Category Archives: Community-based care
Community Health Centers serve more than 22 million people at more than 9,000 sites located throughout all 50 states and U.S. territories, and have become needed health centers in particular for people newly insured under the Affordable Care Act (ACA) who have not previously had relationships with healthcare providers.
The National Association of Community Health Centers (NACHC) was organized in 1971 and works with a network of state health center and primary care organizations to serve health centers in several ways, including to:
- Provide research-based advocacy for health centers and their clients.
- Educate the public about the mission and value of health centers.
- Train and provide technical assistance to health center staff and boards.
- Develop alliances with private partners and key stakeholders to foster the delivery of primary health care services to communities in need.
Ronald A. Yee, MD, became chief medical officer of the NACHC last year. NewPublicHealth recently spoke with Yee about the mission of health centers and their new roles under the Affordable Care Act.
NewPublicHealth: What field of medicine did you practice before taking on your new role?
Ronald A. Yee: I am a family physician. I worked for 20 years at a community migrant health center in Fresno County. I basically practiced full-scope family medicine including obstetrics, so I was delivering babies up until October of last year when I came to NACHC. So I was on the frontlines doing patient care and I was also the chief medical officer for our health center. I got involved earlier in my career with NACHC on a state and then national level, was on the board and then became chief medical officer.
NPH: Who is most likely to use the services of a community health center?
Yee: Health centers provide about one quarter of all the primary care visits for low-income populations, which include about one in seven people who are uninsured, or one out of every 15 Americans. With the roll out of the Affordable Care Act we’re seeing a big surge in demand among the newly insured, whether that’s through Medicaid expansions or the health insurance exchanges. Many of our patients who previously paid on a sliding scale basis are now covered through the ACA, which is helping us extend the funding we have.
“Building a culture of health means recognizing that while Americans’ economic, geographic, or social circumstances may differ, we all aspire to lead the best lives that we can,” wrote Robert Wood Johnson Foundation president and CEO Risa Lavizzo-Mourrey, MD, MBA in her 2014 President’s Message, released earlier this week. Laying out the plans for achieving those goals, Lavizzo-Mourrey added: “for the Foundation, it also means informing the dialogue and building demand for health by pursuing new partnerships, creating new networks to build momentum, and standing on the shoulders of others also striving to make America a healthier nation.”
The Foundation’s wide-ranging plans to “inform the dialogue” included a plenary talk by Mark McClellan, co-chair of the RWJF Commission to Build a Healthier America, and a former head of both the Food and Drug Administration and the Centers for Medicare and Medicaid Services. McClellan spoke at the AcademyHealth National Health Policy Conference in Washington, D.C., last week — less than a month after the release of the Commission’s 2014 report.
“To become healthier and reduce the growth of public and private spending on medical care, we must create a seismic shift in how we approach health and the actions we take,” said McClellan, “As a country, we need to expand our focus to address how to stay healthy in the first place.”
McClellan told a very attentive audience that critical needed changes include:
- Improve opportunities [for people] to make healthy decisions where we live, learn, work and play
- Improve access to a good education, jobs and health care
- Work across sectors, collaborating to improve the health of all Americans
- Make investing in America’s youngest children a high priority
- Fundamentally change how we revitalize neighborhoods, fully integrating health into community development
- Adopt new health “vital signs” to assess non-medical indicators for health such as jobs, income, housing, transportation and access to healthy food.
- Create incentives tied to reimbursement for health professionals and health care institutions to address non-medical factors that affect health.
McClellan cited two examples of organizations that are addressing issues beyond healthcare in order to improve health:
- Health Leads, a national health care organization, enables physicians and other health professionals to systematically screen patients for food, heat, and other basic resources that patients need to be healthy and “prescribe” these resources for patients.
- The Medical-Legal Partnership program removes legal barriers that impede health for low-income populations by integrating legal professionals into the care team. These volunteers intervene with landlords, social service agencies, and others to address health-harming conditions ranging from lack of utilities to bedbugs to mold in rental properties.
- Read Risa Lavizzo-Mourrey’s President’s Message
- Read the report of the 2014 Commission to Build a Healthier America
Many of the sessions at the National Association of Counties (NACo) Health Initiatives Forum meeting in San Diego this week have been moderated by Nick Macchione, director of San Diego’s Health and Human Services Agency and vice chair of the Healthy Counties Initiative Advisory Board. Macchione is a key architect of Live Well San Diego, a program voted in by the San Diego Board of Supervisors that is a long term, comprehensive and innovative strategy on wellness with a goal of helping all San Diego County residents become healthy, safe and thriving.
NewPublicHealth spoke with Nick Macchione ahead of the forum. Senior Policy Advisor Julie Howell and Dale Fleming, director of strategic planning and operational support, joined the conversation.
NewPublicHealth: The buzz about San Diego is that you’re working hard toward population health improvement.
