Culture of Health News and views from the Robert Wood Johnson Foundation Thu, 27 Aug 2015 08:59:00 -0400 en-us Copyright 2000- 2015 RWJF (RWJF) <![CDATA[What Hurricane Katrina Taught Us About Community Resilience]]>

Hurricane Katrina left a path of destruction, death, and suffering in its wake. Its uneven recovery has taught us valuable lessons about community resiliency that will help us prepare for the next storm and beyond.

New Oreleans St. Bernard Housing project. Girl on scooter.

Ten years ago Risa Lavizzo-Mourey visited Gulfport, Mississippi, and witnessed firsthand the devastation and ruin wrought by Hurricane Katrina. “We may not be able to fix the broken levees, restore ruined cities, house the homeless, or feed the hungry,” she wrote soon after. “That’s not our job. But we most certainly can apply Katrina’s lessons to the wide range of good work that we support...”

On the 10th anniversary of Hurricane Katrina, we must reflect on valuable lessons learned from this cataclysmic event, the complexity of recovery, and the disastrous health outcomes that can result from a fundamental distrust between residents and government agencies. Katrina’s devastation and the Gulf’s uneven recovery also have served as an opportunity for studying resiliency—the capacity of communities to prepare for, respond to, and recover from adversity whether in the form of a natural disaster, economic downturn, or a pandemic.

This emphasis on community resilience represents a paradigm shift in emergency preparedness, which has traditionally focused on shoring up infrastructure (reinforcing buildings, roads, and levees), improving detection of new hazards to human health, and being able to mount an immediate response to disasters. Katrina and subsequent threats such as Hurricane Sandy, the Florida panhandle oil spill and the H1N1 epidemic have taught us that to be truly prepared for the long-term impact of adversity communities must also develop a different set of assets: those that build strength through promoting well-being and community engagement.

This means forming strong social networks and developing sustainable programs with community-based organizations, faith-based organizations, and other neighborhood-level groups that can participate in a prompt response and recovery effort. Building resiliency involves fostering neighbor-to-neighbor ties, improving risk communication, and encouraging multi-sector partnerships between government, business, and community organizations. Finally, community resilience also depends on incorporating equity and social justice considerations into preparedness planning—making sure health and other support services are accessible to everyone, in particular the most marginalized residents.

In New Orleans and throughout the Gulf, work is continuing on rebuilding sustainable communities that will be more resilient in the face of future disasters. These efforts also have real-time benefits for promoting general health and wellbeing in these communities—especially for the region’s most vulnerable populations. For example, activities that boost preparedness by fostering community engagement—such a campaign to strengthen neighborhood social ties, a volunteer effort to visit elderly residents, and improved methods of communication—can also be a platform for addressing neighborhood public safety concerns. Collaborative activities like these simultaneously strengthen community social ties and improve dialogue and trust with public agencies.

Commission NOLA built environment 3

This notion that building resiliency into communities can have dual benefits was the spark for the first ever large-scale demonstration project to build and measure resilience. In 2013, we led this project in Los Angeles County. The county, which spans 4,000 square miles from coast to desert, is home to an economically, ethnically, and racially diverse population of 10 million people. Roughly 80,000 of its residents are homeless and approximately one in six live below the poverty level. LA County is at risk for earthquakes, fires or other natural disasters, but many of its communities also face chronic stressors such as violence, segregation, poverty, and homelessness. We took lessons learned from the impact of Katrina and applied them to a framework for building resiliency in 16 LA county communities. The hope was that a focus on strengthening social networks and multi-sectorial engagement in public health broadly would not only bolster emergency preparedness but also help these communities address the chronic stressors they face.

The community resilience framework we developed for the Los Angeles County Department of Public Health was designed to both augment public health preparedness and reinforce longer standing public health approaches to improving community health and wellbeing (including social, emotional, physical, and economic factors). The emphasis was on neighborhood connectedness: Residents were encouraged to meet other local residentsand to prepare both individual and community disaster plans; they were provided online resources to improve appropriate responses to emergencies. We developed a resilience tool kit for community organizations to build coalitions and coordinate neighborhood strategies to increase community preparedness and specific mitigation and adaptation skills. Finally, we identified metrics to help measure and evaluate how well certain interventions promote resiliency.  

This work in Los Angeles continues with support from RWJF. It also contributes to the Foundation’s larger commitment to building a Culture of Health in communities throughout the nation. All of the assets, systems, and dynamic partnerships that help make a community resilient to a range of challenges—natural disasters, infectious disease outbreaks, terrorism, and chronic stressors—are essential elements in our long-term strategy for ensuring that all people have the chance to live long, healthy lives. These include such key action areas as making health a shared value and fostering cross-sector collaborations to improve well-being.  

There is much work to be done in figuring out the specific actions that can make communities more resilient. As we’ve seen in New Orleans, in Joplin, MO (the scene of 2011’s powerful and deadly tornado), and in the communities that make up Los Angeles County, one size does not fit all when it comes to strengthening the social connections and multisector engagement efforts that build resiliency and emergency preparedness. RWJF will continue to fund research and design programs in these areas. If you are working to make your community stronger and more resilient, we invite you to learn more about what RWJF funds, and subscribe to our funding opportunity alerts.

The Foundation is taking the commitment to resiliency even further. Last year, we assumed support and operation of the National Health Security Preparedness Index in a transition from the Centers for Disease Control and Prevention. The Index ranks each state on six different parameters, including health security surveillance, community planning and engagement and healthcare delivery. Several of the NHSPI parameters deal specifically with community resilience. We expect that the index will be a catalyst for broader cross-sector collaboration and community engagement in preparedness.

Hurricane Katrina left a path of destruction, death, and suffering in its wake. Its recovery, halting and incomplete as it has been, has taught us valuable lessons about resiliency. It would be a tragedy if all this happened and we had learned nothing.  


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

Anita Chandra, DrPH, MPH, is a senior policy researcher and director of RAND Justice, Infrastructure, and Environment at the RAND Corporation. She is also on the faculty of the Pardee RAND Graduate School. Read her full bio.


Thu, 27 Aug 2015 08:59:00 -0400 Alonzo L. Plough Emergency Preparedness and Response Public and Community Health <![CDATA[A Community Food Market Where Dignity is at the Center]]>

The Daily Table’s model simultaneously addresses food insecurity and promotes health in a respectful, dignified manner for all customers who walk through their doors. Here's how.

The Daily Table Image via The Daily Table

When we opened the first Daily Table grocery store in Dorchester, Massachusetts this past June, I was eager for early customer feedback. I’ll never forget one of the responses we got:

I was able to check out your new store today and was very impressed. It was also the first time in a while that I didn't feel like crying at a grocery store.  Money is always tight and with kids I often have to settle for some not so healthy choices just because that's all I can afford right now. I just wanted to thank you and let you know that you are already making a huge difference for families!”

Nobody should face tears at the grocery store. Unfortunately, it happens more often than you might imagine, especially when single moms and low-income shoppers confront the daunting task of buying nutritious food to feed themselves and their families. That’s why I started Daily Table as a nonprofit community food market―to sell delicious, wholesome food at very affordable prices.

Daily Table is a store with a mission, designed to reach individuals who struggle to eat well, many of whom also face health issues that stem from a poor diet.  Responding to the sad truth that nutrients are expensive and calories are cheap, Daily Table believes that the solution to hunger and obesity in America is not just a full stomach, but a healthy, affordable meal. In short, it is a health care initiative disguised as a grocery store.

We sell fresh produce and groceries, as well as prepared meals that are cooked on-site in a professional kitchen every day. We believe that the food we eat with our families plays a big role in our well-being so we make sure that everything we offer has our customers’ health (and wallets) in mind. Every food in the store meets nutritional guidelines for salt, sugar and fiber, and can be purchased with Supplemental Nutrition Assistance Program (SNAP) funds. Because customers get to come in and choose what they want in a normal shopping environment, it supports dignity and increases the likelihood it will be consumed.

A unique sourcing strategy also distinguishes Daily Table from the average neighborhood food market. While one in six Americans is food insecure, up to 40 percent of the food produced in this country is wasted: tilled back into the soil at farms, left in dumpsters behind supermarkets, and thrown into wastebaskets in our homes. Daily Table relies on manufacturers, growers and supermarkets to donate their perfectly edible, excess food as a primary source of our food supply. In this way, Daily Table can keep its prices so low that they are comparable to traditional fast-food alternatives in the neighborhood.

As a retail store, Daily Table’s flagship location is anchored in the Dorchester community outside of Boston. It has created about 30 new jobs, with 75 percent of the store’s retail and kitchen hires living within a two-mile radius of the store. The retail space is bright, clean, and inviting, and the store team treats customers with respect and warmth, creating a welcome and enjoyable shopping experience for all.

Unlike most nonprofits, Daily Table’s retail-based approach to its mission aims to be financially self-sustaining. While many generous foundations and individuals (including the Robert Wood Johnson Foundation) provided funds to cover the costs of renovating our store and to support us through an initial growth phase, our goal is for the revenue from our food sales to cover the cost of operating the business. Being in this start-up phase is not easy. Right now, our chief priorities are to build a steady supply of donated food with more variety for our customers, and spread the word to increase the number of shoppers.

Daily Table’s model simultaneously addresses food insecurity and health in a respectful, dignified manner for our customers. It also presents a unique, market-based solution to the problem of wasted food. We’re confident that this combination will help the communities we open in build a Culture of Health, and give us a solid foundation to expand into other markets. Beyond our pilot location in Dorchester, plans are to expand first to other sites in Boston and then to more cities in the US. After all, the need for affordable, delicious, convenient and wholesome food is everywhere—and shoppers shouldn’t have to cry in grocery stores, unless they’re tears of joy.

Tue, 25 Aug 2015 14:46:00 -0400 Doug Rauch Healthy Food Access <![CDATA[Patient and Citizen Engagement for Health: Lessons from Jönköping County, Sweden]]>

What can a small Swedish county teach us about building a Culture of Health in the United States? We visited Sweden and brought back some valuable lessons on patient and citizen engagement.

Rooftops and landscape of Jönköping, Sweden Copyright Guillaume Baviere

Imagine a society where everyone has the means and opportunity to make choices that lead to the healthiest lives possible––a society where health is valued by all, and no one is excluded because of chronic illness or other limitations. This is what we call a Culture of Health, and it’s what, in collaboration with others, the Robert Wood Johnson Foundation is working to build in the United States.

We know that to achieve this ambitious vision, we must look to––and learn from––promising approaches across industries, disciplines and geographic borders. This is why we recently visited Jönköping, a small county in south-central Sweden, where patient and citizen engagement has brought about remarkable results: kidney failure patients operate dialysis machines on their own schedule, complex patients—such as people with schizophrenia—actively participate in designing their own care and children’s preferences and experiences are listened to, so services can improve from the children’s point of view.

Jönköping is the world's laboratory for quality improvement and population health.
-Helen Bevan, Director, NHS Improving Quality, National Health Service of England

Map of Jonkoping, Sweden Source: Google Maps

Jönköping was first recognized worldwide as a center of excellence in health care quality improvement when it participated in the Robert Wood Johnson Foundation/Institute for Health Care Improvement “Pursuing Perfection” initiative. But its excellence predates that recognition: for 25 years and counting, Jönköping County’s health care performance has consistently ranked among the best in Sweden.

What’s relevant for us is Jönköping’s innovation in two key principles central to our Culture of Health Action Framework: integrating health and social services and achieving genuine co-production of health and well-being by patients and citizens, who are the experts of their own situation.

One of the keys to Jönköping’s success is that professionals throughout the region—nurses, physicians, social workers and others—begin each day by asking, “How could we do better?” To answer this, they rely not only on professional meetings (e.g., formal and informal collaboratives and teams, leadership-sanctioned strategic discussions) but also meaningful engagement of patients and citizens. In this way, workers in health and social care produce a Culture of Health not for but with the people they serve. They make improvement part of the routine, and ‘customer-orientation’ part of the improvement.

The integration of health and social care services is not easy—colleagues overseas and throughout the developed world all report major challenges. Even in Sweden, where both health and social services are funded primarily through taxes, jurisdiction issues can threaten handoffs and transitions. Counties run health care, but each municipality (and there are several in each county) provides its own social care services, with private clinics competing alongside these public systems.

This is what makes Jönköping’s approach to addressing these challenges particularly clever. They have turned integration of services into a quality improvement challenge, and engaged patients and citizens to not only help identify what is going wrong or can be improved, but to become an active part of the solution. A unique improvement resource, Qulturum, supports these efforts, along with Futurum, its research arm, and FoUrum, a collaboration of the municipalities focused on improvements in social care.

On our trip to Jönköping, we were able to see first-hand how they are working to build a Culture of Health, and found the following three examples of patient and citizen engagement particularly compelling.

The “Health Dialogue” for Population Health

As children grow and people age, new risks—and opportunities for wellness—take shape. “Health Dialogue” puts those life transitions on the agenda. School nurses do motivational interviewing of children at ages 10, 14 and 17. Primary care providers do the same with adults to address lifestyle choices and other concerns at ages 40, 50, 60, and now 70. These dialogues acknowledge the changes that come with development, adulthood and aging, focusing on prevention and self-management of disease. Nurses and primary care providers help people explore what is most meaningful in their lives going forward. Then they work together with people’s own capacity for self-care, as well as social and health care services, to ensure their goals are met.

