Early intervention RWJF Staff Views <![CDATA[Exactly How Much DOES That Appendectomy Cost?]]> L1031049

Want to know one of health care’s dirty little secrets? While we know how much the country spends on care each year, we have little understanding of what it actually costs to provide care.

Think, for example, about an appendectomy. What does it really “cost” the health care system to perform that procedure? The answer is complex, and of course it includes everyone’s time—from the surgeon to housekeeping staff—and it also includes the drugs, equipment, space, and overhead associated with your stay.

The cost of your visit will also depend on who is delivering your care. A consult with a registered nurse (RN) is less costly to the hospital than one with a physician.

Then, consider insurance. If the price your carrier pays for that RN consult is $85, but the price another carrier pays is only $65, what does it actually cost the hospital—and how do those variances affect what you pay both out-of-pocket and for insurance premiums? Moreover, health care providers are currently not trained to think about the costs of the care they provide—and often have no incentive or means to even consider those costs.

These complexities have made it difficult to reform the way we purchase and pay for health care.

Vivian S. Lee M.D Vivian Lee, MD, PhD, MBA

We spoke with the University of Utah’s Vivian Lee, MD, PhD, MBA, senior vice president for health sciences, dean of the School of Medicine and CEO of University of Utah Health Care, about an impressive effort their health system undertook to develop a comprehensive costing tool they call “Value-Driven Outcomes.”

What’s unique about the tool is not only the detailed level at which the health system is able to understand its costs, but also that the tool was rolled out with substantial physician support and engagement—rather than being perceived as a tool that was intended to punish high-cost performance.

Q: Why did University of Utah create the Value-Driven Outcomes tool?

All of us recognize that in our health care systems, we are being held accountable for providing value, and one of the greatest challenges to this is measurement. We haven’t been able to measure value, much less put that metric in our providers’ hands to inform their delivery. I, for one, am constantly amazed at our lack of knowledge about costs in our health care systems.

Beyond tackling the costs of care, we also recognized we had little data to share with providers about their outcomes or the quality of care they were providing. A wide range of quality metrics are beginning to impact our reimbursement and our rankings, and yet providers’ ability to track their own metrics has fallen short.

Of course, the key is putting those two together—outcome and costs. In most industries, a key measure of performance is the value provided by the business. In health care, that means looking at quality (which includes outcomes and satisfaction) measured against the costs of care. Our goal was to put these measures into our providers’ hands, so they could begin to manage themselves, and we as health system leaders could roll up the data to manage the entire system.

Q: How were you able to develop the tool?

About two years ago, we launched a new project, which we called Value-Driven Outcomes (VDO). We started with our version of a “sequestration.” We put a group of our top performers and senior leaders from finance, decision support, quality improvement, biomedical informatics, and IT (among others) into a building in our University’s Research Park. We pulled them out of their daily roles three days a week for six months and gave them a challenge: Come up with a tool that would enable us to visualize our value—that is, ideally, to be able to plot our outcomes against our costs—and to do this for every patient, every provider, and every diagnosis in our system.

Critical to our success was our strong enterprise data warehouse. With a whole series of intelligent business tools, our teams extracted vital data and developed web-based user interfaces that were simple and intuitive enough for our providers to use.

This was no modest undertaking. The initial beta version of the VDO involved more than 150 million lines of code.

Q: Can you share an example of the types of costs your tool is able to capture?

The short answer: just about everything. The Value-Driven Outcomes tool starts by organizing cost type grouping, which includes laboratory, supply, pharmacy, diagnostic imaging, operating room time, hospital facility charges and others. These groupings are aggregated by diagnosis and provider groups. From there, we can drill down into each category to view costs by professional and facility direct costs. If we need to, we can dig down even further to look at each and every supply, imaging service or lab test a particular provider uses in a specific episode of care. We can even get down to individual patients. We can now see our system’s costs from 30,000 feet to below sea-level—and just about everywhere in between.

Q: What’s your sense of how common the ability to understand costs at this level is among other health care providers?

