Jan 31 2014
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In San Diego, a Big Push for Better Health

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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.

Julie Howell: When the Live Well Initiative got started a construct that captured everybody's attention was the notion of 3FOUR50. That three behaviors—smoking, lack of exercise and poor nutrition—contribute to four chronic diseases: cardiovascular disease including stroke, cancer, diabetes and respiratory conditions. These cause more than 50 percent of the deaths in the county. That sort of simple construct helped people to understand what the problem was and that, in fact, there were some things that we could do about it individually and collectively that would contribute to wellness.

There was an analysis done of the economic impact of these conditions in San Diego that demonstrated that the health care cost from these conditions exceeded $4 billion. That helped to get the attention of the County Board of Supervisors to embrace Live Well from the beginning. So I think that’s an important starting point in terms of how we use data.

Macchione: The potent simplicity of 3FOUR50 is how it’s leading change in a cultural movement and how it’s improving the lives of children and how we've transformed the second largest elementary school district that had alarmingly high rates of obesity and overweight children, and over two years of embracing a Live Well framework reduced it by 2.2 percent. That’s 800 kids or the size of an entire elementary school.

That’s one of many stories of transformation that have taken place. What’s important is that these entities, schools, chambers of commerce, markets, food markets, faith communities, non-profit, health care, hospital systems, on their own have raised their hand and said, we want to join you. They’ve passed resolutions and they do ceremonial things. We have our board that goes there. We make a big deal of it and they make the commitments—the tenets of driving and then joining us and improving the health and the safety and the wellbeing, and I think that’s highly unusual.

It shows how these traditional large health systems are beginning to see the value of population health and the context of how that fits in with wellness. So we have stories behind stories behind stories which are about people's lives that we are transforming and when I say we, it’s the broad we, not the county government or my team.

NPH: How has requiring and using new data sets helped the city’s health goals and best practices?

Fleming: We use very high level community indicators that we can then stratify by various population groups but also geographically such as food insecurity for the entire region, for example, or unemployment. These are big measures that no single entity can move on their own. So it takes some of the political angst out of involving multiple political jurisdictions and working in the same area because we realize we have to row together in order to achieve these big accomplishments. And we're also using very simplistic indicators and language to describe them, areas of influence, for example, rather than domains and the top ten indicators are very approachable, very understandable to the lay person so they can act on their own to improve their own health and their own situation.

But, the indicators are also high level enough so that we can work in collaboration with school districts, with community colleges and four-year institutions. We can work with city jurisdictions that control parks and roads and other elements that are required for us to move forward. We took these ideas from the U.S. Centers for Disease Control and Prevention’s listing of social determinant measures that are available at the local level so that we would be able to drill down.

We're also looking at other data efforts that try to activate and motivate entire communities such as Gallup’s Principles of Well Being and the American Human Development Index, that takes data down to the congressional district level, and Robert Wood Johnson’s County Health Ranking that reports out of the county level.

Those are just some of the ways in which we came up with our indicator framework. The data is too big for any single individual to work on, so then we identified the sectors that can have an impact, what the evidence or best practice says they can do. And then we try to add supports to that to help people move in that direction, and ultimately, what we want to do is to be able to map those indicators all the way back to operational measures within different departments and different organizations, down to the individual what they can do on a daily basis.

Tags: Community Health, Healthy communities, Local government, Public health agencies, Social determinants of health