“What Is Best for Esther?” Integrated Care for Complex Conditions

 The Esther Network has captured international attention. Esther is any patient with complex chronic conditions, and some acute needs, too. Esther is not any one real person, but a persona that represents the challenges any patient could face in a complex system. Esther can be an elder with several comorbidities, a complex patient needing multiple health and social services, or perhaps an individual with schizophrenia or dementia. Regardless of Esther’s condition, he or she fully participates in all aspects of care planning, and his or her story is the basis for coordination––patients are true co-producers of their care. The drivers for success are management support across the network and trained “Esther Coaches”––who work together with the patient and their team of health and social care professionals to ensure that individualized care plans are established that reflect each patient’s unique situation and stated wishes and needs. Each team member is reminded always to ask, “What is best for Esther?”

A chart showing the impact of the Esther Network on unnecessary days in the hospital. The Esther Network for coordinating the care of complex patients has significantly reduced unnecessary days in the hospital across the region. Source: Governance International

The “Children as Relatives” Project

The world over, children are the “forgotten relatives” of sick or dying parents and caregivers. Given the trauma of parental death, illness, or incarceration, and our knowledge about how such Adverse Childhood Experiences can influence both mental and physical health throughout children’s lives, this is a big public health issue. Swedish law says medical practitioners must explain what is going on to children in terms they can understand, but the quality of these conversations is variable. In a complex system, whose responsibility is it to speak to the child?

Jönköping’s answer is to use the approach they know best: they asked the children what they wanted to know. Each professional that touches the patient or child gets a checklist indicating what is necessary to do, ask and say. By collaborating across disciplines and sectors, professionals ensure someone is designated to speak to the child, or several providers share the task so a child’s needs do not fall through the cracks. Loving relatives, faith-based organizations, and teachers or school nurses often take part. This is quality improvement, citizen participation, plus an intelligent use of community and family assets all rolled into one!

Europe has better health outcomes than the US, possibly because it invests in social services and integrates them with health care. And yet, in Europe they bemoan the problems of coordinating—just as we do in the US! Sweden’s overall health and social care are some of the best in the world and still they find integration to be a challenge. Yet Jönköping shows that building a Culture of Health can be done—and that a collaborative culture of continuous improvement may be the best way to do it.

Galina Gheihman is a student in the New Pathway Program at Harvard Medical School. Read her full bio on LinkedIn.

Laura Leviton is senior adviser for evaluation at the Robert Wood Johnson Foundation. Read her full bio.


Thu, 20 Aug 2015 12:00:00 -0400 Laura Leviton Public and Community Health International <![CDATA[Want a Healthier Workforce? Investing in Community Health Can Pay Off]]>

Regardless of what sector they occupy, businesses have a critical role to play in improving the health of their employees and in forging vibrant, healthy communities beyond their own walls.

Beyond Four Walls

Nearly 80% of U.S. employers now offer workplace health promotion programs aimed at improving the health and productivity of their workers. The most comprehensive of these programs—mainly at larger companies—have employees doing yoga poses at lunchtime; 7-minute workouts during breaks, or spinning at the on-site gym. Cafeterias may offer salad bars and heart-healthy entrees while vending machines are stocked with wholesome snacks and water instead of chips and soda. Some companies provide free weight loss counseling or connect employees at risk of heart disease or diabetes with a health coach. The entire workplace may be smoke-free.

But what happens when employees leave the four walls of these healthy workplaces and go home? If they live in neighborhoods with scarce green space, poor access to active transportation, few nutritious food options, or in communities plagued by crime or pollution, it can be very difficult for employees and their families to continue making healthy lifestyle choices. For businesses, the desired impact of their workplace health promotion programs will necessarily be limited.

So how can companies promote health both within and beyond their four walls? The first step, according to a new report released by the Vitality Institute, with funding from RWJF, is for organizations to better understand the connection between where employees live and their health status. In the report, titled Beyond the Four Walls: Why Community is Critical to Workforce Health, researchers found that employees working in particular sectors, such as transportation and warehousing, manufacturing, and public administration, are more likely to smoke and are at higher risk for obesity, diabetes and heart disease. Interestingly, these sectors were also more highly concentrated in U.S. counties with elevated levels of smoking and obesity and chronic diseases like diabetes and hypertension. It’s clear, according to the Vitality Institute report, “Major employment sectors with unhealthy work forces are more likely to be located in counties with poor health, demonstrating the linkage between community and workforce health.”

That’s where cross-collaborations between businesses and community partners become important. Currently, only a fraction of companies address the environmental and social drivers of workforce health at the community level. The ones that do employ best-practice strategies—many of them described in the report—could be emulated by other organizations. These strategies fall into three main categories, often combined:

1) Strategic use of philanthropy—giving to the community via financial donations and non-cash contributions such as time, expertise, and resources

2) Corporate social responsibility—promoting positive social and environmental change, even if there is not an immediate financial benefit to the company

3) Creating shared value—business policies and practices that enhance the competitiveness of a company while advancing economic and social conditions in the surrounding communities

Workplace and community infographic

Kaiser Permanente’s Community Health Initiative is a great example of the strategic use of philanthropy. Through its Healthy Eating and Active Living collaboratives, the health care giant has allocated more than $50 million in grants to 50-plus communities within its service area. These are communities where people insured by Kaiser live and also where many employees reside. Through the HEAL initiative the company supports existing community groups in such efforts as increasing physical activity in schools, building bike and walking paths, improving access to fresh fruits and vegetables, and influencing urban planning. The idea is to engage and invest in these communities so that healthy choices are easy to make and readily available to all residents.

Another example is Dow Chemical Co.’s collaboration with the Michigan Health Improvement Alliance (MiHIA), a multi-stakeholder group that is working to improve health and health delivery in 14 counties in central Michigan—home to Dow’s headquarters. Noting the elevated rate of diabetes in these counties and among employees, the company worked with many organizations in the private, public, and non-profit sectors as well as with the Center for Disease Control to develop a diabetes prevention program integrated into its workplace health promotion efforts. Eventually, Dow extended this program—as well as other health and prevention strategies—outside its four walls, taking a leadership role within MiHIA in implementing the CDC’s Diabetes Prevention Program in central Michigan. This is a great example of a shared value strategy—while the initiative benefits the community as a whole, Dow has seen a reduction in the burden of chronic disease among employees and their families. A study by Towers Watson comparing employee health at Dow with peer companies found that the prevalence of chronic conditions among Dow employees was 17% lower while the company also spent 17% less on diabetes and other chronic conditions.

The Vitality Institute report has other examples of promising strategies businesses can use to help improve community health while also reaping benefits in employee health, product development (i.e. healthy food and beverages options), and corporate reputation. The authors also drive home an important point we make often at RWJF: our health is affected by where we live, learn, work and play. To have the greatest impact businesses need to first understand which health issues are most prevalent amongst their employees and in the local communities in which they live. Community interventions needed to address obesity and diabetes in the manufacturing sector, for example, might be different from those best suited for reducing high rates of smoking and hypertension in retail workers.

In the end, The Vitality Institute report serves as a call to action, offering strong evidence for the link between employee and community health. It also offers a blueprint of sorts for increasing cross-sector collaboration that presents a win-win opportunity for employers and community groups. Regardless of what sector they occupy, businesses have a critical role to play in improving the health of their employees and in forging vibrant, healthy communities beyond their own walls.



Marjorie Paloma, MPH, is a Director at the Robert Wood Johnson Foundation (RWJF) leading RWJF's efforts in engaging business for health. Read her full bio.

Tue, 18 Aug 2015 10:40:00 -0400 Marjorie Paloma Public and Community Health Disease Prevention and Health Promotion <![CDATA[How Food Marketing Can Help Kids Want What’s Good For Them]]>

If we want to ensure that all children are able to grow up at a healthy weight, companies can play a role by continuing to reduce marketing of unhealthy foods and beverages and increase promotion of healthy choices.

A student drinking from a carton of milk.

When it comes to helping Americans eat healthier, the conversation often focuses on price and access. But, there’s a third, equally consequential, condition: desire. Preference is shaped by myriad factors and the effects of marketing and advertising are of paramount importance. Food and beverage companies spend hundreds of millions of dollars to market their products, and their investments produce results: adults and kids are swayed by marketing.

A new report from the UConn Rudd Center for Food, Policy & Obesity reveals that a majority of the largest food and beverage companies are spending a disproportionate amount of money advertising their nutritionally poor products to Black and Hispanic consumers, especially youth. While food marketing is not inherently bad—it appears Sesame Street characters could be great “salespuppets” for fruits and veggies—it becomes a problem when it features unhealthy products known to contribute to obesity and other poor health outcomes. And, with rates of overweight/obesity higher among Black and Hispanic kids and teens, this type of business approach is especially harmful.

Fast-food and other restaurants—many of which are known to promote products high in calories, fat, and/or sodium like French fries and chicken nuggets—represented almost 40 percent of food-related advertising spending on Spanish-language and Black-targeted TV networks. Other primarily unhealthy categories of foods/beverages, especially candy and snack items, dedicate a high proportion of their advertising budgets to Spanish-language and/or Black-targeted TV.

Conversely, advertising spending for more nutritious items, like healthier dairy products, juice and water, and fruit and vegetable brands, on Spanish-language and Black-targeted TV was less than the spending for these same items on all TV in total.

Over the years, a multitude of food and beverage companies have overhauled some of their most deep-rooted business practices to help kids and their families make healthier choices. And, they’re finding that these changes can benefit their bottom line, too.

In an effort to specifically reform their marketing practices, a number of these companies, many of which were analyzed in Rudd’s report, belong to a self-regulated program and they’re making good on their pledges to improve the ways they market to young kids.

However, more work can and must be done. While the national childhood obesity rate has leveled off and some places around the country are starting to see declines, racial and ethnic disparities persist. We all have a role to play—including industry leaders—in making progress more equitable.

The report offers recommendations on ways companies can improve their overall marketing practices, which would greatly benefit Black and Hispanic youth. Building on the efforts that are already underway, a couple of recommendations include expanding the products and types of marketing covered by the self-regulatory program and the companies’ commitment to increase the sale and availability of healthy products.  

If we want to ensure that all children—no matter who they are—are able to grow up at a healthy weight, companies need to continue reducing their highly influential marketing of unhealthy foods and beverages and increase promotion of their healthiest items. And, those populations adversely affected by the childhood obesity epidemic should be prioritized at the forefront of these changes.  

This way, we’ll be more likely to desire what’s actually good for us, and not just what’s put in front of us.

Victoria Brown, is a senior program officer, working to engage business around health for the Robert Wood Johnson Foundation. Read her full bio.

Tue, 11 Aug 2015 14:45:00 -0400 Victoria Brown Childhood Obesity <![CDATA[Reaping the Rewards of the Culture of Health Prize]]>

It's been a year since Brownsville, Texas, won the Culture of Health Prize for its engagement of leaders across sectors to improve local health outcomes. Here's what the community has been up to since.

Brownsville, TX 2014 Culture of Health Prize Winner

Brownsville, Texas, had plenty to celebrate when it became one of six communities to win the Robert Wood Johnson Foundation’s Culture of Health Prize in June 2014. This predominantly Hispanic city along the U.S.-Mexico border is one of the poorest in the country. Seven in 10 residents are uninsured, 8 in 10 are overweight or obese, and 1 in 3 has diabetes. Yet the community’s efforts to improve health—including new bike trails, community gardens, and a successful bilingual public health education campaign—have earned it wide respect and national recognition, along with $25,000 that goes with the RWJF Culture of Health Prize.

City officials are still discussing how to use the prize money. One option is commissioning a piece of artwork that could be moved around to highlight various initiatives, such as the periodic CycloBia events that make some of the city’s streets car-free for a day so that residents can bike, run, or engage in other physical activity.

Yet the money’s significance pales in comparison to all else that has happened since Brownsville won the Prize. The award “has given us great visibility,” says Rose Zavaletta Gowen, a physician and Brownsville city commissioner who has led many of the municipality’s health improvement efforts. “We were working on our own, almost incognito, before, but winning the Prize has pushed us out into the open.” Consider what has happened since:

  • Surveys of city residents have shown progress in boosting physical activity; for example, 45 percent of those who attended at least one CycloBia event reported that they got more activity each week afterward. Partly as a result, the local Valley Baptist Legacy Foundation stepped in with $100,000 to help build a broader network of trails to encourage biking and bicycle tourism in surrounding Cameron County and 10 other area cities.
  • A team led by Kathleen Schmeler, MD, from Houston-based M.D. Anderson, along with Belinda Reininger and other colleagues from the University of Texas School of Public Health regional campus in Brownsville, tackled the area’s high cervical cancer rates in women. Promotoras, or community health workers, have been trained to recruit local women for cancer screening; the goal is to boost the number screened by 4,000, or 30 percent, over the next several years. Local Brownsville health care providers have been schooled in providing needed follow up care. Schmeler and her colleagues in Houston tele-mentor them weekly under the auspices of Project ECHO, a former Robert Wood Johnson Foundation grantee.
  • A Rice University engineering professor, Rebecca Richards-Kortum, has engaged her students to develop tools that can help provide health care in Brownsville and other low-resource places in the U.S. One team will work on an inexpensive point-of-care blood sugar test for diabetes that can be used in a home or clinic; another on developing low-cost manikins, or models of the human body, to help train providers to care for the foot ulcers experienced by many diabetes patients.
  • One of the area’s largest foundations, Methodist Healthcare Ministries of South Texas, took note of Brownsville’s prize-winning performance, and engaged key city leaders including Gowen in a broad collective impact initiative to address diabetes in four local counties. The target is to decrease the region’s prevalence of type 2 diabetes—double or triple the national average—by ten percent as of 2030. What’s more, through Methodist’s initiative, Brownsville is also slated to receive monies from the federal Social Innovation Fund to train promotoras and other local care providers to help diabetes patients with the mental and behavioral health issues many experience, including depression.