We are starting to see other systems get a better picture of their actual costs, but our sense is that such granular views are relatively new to the industry. Only a few years ago, Michael Porter, PhD, and Robert Kaplan, PhD, thrust this decades-overdue costing conversation into the spotlight with a game-changing paper, “The Big Idea: How to Solve the Cost Crisis in Health Care.” Published in Harvard Business Review, the paper zeroed in on providers’ “complete lack of understanding” about health care delivery costs. This costing void, they explained, made it nearly impossible to improve processes, eliminate unnecessary procedures, and deliver better outcomes. According to the Harvard business professors, figuring out the costs would be the “single most important lever to transform the value of health care.”

We could not agree more.

Q: One of the most interesting things about your tool was the way in which it was developed and rolled out. You speak a lot about the importance of understanding what physicians want and need when it comes to practicing care. How did you work with your providers so that everyone felt like Value-Driven Outcomes was something they owned, and a useful tool for their work? And what are some examples of how that’s playing out?

By the time we had developed a functioning VDO tool, our system already had two things going for it: engagement and process improvement training. My predecessor, Lorris Betz, MD, PhD, championed our Exceptional Patient Experience initiative, designed to engage providers in a culture shift toward more patient-centric care. In 2012, University of Utah Health Sciences became the first academic medical center in the nation to publish our patient satisfaction scores online, with complete transparency and ultimately, full engagement of our providers. The impact? Nearly half of our providers are now in the top 10th percentile and one-quarter (25%) are in the top 1st percentile in patient satisfaction compared to national benchmarks.

At the same time we launched the VDO project, we also began a systemwide roll-out of LEAN training in partnership with the University Of Utah Eccles School Of Business. LEAN is a production practice, mostly developed by Toyota, that we and others have adapted for our health care systems. Essentially it is a process of producing something with the most efficiency (fewer resources) and the most effectiveness (creating a better value), all the while focused on the highest level of quality. The responsibility for ensuring the best outcomes is held by the people on the front lines—in our case, all the people engaged with the patient in the practice of health care. This efficiency training and engagement has helped providers who participated in our earliest pilot projects embrace the VDO tool and enabled them to use the data, working closely with our value engineers, to drive process improvement.

We also discovered some things that we didn’t completely expect. First, we came to realize that by putting the VDO tool in providers’ hands, we tapped into a profound desire on the part of many to help be a part of the solution. Most of us entered health care to do good. Our providers now have the tools and capability to impact not only their patients, but also the ways in which we, as a system, deliver health care. We also found with our patient satisfaction initiative and with VDO, our providers’ competitive natures can be useful drivers of change. Our providers want to be the best, whether it’s in patient satisfaction or in quality and value. By making the data accessible and easy to understand, we’ve managed to engage our physicians and have real improvement to show for it.

Q: What are some of the changes and improvements you’ve seen since implementing the tool?

This process improvement has been limited to some pilot studies, and even there, it has translated already into more than $2.5 million in savings for our system and helped us pave the way to accepting more risky payment models. For example, our hospitalists have harnessed VDO to gain a view of how many tests they are ordering. This view has empowered them to change their rounding structures, create attending-approved checklists and save more than $550,000 so far this fiscal year in unnecessary tests, without diminishing patient outcomes. VDO helped one University of Utah physician group realize that a commonly prescribed bronchodilator that costs $200 delivered the same outcomes for most patients as a similar $15 drug. By switching to the less expensive bronchodilator, the group was able to save more than $200,000 a year.

All these process and care improvements stem from our new ability to quantify and continually improve the value we deliver. Specifically, VDO gives us the ability to question whether the quality and outcomes of the care we deliver to patients is worth what we, and ultimately they, pay for it.

Q: How has getting a solid handle on costs positioned University of Utah to move into a national environment that’s focused on changing the way providers are paid?

Having a solid handle on costs is the necessary first step for any health care system to be willing to become more financially responsible for our patients’ outcomes. Take Medicaid in Utah, as an example. In the past, we could care for Medicaid patients and then send a bill to the Medicaid office and expect to be paid for our services. In the past year and a half, our health plan has received a fixed amount of revenue from the state of Utah to cover all the care we deliver to Medicaid patients. This means that whether cardiac Medicaid patients, for example, receive bypass surgery or just need a coach to help them improve their diet and exercise, we are paid the same amount for their care. To be successful with these patients, we must know how effective the cost of the care we provide is for their condition.