Nick Macchione: I think the excitement about San Diego is that we have earned a reputation as a health innovation zone by having a collective impact on health and wellness. Our deeds demonstrate our words because over the past decade there have been five major broad-based population health improvements: reduction of heart disease and stroke; reduction of cancer rates; reduction of childhood obesity; reduction of infant mortality; and reduction of children in foster care. That reduction is extremely important to population health because we also look at the social determinants of health and not just pure health care.
We've taken an ecological approach to population health—working with partners across all sectors and coming together not just from traditional health care but beyond that to public health, social services, business, community, schools and the faith community.
And we’ve done that in the context of optimizing existing resources to improve outcomes. We’ve been blessed with a lot of competitive federal grants and philanthropy investments, but really the framework is how we leverage and optimize what we have first before we go and seek to augment with other resources. That has worked exceptionally well and that’s earned us that innovation zone reputation.
NPH: Tell us about Live Well San Diego.
Macchione: Live Well San Diego is a comprehensive public health initiative that involves widespread community partnerships to address the root causes of illness and rising health care costs. The tagline is healthy, safe and thriving. We think it’s a great template that communities can use, it’s transferable because San Diego has every imaginable bio-climate except a tropical rainforest. So we have desert towns, we have rural communities, we have mountain villages, we have beach towns and everything in between urban core. We also call it Project 1 Percent because 1 percent of San Diego represents the nation both in its diversity and its population. So, if we can achieve what we're achieving on advancing population based health in a broad scale it can be demonstrated throughout the country.
Late last year the Grand Rounds program of the U.S. Centers for Disease Control and Prevention (CDC) held a webinar on water fluoridation, a public health intervention that has been a priority in the United States for nearly seventy years.
Fluoridation, which has been shown to significantly reduce cavities in children, has been recognized by the CDC as one of 10 great public health achievements of the 20th century. Despite the benefits such as cost savings, however, CDC says there are ongoing challenges in promoting and expanding fluoridation.
NewPublicHealth recently spoke with Barbara Gooch, DMD, MPH, Associate Director for Science in the Division of Oral Health at CDC’s National Center for Chronic Disease Prevention and Health Promotion, about the challenges and benefits of water fluoridation and other emerging oral health improvement opportunities.
NewPublicHealth: What has been the historical impact of fluoridating water in the United States?
Dr. Barbara Gooch: All water generally contains fluoride, but usually at a level too low to prevent tooth decay, so community water fluoridation is a controlled adjustment of fluoride in a public water supply to an optimum concentration for the prevention of tooth decay.
That optimal concentration has historically been set at about 1 milligram (mg) of fluoride per liter of water, or 1 part per million. Fluoride was first introduced in the United States in Grand Rapids, Mich., in 1945. For cities that implemented community water fluoridation in the 1940s and 1950s, there was a dramatic reduction in tooth decay among children. Sometimes that reduction was greater than 50 percent. It has really been a major factor leading to the improvement in U.S. oral health.
When we compare the National Health and Nutrition Examination Survey done in the early 1970s with one conducted from 1999 to 2004, we found that the percentage of adolescents with one or more decayed teeth decreased from 90 percent in the early 1970s to 60 percent in the ’99-’04 National Survey. And while the number of teeth affected by tooth decay was an average of six in the 1970s survey, the instance was reduced to fewer than three in the later survey.
NPH: There are other sources of fluoride now, such as toothpaste. Is community water fluoridation still important?
Gooch: Current studies indicate that community water fluoridation increases the prevention of tooth decay by an additional 25 percent despite other sources. But the other very important factor about community water fluoridation is in order to receive its benefits, if you live in a fluoridated community. all you have to do is drink the tap water. And we can also show cost savings. One study estimates that for every dollar spent on community water fluoridation, you save about $38 in dental treatment costs.
NewPublicHealth Q&A: John Auerbach and Cheryl Bartlett on the Massachusetts Prevention and Wellness Trust
The Massachusetts Prevention and Wellness Trust is a four-year, $60 million project designed to support prevention and health-promotion activities in the state. The first project of its kind in the United States will fund six to 12 collaborative initiatives, and partners on the initiative will include municipalities, community-based organizations, health care providers, regional agencies and health plans. Information on the Trust is detailed in a new report prepared by the Institute on Urban Health Research and Practice at Northeastern University and funded by the Robert Wood Johnson Foundation.
The vision behind the creation of the project is to give all Massachusetts residents the opportunity to live in communities that promote health, as well as seamless access to all community and clinical services needed to prevent and control chronic diseases. It was created because while there is access to health insurance and health care in Massachusetts, health costs continue to rise. The goals of the project include:
- Reducing the rate of the state’s most costly preventable health conditions
- Reducing health disparities
- Increasing healthy behaviors
- Increasing the adoption of workplace wellness programs
- Developing a strong evidence base of effective prevention programs
In order to implement these goals, the Massachusetts Department of Public Health identified four priority areas: tobacco use, childhood asthma, hypertension and elder falls prevention—all of which should be considered closely when working to reduce health disparities and co-occurring mental health conditions in these areas.