Those spearheading these new efforts say that Brownsville’s success in winning the RWJF Culture of Health Prize focused their attention on the unique local capacity to improve health. They say the critical engagement of city leaders like Gowen—and the cross-sector collaboration among areas such as health care, education, and business—are a major force multiplier in a region where other resources are scarce.

“It will forever be in their favor that they were recognized,” says Patricia Mejia, director of community engagement at Methodist Healthcare Ministries. “They are teaching us many things about creating a Culture of Health. They are one bright spot in a very tough location of the U.S. And they are able to say, if it can happen here, it can happen anywhere.”  


A First Friday Google+Hangout on the RWJF Culture of Health Prize took place on Friday, August 7. Winners of the 2015 Prize will be announced on October 28, 2015.
Susan Dentzer

Susan Dentzer, Senior Policy Adviser at the Robert Wood Johnson Foundation, former Health Affairs Editor-in-Chief and Health Policy Analyst, The NewsHour with Jim Lehrer, is one of the nation's most respected health and health policy thought leaders and journalistsRead more of Susan’s posts.

Mon, 10 Aug 2015 15:25:00 -0400 Susan Dentzer Social Determinants of Health Public and Community Health First Friday Google Hangouts <![CDATA[A New Approach to a Healthier New Jersey]]>

New Jersey Health Initiatives is investing in grassroots solutions to local health challenges in our own backyard, with 10 New Jersey communities serving as laboratories to learn what it will take to build a Culture of Health.

New Jersey Health Initiatives

We’re trying a new approach to building a Culture of Health in communities across New Jersey. It’s a creative, grassroots, on-the-ground approach that could become a model for many other cities and towns across America.

For decades, folks in the health field have been working hard to turn around health inequities that mean some kids have a better chance of growing up healthy than others. They’ve done great work, but sometimes in isolation, and often making decisions based on best practices rather than authentic community engagement. Even more often, health organizations’ hands have been tied because the true causes of poor health sit in other sectors: poverty, unaffordable and poor quality housing, fractured or nonexistent transportation systems, and uneven quality education and access to jobs.

Pursuing the Robert Wood Johnson’s vision of building a Culture of Health—which is a big part of our mission at New Jersey Health Initiatives (NJHI)—requires a broad, ambitious, and innovative approach. And maybe some risk and uncertainity. Community health is complicated. For solutions to work well, we have to create opportunities for solutions to come not from the top—not from us, not from the Robert Wood Johnson Foundation—but from community members themselves. Individuals from a cross section of the community need to agree on the biggest local challenges, what assets they have to draw on, and the best solutions for a path forward. The goal is to plant the seeds for continuing change long after the original funding has run out—because it’s owned and driven by the people who are most affected.           

That’s where our experiment comes in. NJHI has made grants to 10 communities across New Jersey to serve as laboratories for testing what it will take to build a Culture of Health. These communities are bringing together broad coalitions of organizations from across sectors; pooling rather than competing for resources, and coming up with collective solutions. While these $200,000 grants were awarded to one trusted community-based organization, the funds are supporting the coalitions of at least five organizations—groups, it should be emphasized, that were already working together.

And that’s important. These are not new coalitions. They are all pre-existing coalitions, alliances within the communities, groups of neighbors who know each other’s strengths and have a track record of working together. Our grants will give these groups the tools and leadership training to do the hard work of figuring out what to do next. They’ll find common goals and overlapping interests, and ways to support each other and the community at large. The four-year grants, which began on July 1, will help these coalitions, already recognized change agents in their communities, become better driving forces for improved health.

Young girls in green shirts dance together on a stage. Youth participating in a NJHI event. (Image via NJHI)

Our grants will give these groups the tools and leadership training to do the hard work of figuring out what to do next. They’ll find common goals and overlapping interests, and ways to support each other and the community at large.

For example, in Jersey City, a wide range of groups, from hospitals and churches to block associations and greenmarkets, are coming in with interests as varied as urban farming, fair and affordable housing, after-school programs, paid sick leave, and smoke-free parks. All of those different perspectives will come together to find shared interests and set collective priorities. We’re already seeing that the diversity of voices increases the potential for innovation and creativity.

In Salem County in the Delaware Valley, New Jersey’s least populous county and one of the poorest and least healthy, the coalition’s initial organizing sessions drew not only a terrific turnout of local officials, health providers, and private business people, but also a contingent of teenagers. The high school kids said they heard about the coalition and wanted to participate in building a Culture of Health; they want to be part of charting a path for the community’s future. That’s a great sign.

The communities are already setting their sights on ambitious goals. Trenton is focusing largely on building a healthy food network for people who live in food deserts. One of the goals for the community of Elizabeth is to create “Healthy & Safe School Zones,” with safe and welcome play spaces, access to affordable healthy food, and medical support for chronic disease conditions—all in concentrated areas around schools.

Many of these coalitions already have been effective working together on other projects. We think they will become more effective as they work together to make good health part of their local culture. And we think both local leaders and everyday citizens will become more aware of the factors that affect their health—and the health of their neighbors. We’re hopeful that this approach could be a model for other states and regions.

But we need to wait and see. It’s too early to offer any concrete results yet—but the payoff could be huge. And if it is, we’ll be that much closer to building a Culture of Health nationwide.

Robert Atkins, PhD, RN, director of New Jersey Health Initiatives (NJHI)

Bob Atkins, PhD, RN is director of New Jersey Health Initiatives and an Associate Professor at Rutgers University with a joint appointment in Nursing and Childhood Studies. Dr. Atkins has a Bachelor of Arts in Political Science and American Civilizations from Brown University and Bachelor of Science in Nursing from the University of Pennsylvania.


New Jersey Health Initiatives is a statewide grantmaking progam of the Robert Wood Johnson Foundation. The program, funded through a grant to the Institute for Health, Health Care Policy and Aging Research at Rutgers University, supports innovations and drives conversations to build healthier communities through grantmaking across the state of New Jersey.

Wed, 5 Aug 2015 16:49:00 -0400 Bob Atkins Public and Community Health <![CDATA[Getting to the Essence of Value in Health Care]]>

In this era of value-based payment, we need to consider how different players within health care approach the value equation.

2013 April Cost Test

How would you judge the value of your health care? A longstanding definition of treatment holds that value is the health outcomes achieved for the dollars spent. Yet behind that seemingly simple formula lies much complexity.

Think about it: Calculating outcomes and costs for treating a short-term acute condition, such as a child’s strep throat, may be easy. But it’s far harder to pinpoint value in a long-term serious illness such as advanced cancer, in which both both the outcomes and costs of treating a given individual—let alone a population with a particular cancer—may be unknown for years. And then there’s the complicating issue of our individual preferences, since one person’s definition of a good outcome—say, another few years of life—may differ from another’s, who may be seeking a total cure.

In this era of value-based payment, it’s worth considering how different actors in the health care sphere approach the value equation. The United States spends far more per person than any other advanced nation on health care, yet our health outcomes lag behind. Meanwhile, health care spending has crowded out investments in other areas like education and social services that may have a greater impact on health outcomes. As a result, getting better value from the nation's investments in health and health care is critical to the Robert Wood Johnson Foundation's goal of building a culture of health, notes Anne Weiss, who directs the Foundation's work in this area. 

Several value-creating initiatives in health care were topics of discussion at the recent AHIP Institute Conference in Nashville, TN, where I served as moderator.

Lowering costs for lab tests: Elizabeth Holmes, founder and CEO of Theranos, has been the subject of a recent New Yorker profile and was featured last year on the covers of both Fortune and Forbes. At 31, she’s famous for founding her company at age 19, then dropping out of Stanford to pursue her goal of making important health information accessible to people when and where it matters. She believes individuals should be “in the driver’s seat of our own care," as she said during her talk at AHIP—and that they should especially have the tools to enable prevention or early detection of disease.

Theranos offers blood tests that use a finger stick and tiny drop of blood, versus the larger needles and tubes of blood that characterize conventional testing. Prices for the tests, which are fully transparent and posted online, are far lower than what is typically charged or that Medicare or other payers will pay. Many even cost less than the copayments or deductibles that patients must incur on standard lab tests.

Among other options, consumers can access the tests at Wellness Centers in Walgreen’s pharmacies, Capital BlueCross retail stores in Pennsylvania, and in some physician offices. They can also make appointments and track their test results through an app. And in Arizona, Holmes persuaded a bipartisan group of lawmakers to enact a state law that now allows any consumer to obtain any lab test without a physician’s order. That’s truly putting patients in charge of their care, Holmes asserted.

Theranos blood tests have been approved by the U.S. Food and Drug Administration, a form of quality assurance that technically isn’t necessary for these types of tests, since they are normally regulated a different section of federal law. And the company recently won the green light from FDA to analyze its test for a sexually transmitted herpes virus outside a highly regulated clinical laboratory, which could pave the way for more Theranos blood tests to be analyzed in wellness centers and other locations, improving efficiency and reducing costs.

Holmes says about 60 percent of patients don’t get the lab tests that their doctors prescribe for them, partly because of cost or fear of needles. So, the ultimate value for consumers may well be those low prices, ease of access to the tests, and the need to extract just those tiny drops of blood.

Theranos A patient receiving a Theranos blood test. (Image via Theranos)

Personalized medicine: President Obama’s Precision Medicine Initiative, the Patient Centered Outcomes Research Institute, and proposed legislation in the US House of Representatives on 21st Century Cures, all have in common the core understanding that a given health intervention that works for one person may not work for another.  According to Colin Hill, chairman and CEO of GNS Healthcare, a good guess is that about half of treatments given today fall into that category, leading to $500 billion to $1 trillion annually in what in effect is health care waste.

Fortunately, the tools exist to propel us past “knowledge blind spots” that still have the wrong care directed to a particular person. These tools include genetics and genomics, electronic health records, “Big Data,” predictive analytics, machine learning, artificial intelligence, cloud computing. Many of these tools are now brought to bear in diagnosis and treatment of some cancers, such as melanoma and leukemia, in which the cancer's molecular "signature" can be identified and targeted drugs prescribed.

But true value in health care may only come when far more conditions are treated with personalized medicine, says Hill, whose company performs data analytics for health plans, providers, pharmaceutical companies, and others. For example, through a current research partnership with the Inova Translational Medicine Institute, a division of Virginia-based Inova Health System, Hill’s company is using genetic sequencing and EHR’s to help predict the risk of premature birth, which causes an estimated 10,000 US deaths and at least $28 billion in health spending annually. It’s hoped that knowing who’s vulnerable ahead of time could lead to tailored interventions that could forestall the worst birth outcomes.

At AHIP, I asked Hill how many medical decisions today are made on the basis of such advanced analytical techniques. “Somewhere between 1 percent and 10 percent,” he replied.

For all of us who seek value from our health care dollars, that’s a sorry equation, indeed.

Susan Dentzer

Susan Dentzer, Senior Policy Adviser at the Robert Wood Johnson Foundation, former Health Affairs Editor-in-Chief and Health Policy Analyst, The NewsHour with Jim Lehrer, is one of the nation's most respected health and health policy thought leaders and journalists. Read more of Susan’s posts.

Mon, 3 Aug 2015 13:57:00 -0400 Susan Dentzer Health Care Costs Health Care Payment Reform <![CDATA[Harnessing the Power of Shared Data Across Sectors]]>

Silos of data need to be opened up across sectors to reveal hidden connections with the potential to improve health outcomes. Here's how RWJF is investing in innovative solutions.

Shared data

A year and a half ago, the Robert Wood Johnson Foundation wrote about the groundswell of interest in connecting health care systems with other organizations and their local communities to build a Culture of Health. Since then, the Data4Health listening tour and the launch of Data Across Sectors for Health (DASH), have given more evidence to the importance of data—or the flow of information—in creating and benefitting from these connections. With work the Foundation and others across the country are doing, the “connections checklist” is increasingly taking shape.

In communities large or small, data can become a bridge between one organization’s need and a very different organization’s solution. In Rochester, New York, the business community took a hard look at a most alarming expense they faced—soaring health care costs. In 2009, the Rochester Business Alliance entered into a strategic partnership with the Finger Lakes Health Systems Agency to build a healthier workforce and lower costs. Analyzing data about community health issues revealed a shared concern about high blood pressure. The Agency developed community-based interventions that the Business Alliance and local businesses could use to help their employees and the wider community understand the importance of controlling their blood pressure. Working together, this collaboration has improved the county’s blood-pressure control rate by over 7%.

Underlying this community connection is a data connection between health care and the business community that brings root-cause analysis and rapid-cycle evaluation together to really focus attention towards groups of people who are at highest risk of uncontrolled hypertension. The Agency created a registry of information from electronic health records (EHRs) to fully understand the situation and monitor any changes brought about by their activities. Careful stewardship of sensitive information, real results, and the tantalizing promise of further benefits are sustaining and expanding this partnership.

The promise of benefits from connecting health care data with other sectors is where the Colorado Health Observation Regional Data Service (CHORDS) seeks to build upon the success of this data-driven public health surveillance tool to realize new benefits. CHORDS aggregates clinical and demographic information from health care partners’ EHRs. Queries are used by public health and health care delivery sectors in the Denver metro area to make data-driven decisions about targeted interventions, as in Rochester. Multiple public health jurisdictions are working with each other and community partners to understand and use data, including targeting resources and evaluating intervention impact within their communities. Clinical data obtained through CHORDS have been integrated with social, economic and community data and displayed at smaller geographic levels (e.g., neighborhood). This helps policy makers consider the health impact of decisions made in sectors outside of those traditionally considered “health-related.” For example, layering census, eligibility, and EHR clinical information with health services location or public transportation helps identify high need neighborhoods with limited provider access or transportation options; enabling planners to make decisions about bus routing that are more responsive to community needs.