Another model of payment we can begin to feel more able to manage is bundled payments, where insurers and employers who contract for direct payment have already started to say, “We will pay you $X, for this diagnosis.” We can engage in those new ways of thinking about medical payments if we have the right tools, and this could be a real win for businesses and employers who want to get on top of health care costs.

As a result of these payment models, health care systems will ultimately begin to share the risk for those patients’ care. This doesn’t mean we will do the least amount for them to get them home again. This means we have to be able to care for them with the greatest efficiency and effectiveness to restore their health and give them the ability to return home safely for as long as possible. In fact, if we don’t do enough, they’ll be back at our hospitals, which isn’t good for anyone.

Q: Are you seeing other examples of health systems and providers embarking on similar efforts?

We’ve heard about launches of similar initiatives from University HealthSystem Consortium, Kaiser, University of Pittsburg Medical Center and others. Harvard Business School has a tool they’ve been using with a few health care systems (MD Anderson, Mayo Clinic, Cleveland Clinic) called Time-Driven Activity Based Costing (TD-ABC), as a result of Professor Robert Kaplan’s efforts. In fact, we recently completed a University of Utah/Harvard Business School partnership project that focused on using VDO and TD-ABC data to improve processes around 4 different episodes of care and in our billing procedures.

Generally speaking though, there continues to be a lack of data about the costs of care to any level beyond the general ledger. We hope that we can share some of the lessons we’ve learned to enable others to develop tools like Value Driven Outcomes.

Q: What advice would you give to health systems and provider groups that are interested in developing something similar to Value-Driven Outcomes?

Bite the bullet and do it. And we here at the University of Utah are here to help in any way we can. This is a nationwide problem that demands a nationwide solution and we all need to work together to succeed. Understanding your costs is fundamental to business management.

Yes, the health care system is broken. Yes, each of our systems and populations is different. Yet we have to remember that our ultimate purpose is to offer value to society. To be able to deliver that value, we have to start by measuring it. It’s so basic and so clear. Don’t give up. As Colin Powell once said, “Perpetual optimism is a force multiplier.”

While the University of Utah example is compelling, we know other efforts are under way across the country aimed at helping providers prepare for a new financial environment. But those examples aren’t easy to spot, so we’re looking to you for help.

Here’s how:

  • Learn more about Value-Driven Outcomes by viewing a recording of Lee’s webinar. If you’re interested in learning more from Lee and her team, let us know that in the comments below, as well.
  • Share in the comments below what you or your organizations developed to help understand the cost of delivering care. How are you sharing what you’re learning?
Fri, 1 Aug 2014 16:29:00 -0400 Andrea Ducas Cost of care Payment reform Data Health IT <![CDATA[If It’s Broken, They Fix It]]>  A nurse fills a syringe, while another nurse watches

By “broken,” we mean medical equipment or processes that could use a little improvement—and sometimes a lot of improvement. And by “they,” we mean nurses who harness the power of their own creativity, often using whatever material they have on hand—and sometimes taking inventiveness to a whole new level.

They call them MakerNurses, eager participants in the emerging “maker” movement. One MakerNurse, Roxana Reyna, RN, of Corpus Christi, was honored at the recent White House Maker Faire for her innovative wound-care techniques in caring for infants born with their organs outside of their bellies, sparing them immediate surgery.

RWJF supports such nurse-inventors through the Little Devices @ MIT initiative’s MakerNurse program, because they hold the potential to make health care more effective and affordable.

It’s a sound investment with even larger possibilities, said RWJF President and CEO Risa Lavizzo-Mourey, MD, writing in the professional social networking site LinkedIn.

“The “maker” movement has the potential to empower all kinds of people to devise the solutions that make possible a Culture of Health—not just nurses, but caregivers, patients, and family members, all creating and sharing devices and ideas that improve health.”

Read Lavizzo-Mourey’s blog post on LinkedIn

Wed, 30 Jul 2014 15:25:00 -0400 Risa Lavizzo-Mourey Disruptive innovations Nurses From the President <![CDATA[Advanced Practice Nursing: Providing Care and Promoting Health]]>
Check out an August 1 Google+ Hangout with the Campaign for Action and RWJF.

The U.S. population is growing, getting older and suffering from more chronic disease. Thanks to the Affordable Care Act (ACA), more people are gaining health coverage and the means to obtain care. And there’s a widespread view that the country faces a drastic shortage of doctors—and primary care providers in particular.