A new infographic created for the Prevention and Wellness Trust’s inauguration perfectly illustrates how community links work together to improve health under the principles of the Trust. For example, a diagnosis of hypertension would need a provider to prescribe medications, but the obesity and exercise needs that would also improve the condition for many patients requires input from other community entities, including:
- Classes in exercise, medication and stress reduction by community agencies
- Chronic disease self management classes and home visits for medication use instruction by a community agency
- A neighborhood policy that provides support for transportation changes to encourage walking or biking and zoning for healthy food stores
- A neighborhood policy that provides support for more accessible recreation options in parks and city centers for increased stress reduction
- Workplace policies that provide support for workplace wellness programs that help provide and encourage exercise, healthy foods and stress reduction
NewPublicHealth recently spoke with John Auerbach, a Professor at Northeastern University and the primary author of a report on the Trust, and Cheryl Bartlett, public health commissioner of Massachusetts and the lead person charged with its implementation.
New research presented at the American Public Health Association (APHA) annual meeting in Boston today finds that when public health funding increases in a community, its rates of infant mortality and deaths due to preventable diseases decrease over time, with low-income communities experiencing the largest health and economic gains.
According to the research, conducted by Glen Mays, PhD, MPH, director of the University of Kentucky’s National Coordinating Center for Public Health Services and Systems Research, each ten percent increase in public health spending over 17 years led to a 4.3 percent reduction in infant mortality, as well as reductions of 0.5 to 3.9 percent in non-infant deaths from cardiovascular disease, diabetes, cancer and influenza.
However, these health gains were 20-44 percent larger when funding was targeted to lower-income communities. Increases in public health spending also correlated with lower medical care costs per person, especially in low-income areas. The study, which analyzed data compiled by the National Association of County and City Health Officials from 3,000 local public health agencies over a 17-year period, also found that lower death rates and health care costs were seen especially in communities that allocated their public health funding across a broader mix of preventive services.
“The results clearly show that better health and lower health care costs are possible if we simply change how and where we allocate public health funding, even if new money isn’t available, said Mays. “And it also shows that new resources, such as funding from the Affordable Care Act’s Prevention Fund, can have a larger impact if targeted to lower-resource, higher-need communities and if spread across a range of prevention strategies.”
>>NewPublicHealth will be on the ground throughout the APHA conference speaking to public health leaders and presenters, hearing from attendees on the ground and providing updates from sessions, with a focus on how we can build a culture of health. Follow the coverage here.
NewPublicHealth spoke with Mays about the new study just before the APHA annual meeting began.
NewPublicHealth: What are the key findings of the study?
Glen Mays: We’ve done prior studies that show communities that invest more on public health realize gains in health status and, over time, those communities see slower growth in medical care costs. So the goal of the study is to look at who benefits most from investments in public health.
What we found was that, not all that surprisingly, communities that are more economically constrained, that have lower income communities with higher poverty rates and lower socioeconomic status, tend to benefit the most from investments in public health activities over time. These low-resource communities see larger reductions in their preventable mortality, and they also see larger reductions in their medical care costs over time from investments in public health spending compared to more affluent communities. We expected to find that, but this is the first time we’ve been able to document the size of that effect. Those communities see about twenty percent higher rates of health and economic gain from their spending compared to more affluent communities.
NewPublicHealth is partnering with Grassroots Change: Connecting for Better Health to share interviews, tools, and other resources on grassroots public health. The project of the Robert Wood Johnson Foundation Health Group supports grassroots leaders as they build and sustain public health movements at the local, state and national levels.
In this Q&A, conducted by Grassroots Change, Shannon Frattaroli, PhD, Associate Professor at the Johns Hopkins Bloomberg School of Public Health, Center for Injury Research and Policy, shares her perspective on grassroots power and the future of public health. Her research helps answer two critical questions: Why are grassroots movements so important; and what is a public health movement, anyway?
>> Frattaroli’s interview has been edited for NewPublicHealth. View the full interview at GrassrootsChange.net.
Grassroots Change: What do you see as the role of grassroots movements in public health?
Shannon Frattaroli: There’s tremendous potential. Public health at its core is about the public. The public should have a voice in public health, and grassroots movements are one way for that to happen. The public has been very engaged in policy issues or problems throughout the history of public health. When people get engaged and are strategic with regard to policy change, things can happen quickly. And change can happen in a way that feels more legitimate. I think it’s where we should be moving in the future.
GC: What does “grassroots movement” mean? How are grassroots health movements different from other types of advocacy?