While checklists can look easy, we are learning that this stuff is hard. From different collaborations, to different use cases, to different health aims to different tools, challenges and opportunities change. However, by keeping our focus on the connections of data and information systems across sectors to improve community health, we have identified key areas, such as financial limitations, collaboration building, and data exchange that will be important to address in order to build the field. Limited financial resources will always present a challenge, but we have clearly heard that technical and analytical resources are also scarce. Data can be used to foster multi-sectoral collaborations to address community problems, and multi-sectoral collaborations can help manage the use of the expertise, share it, value and reimburse it, but building collaborations is an art. Silos of data need to be opened up to reveal the connections that will build our nation’s culture of health. The program mentioned at the beginning of this post, DASH, has released a Call For Proposals seeking innovative solutions to these challenges.

Communities all over the country are doing impressive things, and as we learn about them, our own toolkit will evolve and grow. Through DASH, RWJF would like to hear about your attempts, successful or not, to share data across sectors. Our shared purpose is to strengthen how different kinds of organizations work together and use data together to improve community health. Let us know and help us learn from other exciting examples that you know about. Contact or take a survey to share your story and get connected to others in your field. Let’s keep building bridges with data.

Interested in playing a role in the emerging field of shared data across sectors? Apply for funding through the DASH program by July 29th >>

Fri, 24 Jul 2015 09:47:00 -0400 Hilary Heishman Health Data and IT <![CDATA[Three Things the United States Can Learn About Public Health From Around the World ]]>

When it comes to bridging health and health care delivery, the U.S. has an opportunity to learn from global innovations that link the public health, social services, and health care systems.

Globe Image via Joseph Li

It started with three hundred Boy Scouts from across Uganda being trained as “social monitors”. They were tasked with reporting the conditions of their communities to Uganda’s Ministry of Health through their mobile phones. In less than a year, these “U-reporters” grew to over 89,000. The U-report itself is a free SMS-based system that allows young Ugandans to share what’s happening in their communities and work with community leaders and government to affect positive change. The information gathered is disseminated through radio, TV, websites, youth events, community dialogue and other ways.

This system of real time surveillance is a vital new development for the world’s fifth-fastest growing country. Reliable health information in Uganda can mean the difference between life and death. As has been seen recently, epidemics like Ebola or West Nile thrive on information delays. Furthermore, U-reports are empowering Ugandans to share responsibility for creating healthier conditions within their communities.

The U-report is just one of the many exciting global innovations highlighted in a report by the Robert Wood Johnson Foundation (RWJF) and AcademyHealth. Written by Margo Edmunds and Ellen Albritton at AcademyHealth, the report showcases innovations that link public health, social services, and health care systems. These initiatives serve as examples of bridging otherwise disparate elements of health and health care delivery. The authors deliberately selected racially, ethnically and economically diverse regions around the world to ensure that their innovations were applicable to and reflected the diversity of the United States. A Google Hangout also convened several experts to discuss the report’s findings.  

I sat down with the RWJF's own Katie Wehr and Paul Kuehnert to gather their insights on the report. They stressed how important it is for existing and emerging health professionals to expand their perspectives by delving into the report’s examples and considering how much the United States can learn from them. RWJF is already looking at promising models and approaches from around the globe that can be adapted to our work to build a Culture of Health domestically. Our conversations brought to light three reasons why the United States must pay close attention to how our foreign counterparts are creatively addressing public health challenges in their own communities.

Although the United States spends the most on health care, our outcomes are much worse than other nations.

In 2013, the United States spent a whopping $2.9 trillion a year on health care. That’s almost $10,000 per person and more than any other nation spends. Despite a recent slowdown on health care spending due to the Affordable Care Act, the United States still outspends other countries whose citizens live longer, healthier lives than we do. We also rank behind most countries on several measures of health outcomes, quality and efficiency. A variety of  sources have supported this troubling finding. In 2013, the IOM released a report—Shorter Lives, Poorer Health—highlighting the United States’ status as one of the wealthiest but least healthy countries in the world. Compared to other peer countries, Americans die younger and suffer from more chronic illnesses, including obesity and diabetes, heart disease, lung disease and HIV/AIDS.

It takes more than health care to make a country healthy.

Elizabeth H. Bradley, director of Yale University’s Global Health Leadership Institute, and Lauren A. Taylor offered an explanation for this phenomenon in their book The American Healthcare Paradox. They note that while the United States spends a significantly higher percentage on health care services, we spend much less on education, disability and sickness benefits, family support and employment programs, unemployment benefits, and housing. In sum, it takes so much more than health care to make a country healthy.

At RWJF, Paul Kuehnert is leading efforts to address this very problem by building strong connections between health care, public health and social services—all of which have traditionally operated in siloes. Breaking down these siloes by “bridging” health with health care will help people get the services they need, when they need them. This “bridging” will also better ensure that resources are placed in systems that are not traditionally thought of as health-related but have a significant impact on health: education, housing, and transportation are some examples. Paul notes that acknowledging and addressing the array of needs people have will help them live longer, healthier lives.

To illustrate this, he recounted his career as a public health nurse in the early days of the AIDS epidemic. The stigma that HIV patients faced led many to be fired from their jobs, abandoned by their families, and ultimately homeless on the streets. Food, shelter, and safety were priorities for many before they could focus on getting medical care. Had health care and other sectors been coordinated, many may have faced better outcomes. In addition to addressing disease, Paul notes that bridging sectors helps promote health.  

To strengthen the integration of health services and systems, use the right building blocks.

No innovation or intervention is perfect. And Katie points out that the public health and health care challenges that America faces are too big for one organization to take on alone. But the examples featured in the report help encourage fresh new thinking on how to use public health innovations to tackle health challenges within communities in the United States.

Katie shared a great analogy for how to think about these issues. “When you build a house, you don’t start by putting the walls up. You start by ensuring you have a sturdy foundation in place”, she notes. “This analogy can be applied when thinking about building a strong foundation that integrates health services and systems. The foundation’s building blocks will look different depending on the needs, assets and histories within a given community. The report helps us consider how using the correct building blocks can help communities respond to emergencies, assure access to quality of care, and provide support to ensure that the healthy choice is the easy choice”.

Thu, 23 Jul 2015 10:45:00 -0400 Najaf Ahmad Public and Community Health Health Care Quality <![CDATA[Success Starts Early: What We Can Learn From a 5-Year-Old's Social Skills]]>

Groundbreaking research from a 20-year study has found that the social skills a child exhibits in kindergarten are linked to their health outcomes in early adulthood.

RWJF Culture Of Health Prize - Taos, NM

As I was thinking about writing this blog, I did what I typically do when I need some insight—I asked my kids for help. I asked my 7-year-old son what he thought about sharing. He said, “Sharing is the nice thing to do. You should share your things with your little brother or sister.”

“Why?” I asked.

“Because it makes you feel good and they might just share back with you too.”

So simple, right? And so hard to teach at times!

As a busy working mom of two young children, my days are filled with helping my kids learn how to get along in the world. From learning to feed and dress themselves, to learning how to get along with others and how to recognize and deal positively with their emotions. It’s a job I wouldn’t trade for the world! And it is also one that can be daunting at times, requiring the utmost patience and perseverance. Some days I wonder if I am doing all I can to help them grow up healthy and I know many parents feel the same way.

The good news is that today, more than ever, we have incredible insight into what parents, caregivers, and teachers can do to ensure that children grow up healthy. We now know that what was once thought of as “nice” skills to have, like being a good sharer and empathetic, are actually critical to life long health, happiness, and success.

In a newly released study in the American Journal of Public Health, funded by the Robert Wood Johnson Foundation, researchers found that the social skills a child exhibits in kindergarten were linked to their outcomes—both positive and negative—two decades later in early adulthood.

A kindergartener with strong social/emotional skills is 4 times more likely to graduate from college.

Researchers from Duke and Penn State University tracked what happened to nearly 800 kindergarten students from four different locations after those students were evaluated on their social competence skills by their teachers at the age of five. For each child, teachers recorded answers to eight simple questions, such as: Did they share with other students? Were they helpful to the teacher? Did they cooperate or follow directions? These questions then formed the basis of an overall score for each child that represented his or her overall level of positive social skills and  behavior.

Using everything from official records to reports from parents and self-reporting from the participants themselves, the researchers then noted the positive and negative milestones of each student for the next 20 years. The results were dramatic.

Students with lower social competency in kindergarten were also more likely to drop out of high school, abuse drugs and alcohol, or face challenges finding employment. Those students found to have strong social competency skills, on the other hand, were more likely to obtain higher education, full time jobs, and overall good health and success.

These weren’t just small differences either. For every one-point increase in a child’s social competence score in kindergarten, he/she was twice as likely to attain a college degree.  For every one-point decrease in a child’s score, he/she had a 67% higher chance of being arrested by early adulthood. For more findings like these check out the full report.  

While these results are striking, they build upon growing body of research showing there is a strong link between early childhood development and long-range outcomes of youth. We know that the vocabulary our children hear early on will impact how well they can read by third grade. We know whether a child has access to enriching summer experiences can influence whether he/she stays in school and graduates. And we know that exposure to traumatic and stressful events like violence make it more likely children will have health problems as adults.

Now we also know that the social skills a child has or lacks at an early age can help us forecast the success and health of that child later on. If an easy-to-use, simple assessment can tell us what children may be headed in the wrong direction, why aren’t we using those assessments to target interventions that support these children before it’s too late?

Though many social and emotional developmental programs have a proven track record of building social competence, they unfortunately are not yet in widespread use. We need to provide more families and schools access to these beneficial resources, especially during a child’s early years—the peak time for absorbing new information.

All parents know that the joy and love of raising a child is also accompanied by worry. We worry about everything from health to safety to development and education. That worry is often linked to the nagging question in the back of our minds: Am I preparing or helping my child enough to succeed?

Luckily, it isn’t too late. Research also shows us social and emotional skills can be taught and learned. Even more than that, intervening early not only helps ensure more children have a chance at a successful future, but will potentially save our country significant dollars from the reduced costs of incarceration, government assistance and drug treatment programs.

Here at the Robert Wood Johnson Foundation, we are committed to building a Culture of Health in America, especially for children and families. This research now tells us just how important social and emotional development is to ensuring all our children grow up to be healthy, happy, and successful. It’s time for us to focus on supporting families so that we all can provide children with a strong foundation for social and emotional development from the start.

In the meantime, my younger son, who is 4, just ran off with his older brother’s Legos! Time to intervene—my work isn’t done yet!

Learn more about how children's social competence impacts their well-being in adulthood by reading the latest report >

Thu, 16 Jul 2015 16:05:00 -0400 Kristin Schubert Early Childhood Development <![CDATA[Using Social Data to Build Our Evidence Base]]>

Social media offers an exciting opportunity to innovate in health research—but the social data sandbox could use more players to conduct research, share datasets, and generate ideas about what we should be studying.


What do our tweets reveal about our health? What can we learn from Twitter about the health of those in our community? Can analysis of Twitter activity help predict an epidemic like the flu weeks before a community is inundated with cases?

Nicholas Christakis, director of the Human Nature Lab at Yale University and Thomas Keegan, Deputy Director of the Yale Institute for Network Science are conducting pilot studies in San Francisco and Boston to explore these questions and more. With funding from RWJF, Christakis’s lab uses Twitter posts that include mention of flu symptoms to map how the virus spreads outward from individuals to family, friends, and others in their social networks. This mapping method, which identifies central “influential” individuals, offers the possibility of early detection of the flu and therefore early intervention to prevent its spread. In addition to giving health officials and medical personnel a valuable head-start in responding to and preventing the spread of contagious illness, this kind of insight could also help people make decisions about their own behavior, including getting flu vaccines and being more diligent about hand washing.

Christakis’s and Keegen’s work on influenza is a great example of how investigators are increasingly wielding research tools and methodologies that can extract valuable health-related insights from the expanding sea of digital information. Other innovators we have supported and/or admired such as James Fowler, Dev Roy, Daniel Zoughbie, Tom Valente, John Brownstein, Raina Merchant, Damon Centola, are also doing cutting-edge work to advance our ability to derive important health insights from social media data. Others experimenting in this realm include those who consider themselves part of the “quantified self” movement by seeking to derive insights from their own personal data, as well as those applying predictive analytics to datasets that contain millions of records. Because they are frontrunners in an emerging field, these pioneers have had to create datasets and develop novel tools and methods to generate results. In some cases, that has meant adopting the high tech tools from fields outside of clinical or behavioral health science such as agile software development and machine learning.

Our focus on the analyses of social networks and digital information has been evolving for several years now. We have supported research on how offline social networks contribute to obesity and other health outcomes, and explored how personal health data can be used in the clinic, and for understanding public health issues. These methods have shown promise; now we are interested in applying them directly to the challenges and opportunities of building a Culture of Health—including making health a shared value and engaging with a broad array of partners.