So why are so many states seemingly determined not to let advanced practice registered nurses deliver the primary care they specifically trained to provide—and help millions of patients in the process?

Across the country, 31 states impose varying limits on the ability of nurse practitioners (one of the four types of advanced practice registered nurses) to evaluate patients; diagnose, order and interpret diagnostic tests; and to initiate and manage many treatments, including prescribing medications.

Although these limits are often staunchly defended by medical societies and other physician groups, that posture seems hard to defend. After all, federal workforce projections show that the primary care shortage would significantly decrease by 2020 if growing populations of advanced practice nurses and physicians’ assistants were allowed to practice at a level commensurate with their education and training.

Making the argument that states should drop their limits and allow advanced practice nurses to practice in line with their education and training is a key focus of the Future of Nursing: Campaign for Action, an initiative of AARP and the Robert Wood Johnson Foundation (RWJF). (Read more about it.) The Campaign, now in its fourth year, grew out of an RWJF-funded Institute of Medicine (IOM) report in 2010 that recommended raising the level of nursing education and training and making better use of nurses in redesigning and delivering U.S. health care.

All 50 states and the District of Columbia have Action Coalitions organized around the Campaign’s goals, notes Campaign Director Susan B. Hassmiller, PhD, RN, FAAN, RWJF’s senior adviser for nursing. And although there is considerable distance left to travel, there has been progress, as follows:

Building the business case

To recruit more allies, the Campaign for Action has sought to educate corporate leaders, health system executives, and insurers, on the value that advanced practice nursing can bring to their bottom line. Broad and convenient access to primary care is essential to health—and if “employers’ workforces are healthy, they are much more likely to show up at work, and if [employees’]  family members are healthy, it means less stress for them,” says Winifred V. Quinn, PhD, director of Advocacy and Consumer Affairs, Center to Champion Nursing in America, an initiative of AARP, the AARP Foundation, and RWJF.

The center has organized a coalition of companies advocating that states modernize their scope of practice policies; it includes corporations such as Target, whose network of in-store clinics relies largely on advanced practice nurses to deliver care. Quinn says the effort is paying off, as more lawmakers in states like California move to adopt model legislation allowing advanced practice nurses to practice a level of care commensurate with their education and training. In the meantime, a white paper by the Bay Area [California] Economic Institute calculates that enacting such reforms would lead to an increase in the number of nurse practitioners in practice; more primary care visits; and, because of increased visits,  lower per-visit costs.

Getting to “80 by ‘20”

A key IOM recommendation is to raise the overall level of nursing education, with a particular goal of 80 percent of the nation’s nurses having bachelor’s degrees—or even higher ones, such as master’s or doctorates—by 2020. According to the Campaign for Action’s “dashboard” indicators, in 2010, 49 percent of the nation’s nurses held bachelor’s degrees in the science of nursing (BSNs); in 2013, 51 percent did—a 2 percent increase. The rise represents about 30,000 more nurses with bachelor’s degrees—and Hassmiller says that the numbers will rise further as more nurses with associates’ degrees from community colleges enroll in programs to complete their bachelor’s. Since the release of the IOM study, the American Association of Colleges of Nursing reports a 53 percent increase in enrollment among registered nurses advancing to bachelor’s  degrees.

More nurses on boards

The IOM report recommended that more nurses be placed in leadership positions to influence the transformation of health care. In Texas, the local Campaign for Action Coalition has partnered with the Texas Health Care Trustees foundation to train 400 nurses for board service.  “We’re very fortunate that Texas is leading the way on this,” says Alexia Green, professor and dean emerita at Texas Tech University’s School of Nursing, who helped to found and formerly co-led the Texas campaign.

“By virtue of its numbers and adaptive capacity, the nursing profession has the potential to effect wide-ranging changes in the health care system,” the IOM report said. Thanks to the Campaign for Action, that potential is several steps closer to becoming reality.

Tue, 29 Jul 2014 10:50:00 -0400 Susan Dentzer Advanced practice nurses Primary care Susan Dentzer: Toward a Healthy America <![CDATA[Putting a Female Face on the Need for a Culture of Health]]>
A doctor examines a patient.  An image appears on a computer monitor.

Statistics are “human beings with the tears washed away,” an old saying goes. Sadly, the tears behind one set of statistics, showing that women’s life expectancy has been falling in just under half of U.S. counties, have rarely garnered much notice.

How to put a face on this story, to help mobilize corrective action?

Progress toward that end was made last week, when the Robert Wood Johnson Foundation teamed up with Women’s Policy, Inc, a nonprofit, nonpartisan organization that seeks to inform policy-making on women’s issues, to sponsor a briefing on that subject on Capitol Hill. About 75 people, including several female members of Congress, gathered in the Rayburn House Office Building to learn what is driving the widespread trend of poorer female health. (Watch the webcast by clicking here).

They also learned the names of some of those seemingly faceless human beings behind the statistics—names like Melissa, Mary and Maria.

Those were pseudonyms (out of respect for privacy) for real patients encountered by Debbie Chatman Bryant, a 2012 recipient of RWJF’s Community Health Leaders Award and a current RWJF Executive Nurse Fellow.  Bryant, a doctor of nursing practice at the Medical University of South Carolina, directs a program that sends a mobile van into racially diverse and medically underserved communities to conduct mammography and other cancer screening.

  • Melissa, a 35-year-old African American woman expecting her fifth child, was screened through Bryant’s program and diagnosed with advanced breast cancer. Despite treatment, she died not long after giving birth.
  • Mary, 51, is homeless, has a history of mental illness, and still cares for her adult son, who suffers from bipolar disorder. Her breast cancer was discovered and treated successfully, and she continues in recovery.
  • Maria, 46, works as a machine operator, doesn’t have health insurance and, as Bryant said, “let too many years slip by between mammograms.” When her breast cancer showed up on a scan, she was treated, and later relapsed. A so-called navigator on Bryant’s team has helped guide Maria into a clinical trial.

Such faces “represent an inescapable public health crisis of our time,” Bryant told those at the briefing. “We live in a world troubled with health challenges complicated by the stress of social pressures, poverty, fear, and a complex health environment.” The toll is high: Relative to women in other high-income countries, US women lose about twice as much life before age 50 from a host of conditions. These range from troubled pregnancies  to falls, traffic accidents and other unintentional injuries, to diseases linked to obesity, hypertension, and smoking.

Sometimes, part of that toxic stew harming women can be drug and alcohol abuse, according to Nora Volkow, director of the National Institute of Drug Abuse, another lead speaker at the briefing. Fluctuating hormone levels influence women’s responses to these substances and make them prone to abuse and addiction over the course of their lifetimes.

And with women more likely than men to report suffering from chronic pain, Volkow painted a troubling picture of high rates of prescriptions for opioids and other pain-relieving drugs. The surge has led to a sharp increase in deaths from opioid overdoses, which as of 2008 exceeded deaths from heroin and cocaine use combined.

Both Bryant and Volkow lamented the fact that evidence-based interventions and policy responses that could address these problems either go unused or aren’t adopted. Bryant pointed to the fact that her state, South Carolina, has so far declined to expand Medicaid eligibility under the Affordable Care Act. Yet a recently released report from the President’s Council of Economic Advisers estimated that if the state expanded Medicaid, 8,000 more women would receive mammograms and 12,000 more would get pap smears to rule out cervical cancer.

Similarly, Volkow noted, depression often goes hand in hand with chronic pain and is a risk factor for drug use and abuse. But millions of Americans have unmet mental health needs, with about half of them citing unaffordability of care as the key reason.

Clearly, throughout the country, many faces of desperation are female. That’s all the more reason to insure that efforts to build a Culture of Health in America have a distinctly feminine cast.

Fri, 25 Jul 2014 11:29:00 -0400 Susan Dentzer Barriers to care: cultural, gender and racial Community outreach Susan Dentzer: Toward a Healthy America <![CDATA[Doing More Means Doing Less: Young Innovators Lead the Charge]]> CAP_84483_10

Here at the Robert Wood Johnson Foundation, we often talk about the idea of making the healthy choice the easy choice. To many of us, that means putting the cookies in a high cabinet, and putting the fruit on the counter. But when I think about building a Culture of Health in America, and especially within our health care system, making the healthy choice the easy choice means so much more.