Here are some current examples of some cutting-edge work we have already funded in this emerging area of research:

  • The Health Data Exploration (HDE) network seeks to bring together companies making wearable devices and smartphone apps that collect and store personal health data (Think FitBit, Jawbone and RunKeeper) with researchers interested in mining their data for patterns and trends. We expect that personal health data can reveal the ways that everyday activities promote health or lead to disease, and can yield insights about the long-term, cumulative health effects of environment and lifestyle. The HDE Network is undertaking multiple projects that seek to leverage this anonymous and aggregated personal health data in ways that will ultimately transform our understanding of individual and population health.
  • The Atlas of Caregiving Pilot is a yearlong research project exploring the individual challenges and experiences of family caregivers. The project combines traditional research methods, such as surveys and caregiver interviews, while also employing wearable technologies to capture and track detailed information in the home. The data collected from the wearable devices will enrich our understanding of the daily routines and experiences of family caregivers, helping us understand what causes the most stress for caregivers, which caregiving duties come naturally to some but not to others, and what kind of supports would be most useful. With a better understanding of family caregiving in the United States we can develop technologies, services, and policies that improve this experience for all involved.
  • Genetic Alliance’s Platform for Engaging Everyone Responsibly (PEER) is a digital tool that enables individuals to share their health information with researchers and each other on their own terms, advancing the understanding of health and disease. Using PEER, people are able to set their own data sharing, privacy, and access preferences. With support from RWJF, Genetic Alliance is creating a so-called “white label” version of PEER that will allow disease advocacy and community organizations to customize and use the platform with their own members, developing condition-specific disease registries and surveys that can help accelerate research.

Leaders are emerging in this field, but the social data sandbox could use more players, including those interested in doing the research, those with interesting datasets to share, and those with ideas about what we should be studying. Some avenues for exploration include such questions as: How can social media help us identify other kinds of contagion? How might we uncover novel health fixes, including strategies people use to sleep more? Eat better? Get more exercise? How are attitudes about healthy communities changing? How can we detect progress in social determinants of health such as poverty, housing, and transportation?

In the end, we recognize that tackling some of America’s most complex health and policy issues will require investing in the most advanced research tools and evaluation methods—including those that are emerging and unfamiliar. We urge researchers, individuals, and companies to consider joining forces with the Health Data Exploration network to share emerging, innovative ideas for using social media and other digital information to build an evidence base for our Culture of Health strategy. Visit our website to hear about programs and new funding opportunities like our Evidence for Action program and stay connected with us on twitter. It is through knowledge sharing and partnerships that we can accelerate the discovery of powerful solutions to the nation’s biggest health challenges.

Are you using novel approaches to measuring health determinants and outcomes? Apply for funding through our Evidence for Action program today >>


Thu, 16 Jul 2015 14:22:00 -0400 Alonzo L. Plough Health Data and IT Disease Prevention and Health Promotion <![CDATA[Community Development For and By the Community]]>

Many families face rising rents they can’t afford. One local developer revamped an aging historic hotel into affordable housing to transform: "community development being done TO us.. to development done BY us."

Boyle Hotel before and after renovations. Before: The Boyle Hotel in disrepair. After: The Boyle Hotel-Cummings Block Apartments bring 51 new apartments to the neighborhood, all priced for people making between 30 to 50 percent of the area’s median income.

Ten years ago, Los Angeles’ Boyle Hotel was more than down on its luck. The grand old Victorian dame, built in 1889 by an Austrian immigrant and his Mexican wife, was uninhabitable. Over the years neglect had turned the stunning building with intricate period details into a ramshackle apartment house with shared bathrooms and communal kitchens. The wiring was faulty and the pipes leaked. Mold bloomed up walls. Rats scurried along the hallways. Absentee landlords racked up housing code violations, ignoring the residents’ repeated requests for basic protections of their safety and health.

Most of the tenants were older, single men: many of them mariachi musicians scraping by from gig to gig. They’d spend their weekends across the street in the plaza, as generations had going back to the 1930s, exchanging news and waiting for word of a quinceñeara or wedding where they might play. The musicians were a cultural anchor for the neighborhood, so much so that the residence was nicknamed the Mariachi Hotel.

The hotel sits at the peak of a steep hill, and if you look just beyond it you can see the full glory of downtown LA glinting in the sun. Maria Cabildo, Co-Founder and President Emeritus of the East LA Community Corporation (ELACC) and current Chief of Staff to the LA County Supervisor, saw the writing on the wall: The Boyle Hotel was bound to be snapped up by developers, and replaced by luxury rooms with a view if nobody attempted to save it. With plans for the LA Metro to extend its new light rail into the heart of the plaza, she knew that new development wouldn’t be far behind. What would the influx of business mean for the residents – mariachi musicians and families alike – who’d long called the neighborhood home?

Boyle Hotel in Disrepair The Boyle Hotel's absentee landlords racked up housing code violations, ignoring the residents’ repeated requests for basic protections of their safety and health.

With the cost of living in the city skyrocketing, many area families already faced rising rents they couldn’t afford, or they were on lengthy wait lists for subsidized housing. Cabildo grew up in the community and did not want it to face the same fate as so many other LA neighborhoods that lost long-standing residents due to high-end development.

ELACC works in the Eastside communities of Los Angeles, connecting families – especially those struggling to make ends meet – with opportunity. Opportunity for safe, healthy housing they can afford, opportunities to build equity, and to own their own homes.

When the chance came to buy the Boyle back in 2006, they jumped.

As ELACC President Isela Gracian looks back on it, “The place was a disaster. The tenants were suspicious – all they knew were the slumlords who’d ignored them for years.”

The street corning of the Boyle Hotel-Cumming Block Apartments ELACC renovated the Boyle Hotel into an affordable housing project driven by the community's input.

Gracian’s group knew they had to start by listening to members of the community. They needed to bring the community together to talk about what they hoped for the property, themselves, and their entire East LA neighborhood.

The night of the first community meeting, ELACC staff talked with nervous tenants about their immediate concerns: how they would get financial and logistical help for their move and housing during the renovation. They talked with neighbors about the phases of the new development, slated to bring 51 new apartments to the neighborhood, all priced for people making between 30 to 50 percent of the area’s median income. They talked about bringing the Boyle back to its former glory, restoring a point of pride and helping to preserve the community for the community.

“We went from community development being done to us, to development done with us and now to development done by us,” said Cabildo.

ELACC kept the conversations going, through a process they call community-driven development. They hired an organizer to engage residents in decision-making and to get community feedback throughout the renovation. They wove together funding to make sure they could keep rents low. They made arrangements for a mariachi cultural center to take up residence in the building's community space downstairs, so that the community's music and history would always have a home at the Boyle Hotel.

In 2012, the Boyle Hotel-Cummings Block Apartments opened its doors to people from all walks of life, including some of the musicians who’d lived in it years before. I had the chance to visit this project last year as part of the PLACES Fellowship with the Funders’ Network for Smart Growth and Livable Communities. Throughout our visit we heard the message loud and clear that equitable development has to have community members taking hold of the process. And this is an example where this approach came to life. It was really empowering to hear.

Mariachi Plaza in Los Angeles, California. Mariachi Plaza has many traditional stores and community-led resources like a non-profit bookstore and lending library.

The new building sits across the street from Mariachi Plaza, where residents enjoy a family-run ice cream store and a bookstore and lending library that mostly features books in Spanish. The apartments are part of a neighborhood that feels like home. And now that building is not only livable but also desirable – it’s become a place where parents want to raise their children.

Murals at the Mariachi Plaza. Murals in Mariachi Plaza

One of those families is Estrella Palomera* and her four kids. Not long ago, they settled into a new, three-bedroom apartment. Up until then, the family had been constantly moving – sleeping in garages, counting on neighbors turning a blind eye. At night, Ms. Palomera would assemble makeshift beds for the kids out of blankets on the floor. The kids woke up smelling faintly of oil and fumes.

Today, the Palomeras live across from the Plaza, with its murals of guitar-playing angels and red-cheeked dancers. Most weekends, the old men are out singing their sweet, sad songs.  Some days, the kids will catch sight of them dressed in their mariachi best – boots shined, pants creased, guitars gleaming – on their way to a gig. At bedtime, Ms. Palomera tucks the kids in, the youngest of whom had never slept in a real bed before moving into their new place.

Money is still tight, and life isn’t easy. But inside the apartment they’ve found respite. They’re safe and sound, which means tomorrow she can go off to work and they can go to school and not be so worried all the time. For the five members of the Palomera family, there are suddenly a thousand new meanings for this single word: home.

* By request, names have been changed to protect privacy.




Jasmine Hall Ratliff / RWJF

Jasmine Hall Ratliff, is a program officer, for the Robert Wood Johnson Foundation managing projects that create access to healthier foods in underserved communities and connecting community development and health. Read her full bio.

Mon, 13 Jul 2015 12:37:00 -0400 Jasmine Hall Ratliff Built Environment and Health Latino or Hispanic California (CA) P Community Development Community Health <![CDATA[What’s Law Got to Do With It? How Medical-Legal Partnerships Reduce Barriers to Health]]>

Civil legal aid agencies are a proven resource for clinics to support patient needs and achieve health equity by addressing the social barriers to health.

Medical-legal partnerships Dr. Alicia Turlington consults with attorney Randy Compton at the Medical-Legal Partnership for Children at Kokua Kahili Valley health center. (Image via Joseph Esser)

A lawyer as part of the health care team? It's not as strange as it sounds. Many of the social conditions that impede health, such as housing, education, employment, food and insurance, can be traced to laws unfairly applied or under-enforced, often leading to the improper denial of services and benefits designed to help vulnerable people.  

There are eight thousand civil legal aid lawyers in the U.S., and much of their work is directly related to improving health. They ensure access to food, health benefits and insurance for their clients. By fighting for better housing conditions and preventing evictions, they help create healthier physical environments. They help keep families safe and stable by establishing guardianships.

There is evidence that lawyers are more critical than ever to the health of vulnerable people. Each year the Department of Veterans Affairs surveys homeless veterans; the most recent CHALENG survey found that six of the top 10 barriers to housing were legal in nature. And a recent study at Lancaster General Hospital found that each of the hospital's highest-need, highest-cost patients had two to three health-harming civil legal problems.

To address these issues, health care institutions are increasingly forming medical-legal partnerships (MLP) with civil legal aid agencies, where lawyers work on-site at clinics to help screen for and treat patients’ social problems. Lancaster General introduced an attorney into its care team for high-need, high-cost patients. The lawyer helps identify legal problems, supports and extends the work of the case management team, and represents patients with housing, insurance, disability, safety, and employment-related legal needs. Once legal problems were resolved, hospital admissions for these patients dropped dramatically, and costs fell 45 percent per patient.

There are now 273 hospitals and health centers in 36 states partnering with civil legal aid agencies and law schools to screen for and remedy the social barriers that affect the health of vulnerable people. And in April, more than 400 doctors, nurses, social workers, lawyers and public health professionals gathered for the 10th annual MLP Summit to discuss the next frontier for these cross-sector partnerships. The vision: moving from one-on-one interventions to detecting and addressing systemic inefficiencies in clinics and public policies that impact population health.

For example, at Cincinnati Children’s Hospital Medical Center three patients were being threatened with eviction for asking their landlords to improve substandard housing conditions. Doctors there sent the patients to an on-site attorney from Legal Aid Society of Greater Cincinnati. The lawyer discovered that all three lived in buildings owned by the same landlord. By sharing data about asthma admissions and housing code violations, they were able to “hotspot” substandard housing clusters, and together helped get 19 buildings rehabbed and under new management. The reconditioned buildings did not just help those three families; they stocked the healthy housing pharmacy for more people in the community.

Cross sector partnerships like these have the potential to help professionals create health equity, and a build a Culture of Health in which everyone has the opportunity to attain his or her full health potential, and where no one is disadvantaged by social conditions.

Wed, 8 Jul 2015 16:59:00 -0400 Ellen Lawton Social Determinants of Health <![CDATA[A New World of Healthy Design–That You Wear]]>

Wearable technologies have the power to make communicating with health care providers seamless and easy—opening up a new frontier for data tracking and treatment.

Google glass Image via Giuseppe Costantino

Gary Wellman is living the dream. Every morning, he is treated to the nearly cloudless sky that frames Arizona’s nearby Santa Rita Mountains. A retired basketball coach, 72-year-old Wellman happily shares that he “lives on a golf course in Green Valley,” and likes to keep busy. “You can’t sit around when you have arthritis and diabetes like I do.”

About a year ago, Wellman hopped out of his golf cart, stood up to reach for his clubs and found himself on the ground. He suffered from numbness in his feet, a common symptom of diabetes. After that day, Wellman says, “I began to fall a lot on the course. My doctors did all kinds of tests and came up with nothing.”

That is until Wellman’s physician suggested he participate in an experimental treatment for loss of balance conducted in the lab of Bijan Najafi, PhD, a surgeon and director of the Interdisciplinary Consortium on Advanced Motion Performance at the University of Arizona.

Health in Motion

Najafi is one of a growing number of health experts tapping the potential of, an emerging group of objects, often-wearable, that are internet-enabled to track and protect health. All of these “smart” gadgets could eventually become part of what some are calling the “Internet of Things” – a vast network of objects that seamlessly gather data and talk to each other.

We’re heading towards a day when a barely detectable system of sensors could make communicating with health care providers easy, or even let our bodies do the communicating for us. Ideally these objects will help trigger healthy decisions and inform healthy choices.

To give Wellman back his balance and mobility, Najafi’s team attached biosensors to his midsection, hips, knees, and ankles, then linked them all to a computer. During a series of workouts, Wellman would dance what he called his hula. “I moved my hips in sort of a circle. When I reached the proper position, a colored dot would appear at certain points along a grid on the computer screen.”  Ever the sportsman, Wellman worked hard to raise his skill level. “I got really proficient by the end,” he says.

Wellman is now back on the golf course and steady on his feet. “When I start to lose my balance, I can correct it with a hip motion before I fall,” he says.

Naiafi’s achievements were heralded at the recent 2015 American Institute of Architects (AIA) Design and Health Research Consortium, convened by the Robert Wood Johnson Foundation. The AIA consortium supports revolutionary, university-led research in design and health – and that’s where personal devices come in.

The balance-enhancing treatment is designed to help diabetics, cancer patients, and the frail elderly by guiding them through exercises that they might otherwise avoid because of the fear of falling.

“We created a game-based exercise using foot, ankle, and body movements,” says Najafi, who is working on a home version. The game retrains the brain by proving real-time feedback, or provides a workout with safe activities that can be challenging and engaging.

Smart sox

Najafi is also perfecting smart sox—stockings with biosensors that give physicians real-time data on the existence or progress of inflammation—a precursor to foot ulcers—in people with diabetes. “These patients may not feel any pain as the ulcers develop,” says Najafi, noting that the annual tab in the U.S. for foot-ulcer care is between $9 billion and $13 billion. Smart sox have the potential to prevent ulcers by showing doctor and patient where to relieve pressure before the ulcer occurs.

Beyond Fitbit

Najafi’s game-based exercises, smartsox, and other devices are being tested by health design engineers in labs cross the country. They may seem similar to the latest apps and wearable technology flooding the market, but there is one critical difference—clinical accuracy.

Many of these devices are also unique in that they can gather information without the need for the wearer’s intervention. “Research shows that after a few days, 40 percent of users no longer pay attention to health apps,” says Thomas Fisher, dean of Minnesota’s college of design.

One project, by the Center for Connected Health at Partners Healthcare and funded by RWJF, aims to change this statistic. The Center is developing an interactive “engagement engine” that will help consumers select and use trackers to develop and stick to physical activity plans. Other researchers are thinking about how to reach kids by leveraging the digital gadgets they already use, but for health.

Fisher says a potential benefit of these wearable devices and trackers is to, “help people to remain ambulatory and independent, and give health care providers the information needed to improve care and prevent illness.” His department recently won a silver medal from NASA for applications that will help protect the health of astronauts.

In the Wearable Technology Lab at the University of Minnesota , director Lucy Dunne, PhD, focuses on clothing that transmits data as the wearer moves. To test her most recent design, Crystal Compton, a design student, slipped into a comfortable black top that looks like regular fitness wear. “As I bend halfway down, elongating my spine and bringing my shoulders forward, conductive threads woven into the shirt send data on body position to a computer,” Compton explains. The shirt may be used for many things, but the current goal is to measure the movement and shape of the spine during scoliosis treatment.

Decoding Stress

Devices with sensors can do more than capture movement – they can reflect back to us how we feel. Imagine a device that could accurately report your body’s stress response at the molecular level or alert you the moment your immune system is under attack. Precisely measuring these clues to how people fare in certain environments and situations through biosensors is the work of Esther Sternberg, MD, research director at the University of Arizona Center for Integrative Medicine, one of 11 centers selected as founding members of the AIA research consortium.

Immune system proteins “can be measured through perspiration,” Sternberg says. “Our goal is to eventually measure them in real time as well as indicators of inflammation.” In her research, Sternberg and her team found that levels of specific molecules correlated with symptoms of anxiety, stress, and depression.

Dunne also has one more accomplishment in mind—saving lives. One of her latest projects is a glove designed specifically for firefighters. They look like regular industrial work gloves, but they will give the bravest a power reserved for superheroes—the ability to detect the presence or absence of objects in the dark. The sensors in the gloves will prevent them from tripping in smoke-darkened rooms, falling through holes often created as buildings give way to flames. “Linking body, environment, and technology to help people is where we are headed,” Fisher says. “The Internet of Things is moving quickly through huge advances.”

The Internet of Things is taking us towards a day when a barely detectable system of sensors could make communicating with health care providers seamless and easy—perhaps letting our bodies do the communicating for us.

Here’s a look at some of other developments in the evolution of digital health from RWJF grantees:

  • The Health Data Exploration Project  is looking at ways to use “personal health data for public good.” There has been an explosion in the amount of personal health data collected through apps, wearable self-trackers and other “Internet of Things”-type technologies. Taken together, this personal health data could provide new insights in the health of the population, and guide decisions about how to improve public health.
  • Agile Science is exploring a new way to conduct faster, more adaptable research that can help us more quickly understand how tools and technologies can help create healthier behaviors, such as getting more sleep or exercising more.
  • The Atlas of Caregiving recognizes that caring for a family member’s health is hard work, and can have health consequences for the caregivers. To come up with better ways to support caregivers, investigators will deploy wearable technologies to learn about the day-to-day lives of caregivers across different situations. The information will be used to help shape technology development, service delivery, and policy development.
Mon, 6 Jul 2015 10:32:00 -0400 Sheree Crute Health Data and IT <![CDATA[How Can We Measure High Value Care? Consider the Patient Point of View]]>

Health care is centered around human relationships, which is why it's so important the voices of the people the system is designed to help—patients and their families—are heard by those defining and measuring care.  

Summer has come at last! Along with all the usual endings and beginnings that come with this time of year, there’s an important new opportunity for those of us who are passionate about improving health care. The Medicare Access and CHIP Reauthorization Act of 2015 threw out Medicare’s old rules for paying physicians and substituted a new system, one that’s  supposed to reward physicians for delivering high quality, high value care. This is a game-changer many years in the making, but as with any complex new law, the details matter. How will Medicare define and measure high quality, high value care? We can get some hints from CMS’ new strategic vision for physician quality reporting.

If I were granted just one wish by the people who are going to define and measure high value care, I know what I’d say: listen to our voices, the voices of patients and families, the ultimate health care consumers. Listening to patient voices and providing care that is patient-centered can improve clinical outcomes, reduce “waste” in health care by reducing unnecessary testing, and increase the overall care experience for both patients and providers. Health care is centered around human interactions and relationships—it is critically important that those defining and measuring care truly hear the voices of the people the system is designed to help—patients and their families.

I’m not alone in this wish, but it’s easy to get lost in the technical details of how to get patient point of view through the survey methodologies, the sampling frames, and data sources. The next time measurement experts need some inspiration, here’s where they should turn: to the people who live in communities who were part of the Foundation’s Aligning Forces for Quality program, RWJF’s ten-year effort to lift the quality and equality of care in 16 targeted communities. Aligning Forces for Quality communities were the earliest pioneers in measuring and making public information on the quality and costs of health care, and in beginning to tie those outcomes to how much providers are paid.

If you’re in need of inspiration, visit our website and sample one of the talks that spotlights how the voices of patients are transforming the health care system, and how much remains to be done.

Listen to Nate Hunkins in the video above. Nate brought me to tears with his bravery. He let his care team know when they let him down by failing to support him after a serious accident. "Patients like me who go through a dramatic and life altering event deserve more mental and emotional support from their doctors,” he said.  Nate’s story ends on a high note, however, stating,  “Having the courage to give feedback combined with a provider’s willingness to listen and act can result in a higher quality of care.”

Or listen to Moe Rustom, who saw first hand the devastation that occurs when the health care system can’t talk to patients in their own language. One pill a day for seven days? Or seven pills on one day? The results meant life or death.

Or Al Whitaker, who joined others in his community to help prevent and manage diabetes, and whose personal journey took him from fear and ignorance about his illness to celebrating healthy living.

Or Paula Jacobs, whose expertise in health disparities gets her thinking about the years of healthy, happy living her husband has enjoyed since undergoing cancer treatment ten years ago.  Paula knows that the story could have turned out differently had her husband been Black; the odds would not have been in his favor.

These stories, and others, remind us how important it to listen to the voices of patients, no matter how daunting the technical details may be. Now, let’s get to work.


Anne F. Weiss, a director for the Robert Wood Johnson Foundation, leads efforts to achieve the highest possible value from our nation’s investments in improving health and health care. Read her full bio.

Mon, 29 Jun 2015 16:43:00 -0400 Anne Weiss Patient-Centered Care Health Care Quality <![CDATA[Crafting Win-Win Solutions with Health Impact Assessments]]>

Health impact assessments are a powerful way to help communities think broadly about the health implications and equity aspects of policies and projects, so that a comprehensive approach to health becomes routine.

Prison Alternatives Boosted by Health Impact Assessment

Last week, almost 500 attendees arrived in the nation’s capital for the 2015 National Health Impact Meeting. The impressive turnout is a testament to the growing importance of health impact assessments (HIA) as a tool to improve community health outcomes.

As this year’s meeting attendees know, an HIA is a process that helps evaluate the potential health effects of a plan, project or policy outside of the traditional health arena. The findings from a completed HIA can provide valuable recommendations to help communities more effectively foster better and more equitable health among their citizens.

The use of HIAs has grown rapidly from just a few dozen in 2000 to more than 350 completed HIAs today. Dozens more are in the works. The earliest HIAs were mostly applied to the built environment, such as zoning, land use and transportation decisions. However, today the field has expanded to include such areas as energy policies, criminal justice and living wages.

The significant growth is due in no small part to the creation of the Health Impact Project. A collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts, the Health Impact Project is designed to promote the use of HIAs by providing financial, technical and intellectual support. HIAs supported by the Health Impact Project have focused on issue areas including transportation, housing, energy, and even casinos and gaming.

The Robert Wood Johnson Foundation has invested in the Health Impact Project because HIAs are a powerful way to engage a diverse cross-sector of a community in the effort to improve health.

Two videos released by the Health Impact Project showcase HIAs that are receiving recognition at this year’s national meeting. An HIA in Wisconsin (featured in the video above) assessed the potential health impacts of increasing the state’s funding for the Treatment Alternatives and Diversion Fund. This fund provides money to specialty treatment courts and criminal justice diversion programs. As a result of the HIA, advocates won bipartisan support to quadruple the budget. With increased funding, the number of treatment alternative programs jumped from seven to 34, supporting treatment for 3,100 people from 2007 to 2013.

The second video (below) profiles efforts in southern Oregon, where an HIA examined the potential health impacts that upgraded housing could have on the health of residents. Following the HIA’s release, the housing developer used those findings to apply for, and secure, a grant to replace 25 aging and insufficient homes.

Health Impact Assessment Helps Families Replace Unsafe Manufactured Housing

This year’s National Health Impact Meeting built upon successful projects like these by moving beyond a simple discussion of “how to” execute an HIA. Instead, the meeting is taking a broader look at the impact of HIAs, beginning with a session on the opportunity to advance equity in HIA practice. Other plenary sessions included discussions around embedding equity and health into government processes, community organizing and HIAs, and the future trajectory of the field.

Another key session focused on HIAs that have actually resulted in reduced health disparities. One such HIA was led by a faith-based group in the Twin Cities and examined the impact of a light rail project that was initially planned to run through—but not serve—low-income neighborhoods. The HIA looked at the implications of the project, including potential zoning changes, and the possibility of increased gentrification leading to the displacement of long-time residents. As a result of the HIA, at least two new affordable housing policies were submitted to the City Council for review. In short, what started out as a simple transit plan grew into a comprehensive strategy to protect a community and foster positive second- and third-degree outcomes.

Ultimately, HIAs are designed to do just that: to help communities think broadly about the health implications and the equity aspects of policies and projects so that a comprehensive approach to health becomes routine. By providing a framework, HIAs can show the multi-sectoral impacts of decisions, and help community leaders to craft win-win solutions that benefit all sectors involved, while improving health outcomes across a community.

Mon, 22 Jun 2015 15:01:00 -0400 Pamela Russo Public and Community Health Built Environment and Health <![CDATA[New Report: Shifts in the Supermarket Aisles as Demand for Low-Calorie Options Grows]]>

Research shows that supermarkets are responding to the growing demand for lower-calorie options, and that healthier options are good for their bottom line.

Supermarket aisle of juice packs and juice boxes.

At a very basic level, obesity is about an imbalance. Calories in and calories out need to be balanced, and if they’re not, we run the risk of gaining unhealthy weight. Now, that sounds simple, but of course we know it’s not. There’s so much that goes into the choices people, particularly children, are able to make about what they eat and drink and how much they move. The neighborhoods we live in―and where we buy foods and beverages―play an enormous role.

U.S. customers spend over $638 billion in supermarkets every year, so these stores have a major impact on what we all eat and drink every day. A recent report shows that, in keeping with recent changes to consumer demand, supermarkets are increasing their sales of lower-calorie items, and seeing financial benefits because of it.

Between 2009 and 2013, lower-calorie foods and beverages drove the bulk of supermarket sales growth, 59 percent, compared with just 41 percent for higher-calorie items. They also made up 58 percent of total supermarket sales.

This is great news, as it shows supermarkets are responding to the growing demand for lower-calorie options, and that their business performance is benefitting as a result.

But the report also shows supermarkets are not making as much progress when it comes to the foods and beverages that contribute the most calories to the diets of children and teens. Among these items, things like desserts, pizza, snacks, and beverages, higher-calorie items made up 70 percent of sales―lower-calorie ones, just 30 percent.

As Hank Cardello, the lead author, put it, “retailers and manufacturers need to place greater focus on lower-calorie versions of products.” And not just because it will be better for kids’ health. The research shows that if supermarkets grow their sales of lower-calorie items it will be better for their business too.

Cardello makes a few recommendations for how supermarkets might go about doing just that: give lower-calorie items more prominent shelf placement, highlight them on in-store ads and displays, and sell more of them in check-out lanes.