In health care, often the healthy choice actually means doing less—fewer invasive tests and less dependence on medication—and instead watchfully waiting or making healthy lifestyle changes. But it’s not always easy to show a patient that you care when you only have a few minutes to spend together, and ordering a test or prescribing a medication is a simple way to show “I’m doing something to help you.” The trouble is, those tests, procedures and treatments often don't help, and sometimes they can hurt.

Too many people receive unnecessary tests and treatments that don’t help them, and can potentially be harmful to them. Recently, we learned that, every year, about 25 percent of Medicare beneficiaries receive services they don’t need. That means they—and American taxpayers—are paying a lot of money for treatment that provides no benefit. At the same time, there are still far too many people who can’t get the health care they need.

Physicians and researchers tell us that a big part of the overuse problem comes from a “more is better” approach in medicine, and that this approach is conveyed to new doctors as they learn to practice medicine in medical school, and when they start their residencies. In health care, it is easy to err on the side of prescribing a drug or a test or performing a procedure, while the potential harms can be harder to spot.

We believe that clinicians are ready to embrace a new kind of medical culture, one that emphasizes that, often, “less is more.” In addition to other efforts to reduce overuse we have been working with the RightCare Alliance, a project of the Lown Institute, founded by Bernard Lown, MD. Lown encouraged his students to do more for the patient, while doing less to the patient. The RightCare Alliance is working to increase clinician awareness of the causes and consequences of overuse, and to create tools to foster change in the way care is delivered. The project is hosting action-oriented local and national gatherings that focus on reducing overtreatment, fielding a national physician survey to explore underlying drivers of overuse, and developing a toolkit of resources to counter overuse in health care.

Since the “more is better” approach starts in medical training, young innovators in the health professions are just the people to take action to change medicine’s “more is better” philosophy. With support from the Robert Wood Johnson Foundation, the RightCare Alliance has just released a call for proposals for their Young Innovators Grants, which offer funding for students in the health professions, residents, and junior faculty to pilot programs that teach clinicians to recognize and avoid overuse, provide compassionate care, and build more meaningful relationships with patients. Grant award recipients can receive up to $7,000 to cover project expenses, conference travel, and participation in national Right Care Alliance leadership training. We encourage you to check out the call for proposals, and to share it with young innovators in your network!

Those who are just starting out in their health care careers have an important role to play in shaping a Culture of Health, and in making the healthy choice the easy choice in health care. Young innovators are well-positioned to reshape the environments in which they are working, and encourage a culture in which the idea of “more is better” refers to caring and commitment, not to unneeded tests and procedures.

Wed, 23 Jul 2014 13:28:00 -0400 Emmy Ganos Disruptive innovations Health care delivery system RWJF Staff Views <![CDATA[Help or Hype: The True Costs of Robotic Surgery]]> Robotic Surgery

Joe Meyer is the model of a well-educated, engaged patient. A self-described “typical Midwestern guy” who settled in Chapel Hill, N.C., to raise a family and build a career, Meyer did everything in his power to make the best decisions when his 2013 physical produced unexpected and frightening results.

“I live a pretty healthy lifestyle. I exercise. I eat well,” says the 62-year-old chief operating officer of a large manufacturing company. “I was very surprised when my PSA test came back at 5.1 [3 to 4 is normal]. Further testing showed that I had prostate cancer.”

One of more than 200,000 men who are diagnosed each year, Meyer put his faith in his physician and the health care system when gathering information about treatment.

“After the biopsy, they told me my Gleason score was 7. [The higher the score on a scale of 1 to 10, the more likely a cancer will spread.] I realized I was high risk, so I started reading as much as I could about the choices I was offered—hormone therapy, radiation, or prostate removal.” He chose robotic prostatectomy over open or laparoscopic prostatectomy. Surgery, as opposed to hormone therapy or radiation, was widely considered a good decision for someone with Meyer’s prognosis.

Not the type of guy to watch and wait, Meyer says, “I’ve been in management a lot of years. I’ve learned, if you got a problem, you address it right away. He adds that he “would have been happy to choose the non-robotic prostate surgery,” if it had been what was available in his area.