These recommendations mesh well with recommendations on responsible food marketing that Healthy Eating Research published earlier this year. The recommendations point to the need to better define what constitutes food marketing to children and provides examples of ways retailers can promote healthier foods. For example, the authors suggested displaying healthier items at kids’ eye levels, and as part of store display ads or checkout lines. 

So similar strategies can be used both to help kids make healthier choices, and to provide a boost to supermarket sales. That seems like the definition of a win-win effort. As supermarkets make these shifts, they also need to sell more items that are not just lower-calorie, but are also healthy and nutritious. Ensuring that all children are able to grow up at a healthy weight will require making healthy foods and beverages the affordable, available, and desired choice in all stores. Supermarkets must play a leading role in that effort.

Victoria Brown, is a senior program officer, working to engage business around health for the Robert Wood Johnson Foundation. Read her full bio.

Tue, 16 Jun 2015 10:50:00 -0400 Victoria Brown Childhood Obesity <![CDATA[Making the Grade: An Assessment of the Healthy Weight Commitment]]>

Members of the food and beverage industry are taking steps to ensure that their investments towards the Healthy Weight Commitment are making a difference.

A mother and her daughter pushing full shopping carts outside a supermarket.

The food and beverage industries aren’t typically viewed as leaders in the movement to address the obesity crisis and alleviate food insecurity in the United States.

For that reason, the work of a consortium of 16 major food and beverage manufacturers and distributors is particularly interesting. The Healthy Weight Commitment Foundation (HWCF)—which includes such heavy-hitters as General Mills Inc, Kraft Foods Inc, and Nestle USA—is pioneering an innovative way to assess members’ philanthropic programs that target healthful eating and active living, to see just how much impact they’re having. The companies are trying to ensure that their investments--anything from support for local food banks to sponsorship of a 10k race promoting children growing up at a healthy weight-- really make a difference.

The ambitious effort involves a public-private partnership called Commitment to Healthy Communities (CHC) that teams the HWCF with the City University of New York School of Public Health. Using a specially designed framework, CUNY researchers will spend this summer evaluating which practices do and don’t work, on the program, company, and community levels.

Ultimately, researchers will provide each company with a confidential, in-depth report card examining its programs, and a higher-level evaluation of the other consortium members with aggregated industry-level metrics, qualitative results, and anecdotal case studies for illustration. Those data will allow organizations not only to make improvements, but also to share best practices and other information with fellow consortia members. The result should be a smarter and more effective investment in programs aimed at encouraging healthful eating and active living. Eventually, the findings will be shared with a larger audience, and become a broader public resource.

This is a gutsy move. For one thing, it requires that these companies share information with competitors. And it means opening themselves up through a transparent, honest assessment of their programs’ success—or lack thereof.

Most important, CHC demonstrates an important lesson: Building a Culture of Health requires the participation of multiple sectors. And what sector could be more vital than the companies that provide much of our sustenance?  A growing body of evidence shows that private industry, especially food and beverage companies, can be major contributors to building a culture in which there is access to healthy choices for all kids and their families—no matter where they live. This effort is particularly significant because it can strengthen the ability of private industry to engage in a positive, constructive way with other stakeholders, such as community organizations and public health agencies, also working to build a Culture of Health.

Some background: HWCF was founded in 2009 with a goal of reducing obesity rates, part of an agreement with the Partnership for a Healthier America, an independent organization dedicated to advancing the goals of First Lady Michelle Obama’s Let’ s Move initiative. Under the leadership of PepsiCo CEO Indra Nooyi, who is chairman of HWCF, the member companies pledged to cut the number of calories they sell to the American public by 1 trillion by 2012 and 1.5 trillion by 2015. Ultimately, a team of independent researchers, with funding from the Robert Wood Johnson Foundation, found the companies reduced calories by more than four times the amount that they had originally pledged.

This is an industry effort that deserves to be applauded.

Mon, 15 Jun 2015 10:00:00 -0400 Ginny Ehrlich Childhood Obesity Healthy Food Access <![CDATA[Mapping a Path to Longer and Healthier Lives Across Atlanta]]> The Atlanta skyline on a sunny day. Image via City Clock Magazine

Two Atlanta neighborhoods, Buckhead and Bankhead, are separated by a mere five miles. Even their names are just two small letters apart. And yet the high-end shopping mecca dubbed Buckhead boasts an average life expectancy of 84 years, while in Bankhead—a neighborhood in transition that’s home to a newly burgeoning arts community—its residents face a life expectancy that’s a full 13 years shorter.  

This map of Atlanta—one of a series from the Center for Society and Health at Virginia Commonwealth University (VCU), funded by RWJF, shows that our zip codes might be a better predictor of health than our genetic codes. Why? Because where we live affects our health and wellbeing in complex ways. Among them, according to VCU, are a scarcity of jobs and quality schools, and fewer opportunities to access healthy affordable foods and safe places to be active.

This isn’t the first time Atlantans have bore witness to to inequity in their community, and today, community leaders are drawing inspiration from their past. Here in the city that served as the capitol of the Civil Rights Movement, community leaders are responding just as previous generations once did—by bringing together a diverse coalition to advance health equity and serve as a model for communities far beyond the Peachtree State.

VCU Map shows the shortest distances between the largest gaps in health in Atlanta.

This new effort started four years ago, when a group of leaders from a number of key sectors—including hospitals, public health, local government, transportation and community development—formed the Atlanta Regional Collaborative for Health Improvement (ARCHI). Collectively dedicated to assessing the health priorities of Atlanta and crafting local investments that yield results, ARCHI partners meet regularly to discuss benchmarks, action plans, successes and road blocks in their efforts.

Karen Minyard, PhD, director of the Georgia Health Policy Center (an ARCHI member organization), says the group is searching for innovations and aligning existing good ideas in order to optimize the effectiveness of each program.

Informed by the collaborative efforts of ARCHI, the policy center recently conducted a health impact assessment (HIA) to understand how tax incentives to build affordable housing can affect both housing for vulnerable populations as well as community development. By broadly examining the impact of housing, Minyard and her colleagues discovered something that at first glance might seem counterintuitive: Educational disparities could actually be reduced by focusing on affordable housing.

In Atlanta, the Department of Community Affairs awards tax credits for affordable housing projects.

With years of data available to identify the city’s best schools, the Georgia Health Policy Center realized that by adjusting the criteria for this incentive, tax credits could be used to motivate developers to build affordable housing near the city’s strongest-performing schools. The Georgia Department of Community Affairs adopted this recommendation, and city leaders are eager to begin studying its effects.

“This HIA is at the forefront of an increasingly influential field that connects health to community development,” says Elizabeth Fuller, associate project director at the policy center.

In fact, as a community, Atlanta has been a leader in utilizing HIAs to advance health equity. Prior to aforementioned efforts of the Georgia Health Policy Center, an HIA funded by RWJF, and jointly conducted by the Center for Quality Growth and Regional Development and the Centers of Disease Control and Prevention, looked at the health impacts of the Atlanta Beltline—a 22-mile repurposed rail line now serving as a multi-use trail and park system in the heart of the city. When published in 2007, the HIA provided a diverse set of recommendations to improve health outcomes by addressing issues of physical activity, access to healthy foods and safety, among others. Two years ago, the HIA’s recommendation to establish a Beltline police force was implemented virtually word-for-word by the city.

Case studies such as the Atlanta Beltline are the types of results that the Health Impact Project—a collaboration of RWJF and The Pew Charitable Trusts—seeks to foster. Through funding opportunities, infrastructure development and networking efforts, the Project is supporting the HIA efforts of groups like ARCHI and cities like Atlanta to advance health equity in local, state and federal policies.

Finally, looking beyond the use of HIA’s, ARCHI partners are reaching across other traditional boundaries that have separated like-minded leaders in a pursuit of improved health equity. For example, Grady Health System and the United Way of Greater Atlanta recently began a partnership to reduce the volume of costly emergency room visits and improve chronic care for patients.

As health delivery specialists, Grady Health System has worked to identify people who frequently ended up in Grady emergency rooms and then provided that data to the community-focused United Way. The United Way takes that data to reach those who have been identified as heavy users of ERs. It then sends trained community health workers into Atlanta’s neighborhoods to provide these residents with home-based care and case management services.

These types of efforts and coordination could make a difference in communities across the U.S. facing the same life expectancy gaps as Atlanta. By bringing a diverse set of partners to the table, Atlanta is showing the power of collaboration to conquer longstanding challenges and to build a healthy future for all.

Wed, 10 Jun 2015 14:52:00 -0400 Dwayne Proctor Health Disparities Social Determinants of Health <![CDATA[Expanding Opportunities for Rural Communities to Get Quality Care]]>

Initiatives like the Future of Nursing and Project ECHO are expanding opportunities for more communities to get quality health care and lead healthier lives regardless of ZIP code.

Buncombe Farm Land

I read recently in The New York Times about Murlene Osburn, a cattle rancher and psychiatric nurse, who will finally be able to start seeing patients now that Nebraska has passed legislation enabling advanced practice nurses to practice without a doctor’s oversight.

Osburn earned her graduate degree to become a psychiatric nurse after becoming convinced of the need in her rural community, but she found it impossible to practice. That’s because a state law requiring advanced practice nurses to have a doctor’s approval before they performed tasks—tasks they were certified to do. The closest psychiatrist was seven hours away by car (thus the need for a psychiatric nurse), and he wanted to charge her $500 a month. She got discouraged and set aside her dream of helping her community.

I lived in Nebraska for seven years, and I know firsthand that many rural communities lack adequate health services. As a public health nurse supervisor responsible for the entire state, I regularly traveled to small, isolated communities. Some of these communities did not have a physician or dentist, let alone a psychiatric nurse. People are forced to drive long distances to attain care, and they often delay necessary medical treatment as a result—putting them at risk of becoming even sicker, with more complex medical conditions.

There is nothing more reassuring than having a skilled professional in your community who can help you when you need medical care. Recent research has demonstrated that nurse practitioners are more likely than primary care physicians to practice in rural areas, and to treat Medicaid recipients and other vulnerable populations.

That’s why the Future of Nursing: Campaign for Action, a joint initiative of the Robert Wood Johnson Foundation and AARP, is working to remove outdated statutory barriers like the one in Nebraska that prevent advanced practice nurses from practicing to the full extent of their education and training.

The good news is that, since the Campaign began, eight states have modernized their practice laws. Right now, nurse practitioners in 21 states and the District of Columbia have full practice authority; Nebraska and Maryland becoming the first two states to pass legislation this year.

When nurse practitioners can practice to the full extent of their education and training, patients, families and communities benefit. The landmark Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health, concluded after reviewing the evidence that advanced practice nurses provide effective, high-quality care to people and can safely expand access to primary and preventive care. There is no evidence that care provided in states that require advanced practice nurses to work under a doctor’s authority is better than in states where advanced practice nurses have full practice authority.

RWJF Culture Of Health Prize - Taos, New Mexico

We know that empowering nurses, physician assistants, and other clinicians to increase their skills and serve more patients is key to building a Culture of Health in every community. Another innovation that shows similar potential to transform care for rural and underserved populations  is Project ECHO, at the University of New Mexico, which maximizes sharing of best-practice medical knowledge and expertise. The ECHO approach was started to bring the best of specialty care to people in remote New Mexico communities. It links community care providers with specialist teams at university medical centers to co-manage patients who have complex, chronic conditions.

The multi-disciplinary specialist teams use low-cost, multi-point videoconferencing technology to conduct weekly virtual clinics with community providers.  During the clinics, primary care providers in multiple locations present patient cases and work with specialists to determine treatment. Specialists serve as mentors, training community providers to provide care for conditions that previously were outside their expertise, such as hepatitis C, chronic pain, rheumatoid arthritis, and HIV/AIDS. This means that specialty services are now available in communities where previously those services did not exist.

The quality of care is equal to that provided in university medical centers, as demonstrated in a New England Journal of Medicine evaluation of Project ECHO’s hepatitis C clinic. Across the United States, more university medical centers are partnering with community health centers to replicate ECHO. Global interest is mounting, too—ECHO programs currently operate in North and South America, Europe, and Asia.

Initiatives like Future of Nursing and Project ECHO are expanding opportunities for more people in more communities to get quality health care—when and where they need it—and enjoy better health, regardless of their ZIP codes. When more people have access to care, we move closer to attaining a Culture of Health.

Tue, 9 Jun 2015 16:58:00 -0400 Susan Hassmiller Health Care Access Health Care Quality <![CDATA[Building Healthier Places In Birmingham and Beyond]]>

How a section of Birmingham, Alabama is redeveloping and offering greater opportunities for people at multiple income levels. The secret? Engaging the community throughout the process.

With its elegant homes, pleasant park and bustling stores, the Woodlawn section of Birmingham, Alabama was described in a 1950 news article as “a really great section of Birmingham...typical of the fine things in life." Then came the racial unrest of the 1960s, disruption from urban renewal gone awry and white flight to Birmingham’s suburbs. Joblessness and poverty took root; the housing stock decayed. Today, median income in Woodlawn is just $21,000, less than half the level for Birmingham as a whole.

But now Woodlawn is in the midst of a turnaround, aiming to become not just a neighborhood that prospers economically, but also one where people live healthier lives.

Students sell vegetables at the Woodlawn Innovation Network Student Farmers' Market. Some of the schools in the Woodlawn Innovation Network include student-run farmers' markets. Image via Woodlawn Foundation.