Making sure that our system of medical innovation is working well enough to give men like Meyer a full range of treatment options, no matter where they live, and the information needed to make a well-informed, cost-effective choices is the primary goal of Charles D. Scales Jr., MD, and Jonathan Bergman, MD, both urologists and Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholars (2011-2013).

In their case study “Robotic Surgery,” they contend that the rapid uptake and aggressive marketing of robotic prostate surgery is an example of a “‘medical arms race’ between competing hospitals that is driving up health care costs ... while there is scant evidence of improved surgical outcomes and even some evidence that robotic surgery may create problems.” Their work is part of the RAND report Redirecting Innovation in U.S. Health Care: Options to Decrease Spending and Increase Value.

Hidden Risks for Patients

By many measures, robotic surgery appears to be a successful new technology. Bergman offers the option in his practice at the David Geffen School of Medicine at UCLA, and he explains that many patients do have “shorter post-surgical hospital stays.” Meyer, for example, went home from the hospital the day after surgery.

Health care systems have also been purchasing robotic equipment at a furious rate.

“In 10 years, we went from open prostate surgery to robotic surgery being used for 80 percent of cases,” Scales says. “This is dramatic—it’s one of the biggest changes in modern medical practice. It’s also being driven by patient demand. After 2005, hospitals without a robot—primarily the da Vinci®Surgical System—saw an estimated 41.2 percent decrease in cases.”

But Scales and Bergman question whether patients armed with promotional materials, rather than research, are getting the information they need to make the best decisions.

Advertising campaigns touting robotic prostatectomy as the “gold standard” (according to Duke Medicine, where Meyer was treated and Scales is a professor of surgery) and offering reduced hospital stays are common. The Cleveland Clinic promises the procedure allows for “more precision, offering patients improved outcomes.” Columbia University Medical Center contends that patients will experience improved urinary continence and sexual function after surgery.

Information offered online also focuses primarily on robotic procedures. A small study of Internet search results conducted at MD Anderson Cancer Center in Houston, Texas, showed that Internet information on prostate surgery is biased toward robotic prostatectomy.

Scales is not surprised that this type of advertising persuades patients to choose robotic procedures. “Men are justifiably concerned about the effects of any treatment for prostate cancer because it’s linked to their quality of life. Anything that promises to protect that would understandably draw their attention.”

 At least one of those claims holds up. But on others, the benefits are less conclusive. “The robotic procedure does offer faster recovery times [it’s less invasive and there is less bleeding]. But, there’s no data proving improved urinary continence or sexual function. There is also no evidence of better, post-surgery cancer control,” Scales says.  

“The major potential harm is that you do prostate surgery on someone when it is not necessary,” says Bergman. They report that, since 2005, the number of prostatectomies among American men has increased 60 percent.

“I do what the patient asks,” says Bergman, “but we just don’t have the data.” A small number of observational trials are the basis for most assertions that robotic prostatectomy is superior.

“It is misleading to tell prostate cancer patients that robotic surgery will lead to improved outcomes, beyond less bleeding and a shorter hospital stay,” Bergman says. There is also concern that robot-related complications are not shared with patients.

All surgical procedures have a learning curve, Scales and Bergman agree, but a spate of recent lawsuits from injured patients, robotic surgical instrument recalls, and several reports about a da Vinci robot surgical tool burning patients, suggest that more research is needed.

There also may be more to the story. A 2013 study conducted at Johns Hopkins University found that adverse events related to robotic procedures “were underreported to the Food and Drug Administration.”

Rising Hospital Costs

Beyond their concern for patients, Bergman and Scales explain that, while hospitals and physicians earn no more for robotic procedures than open surgical procedures, other hospital fees may be raised to compensate for robot-related costs.

“The savings from shorter hospital stays are erased by the much higher costs of acquiring the robot and replacing the expensive, disposable instruments needed for robotic procedures,” Bergman says. “They can also charge more for services associated with the robot.”

“We are not against new medical technology; we want to see innovative procedures adopted based on research that shows we are doing our best for patients,” Scales adds. They suggest that “moving away from a fee-for-service payment system that rewards hospitals and physicians for procedures to reimbursement based on quality and patient outcomes” would spur patient-centered, cost-effective medical innovation.  

Mon, 14 Jul 2014 10:29:00 -0400 Sheree Crute Medical technology Evidence-based