Examples of this revitalization include:

  • A thriving music scene has developed and is luring start-up businesses and creative people to the neighborhood. Composer, record producer and University of Alabama at Birmingham professor Henry Panion, a frequent collaborator with musicians like Stevie Wonder, renovated a decaying building into a professional recording studio—and in an adjacent one offers music education for neighborhood children. Rock musician Jeffrey Cain helped to launch Communicating Vessels, a company that produces 7-inch vinyl records by Birmingham artists from a storefront recording studio in a part of town now dubbed Music Row.
  • A multisector partnership is working to provide Woodlawn residents with access to health services, wellness programs in schools, “more green space, walking trails, healthy food, quality retail amenities, and more,” according to the organization spearheading these efforts, the Woodlawn Foundation. Central to the vision is mixed-income housing for both poorer and better-off residents, and a redesigning the area’s five schools to focus on “cradle-to-career” STEAM education—science, technology, engineering, arts, and math—and guarantee that up to 90 percent of area kids graduate from high school with substantial preparation for college. The inspiration is the Purpose Built Communities model originally developed in Atlanta, and now spreading across the country with backing from investor and philanthropist Warren Buffett.

Small wonder that Woodlawn’s story is now featured on the Build Healthy Places Network, an effort to link the community development and health and public health sectors that is supported by the Robert Wood Johnson Foundation. Woodlawn’s experience encapsulates key lessons learned from other efforts to revitalize communities and build health equity.

First, cross-sector partnerships are critical, says Donald Schwarz, who directs RWJF’s program work catalyzing demand for healthy places and practices. Community improvement coalitions should include health care providers, public health agencies, urban and transportation planners, architects, education, banking, community development experts, community development financial institutions, and philanthropy. Such partnerships are central to so-called collective impact approaches to addressing complex social problems, such as poor education.  

Second, residents of any community undergoing revitalization must be actively engaged in decision making about plans for redevelopment. One reason is that there can be a fine line between community redevelopment that offers greater opportunities for people at multiple income levels, and outright gentrification that can displace a community’s lower-income residents or seem to exclude them from new amenities, such as revamped parks or new restaurants.

Woodlawn has chosen the former course, not the latter, and longtime residents are pleased. In a video, Arnold King, an elected representative of a Woodlawn neighborhood organization, compliments the Woodlawn Foundation for engaging the community in discussions about goals. “Instead of trying to dictate what’s going on in the neighborhood they come in and try to be a part of it,” opting to be “inclusive, instead of exclusive,” he says.

Construction at the Park at Wood Station housing development in Alabama. Construction at the Park at Wood Station housing development. Image via Woodlawn Foundation

A third lesson is that health equity will only result from more equitable opportunities, such as better education that can lead to higher incomes and more lifetime stability. “We know that if you haven’t graduated from high school, your life expectancy has gotten worse over last 20 years compared to people who have high school diplomas, whose life expectancy has improved,” Schwarz says. Thus, the focus on “cradle to career” education in Woodlawn—starting with a plan to create a new child development center for zero-to-three year olds—can be understood as a means to improve public health as much as anything else.

By expanding economic opportunity, improving education, rehabilitating housing, and emphasizing health and wellness, communities like Woodlawn seek to epitomize the “fine things in life” once again. And among the finest—“the greatest wealth,” as the ancient Roman poet Virgil wrote—is health.

Susan Dentzer

Susan Dentzer, Senior Policy Adviser at the Robert Wood Johnson Foundation, former Health Affairs Editor-in-Chief and Health Policy Analyst, The NewsHour with Jim Lehrer, is one of the nation's most respected health and health policy thought leaders and journalists. Read more of Susan’s posts.

Mon, 1 Jun 2015 11:46:00 -0400 Susan Dentzer Built Environment and Health Social Determinants of Health First Friday Google Hangouts <![CDATA[What’s the Airbnb for Health? Pioneering Ideas Podcast Episode 9]]>

The rise of the sharing economy could surface new innovations in health and health care. The latest episode of the Pioneering Ideas Podcast explores this idea and more.

RWJF Pioneering Ideas Podcast Editorial Art

Could the ideas behind Airbnb — a service that lets people share their homes with strangers — transform health and health care?

Airbnb is just one example of a company that’s emerged as part of the sharing economy (also referred to as the “collaborative” or “peer” economy), an ecosystem of companies all over the world that are fueled by collaborative consumption:

Named by TIME as one of the “10 Ideas That Will Change the World”, collaborative consumption describes the shift in consumer values from ownership to access. Together, entire communities and cities around the world are using network technologies to do more with less by renting, lending, swapping, bartering, gifting and sharing products on a scale never before possible. From Airbnb to Zipcar to Taskrabbit, collaborative consumption is transforming business, consumerism and the way we live for a more fulfilling and sustainable quality of life.” –

Rachel Botsman, an expert on the sharing economy whose TED talk on the subject has been viewed nearly a million times, recently visited the Foundation as part of our What’s Next Health series of conversations with pioneering thinkers. In an email to staff after her visit, she observed that, “to date, there has been a lack of dialogue and actionable insights on the potential to apply sharing/collaborative economy principles to different aspects of health.”

This is not to say that there aren’t examples of collaborative consumption addressing aspects of our lives that are related to health. Take the example Rachel shared with me of Landshare, a company in the United Kingdom that matches people who want to grow food with people who have the space for a garden. Imagine transforming vacant lots in some of the poorest areas of our country into places to grow fresh fruits and vegetables; the sustained effect on Americans’ health and wellbeing could be profound.

The founders of another company, Cohealo, observed that so much health care equipment sits idle for over half of its lifetime, accessible only to a finite group of professionals working in a single location. By encouraging sharing within and across facilities, Cohealo has the potential to decrease costs and waste.

Rachel joins us in the latest episode of our Pioneering Ideas podcast to explain the rise of the sharing economy and to brainstorm how new additions to the movement may help solve some of the thorniest challenges in health and health care. Could your company apply the sharing economy to the ongoing challenge of helping others lead healthier lives?  What are you willing to share to help build a culture of health in America?

Listen below or on iTunes – and, in the spirit of the episode, we hope you’ll share it, too, with anyone you know who’s passionate about building a Culture of Health.

More stories in this episode:

  • Reimagining Medical Education: Discover how emerging technologies and approaches are powering collaboration within and between medical schools;
  • Exploring Agile Science: Explore how “agile science” seeks to rapidly discover and test the most effective paths to healthy behavior change;
  • A Personal Essay on Personal Data: Learn why grantee Gary Wolf of Quantified Self believes access to our personal health data is essential to building a true Culture of Health.

After you listen, share your thoughts below, or join the conversation on Twitter at #RWJFPodcast. And if you have cutting-edge ideas to share about building a Culture of Health in this country, I hope you’ll reach out to me at @lorimelichar or consider submitting a proposal.

Be well.

Lori Melichar

Lori Melichar, a labor economist, is a director at the Robert Wood Johnson Foundation where she focuses on discovering, exploring and learning from cutting edge ideas with the potential to help create a Culture of Health. Read her full bio.

Wed, 27 May 2015 16:47:00 -0400 Lori Melichar <![CDATA[One Cure for the World’s Toughest Challenges? Bold Leaders, Connected]]>

Change leadership means thinking big about impact, responding to urgent needs, and actively tolerating risk. This is the kind of big, bold way of working—together—that will get us to a Culture of Health.

Members of the Camden Coalition make home visit to patients around Camden, NJ.

Just over a year ago, I started in a new role at the Robert Wood Johnson Foundation. Not long after, my colleagues and I began the exciting, challenging, and collaborative process of co-designing four new programs that will develop, train, and network change leaders who will help build a Culture of Health.

You may be wondering – What is change leadership? How do we know it when we see it? And, why is it essential for achieving RWJF’s vision?

>>Could your organization serve as a National Leadership Program Center? View the call for proposals.

Here's the type of challenge our nation's leaders often face:

“For a half-century, charities, nonprofits and local and federal governments have poured billions of dollars into addressing the problems plaguing [many] Americans. But each issue tends to be treated separately – as if there is no connection between a safe environment and a child’s ability to learn, or high school dropout rates and crime.” –The Wall Street Journal, September 2013

Now here's an example of what change leadership looks like:

In 1993, Thomas Cousins, CEO of Atlanta-based real estate investment trust Cousins Properties, Inc., embarked on a lofty mission – to transform the city’s East Lake Meadows public-housing project from an under-resourced, dangerous community into a safe, prosperous, and healthy one. As The Wall Street Journal reported, Cousins and his team “worked with community and city leaders on every major issue at the same time: mixed-income housing, a cradle-to-college education program, job readiness, and health and wellness opportunities.”

The results were significant: By 2013, violent crime in East Lake had gone down 90 percent, employment among families on welfare had risen from 13 percent to 70 percent, and the surrounding area had become populated by stores, restaurants, and other services. Ultimately, Cousins’ multi-sectoral, collaborative approach not only transformed the East Lake Meadows community, but also inspired the creation of Purpose Built Communities, an organization that supports similar projects across the country in order to disrupt the cycle of pervasive, intergenerational poverty.

Cousins is someone who I think embodies change leadership – a concept from the business literature that focuses on initiating large-scale change, responding to urgent needs, actively tolerating risk, and seeking inspiration through collaboration. While change leaders like Cousins may seem like one in a million, I would argue that there are thousands of leaders with the talent and potential for such impact – and that identifying, supporting, and connecting them is essential to building a Culture of Health.  

Take José A. Pagán, for example. He’s a former Fulbright Scholar, World Bank consultant, RWJF Health and Society Scholar, and health services researcher who is now director of the Center for Health Innovation at the New York Academy of Medicine (NYAM). In his current role, Pagán is engaging in change leadership work under RWJF’s initiative Data and Information Systems for Bridging Health and Health Care, where NYAM will work closely with IBM to combine expertise in urban health policy research with expertise in data analytics. Together, the two organizations will examine multiple determinants of child health in Los Angeles and Philadelphia in order to identify strategies for reducing infant mortality.

Another standout change leader, Shiriki Kumanyika, MD, is professor emeritus of epidemiology at the University of Pennsylvania, holds multiple advanced degrees in social work, nutrition, and public health, and is now the president of the American Public Health Association. In 2002, Dr. Kumanyika founded the African American Collaborative Obesity Research Network, known as AACORN. “Instead of looking at [a community] through the problem, we try to understand the people and then see where the problem or issue is situated within their lives,” Kumanyika has said of AACORN’s networked, collaborative approach. The world and its wicked problems are rapidly changing, and it will take leaders like Cousins, Pagán, Kumanyika, and others to ensure we collectively rise to the challenge.

In February 2014, RWJF announced that in order to support our new Culture of Heath vision, we had made the difficult decision to wind down 10 of our Human Capital programs. While such transitions are challenging, they also opened up a world of new possibilities, including the development of four new programs focused on change leaders from multiple sectors and backgrounds: RWJF Diversity in Health Policy Research, RWJF Interdisciplinary Research Leaders, RWJF Multi-sector Leaders for Health, and RWJF New Clinical Scholars.

As Risa Lavizzo-Mourey said in her 2015 President’s Message, our new programs will “engage sectors beyond health and health care, promote teamwork and collaboration, advance diversity and leverage technology to support robust networks and enhance mentoring.” This new paradigm will allow us to support even more scholars and leaders more efficiently, connect people across sectors and disciplines, and capitalize on new and existing resources. It will allow us to invest in people in systemic, interconnected ways that meet the challenges of the evolving landscape of health and health care head-on.

It’s also why we’ve taken an open and iterative approach to our design process.

Late last year, we contracted with seven organizations representing academic, design, futurist, and community development perspectives to help us think through design elements, curriculum components, and other necessary considerations for RWJF’s four new programs. We’ve also incorporated insights and recommendations from a cross-sectorial Design Advisory Committee, which included both RWJF program alumni and grantees and leaders from fields outside of health and health care.  

Does your organization have the tools to manage one or more of these boundary-spanning leadership programs, which will reflect our vision to work with others to build a national Culture of Health? Apply to lead change as a National Leadership Program Center.  

Herminia Palacio, MD, MPH, is the director of the Robert Wood Johnson Foundation's Advancing Change Leadership Team.

Tue, 19 May 2015 09:00:00 -0400 Herminia Palacio Health Leadership, Education, and Training Social Determinants of Health Leadership Views <![CDATA[Clearing the Air in Louisville through Data and Design]]>

Louisville, Kentucky ranks among the poorest in air quality and highest in asthma rates among U.S. cities. A new art installation from Propeller Health shows residents real-time changes in the city's air quality, equipping them with the data to reach their goal of becoming one of the healthiest cities by 2020.

Airbare air quality installation in Louisville, Kentucky

I stand in front of an intriguing art installation on a busy street corner in downtown Louisville, KY, and visualize the invisible. It’s a bright orange steel kiosk outfitted with an interactive touch screen that allows passersby to “see” how air pollution levels change around the city in real time while also learning how these pollutants impact the severity of asthma symptoms. Called AirBare, the installation project was funded by RWJF and represents a unique collaboration between visual artists, big data analysts and local health advocates. By “popping” virtual bubbles on the screen, users find out what causes air pollution and what it will take to reverse it. This is relevant information for residents of Louisville, a city that consistently ranks among the lowest in air quality in the nation and has one of the highest rates of asthma and other respiratory conditions.

My visit to the AirBare installation coincided with a conference held in Louisville in March that brought together economists, health policy folks, food experts and, remarkably, Charles, the Prince of Wales, to examine the issue of air quality and the larger concept of sustainability in this Ohio River Valley city. The Prince, a longtime advocate for environmental issues with connections in Louisville, added star power to the Harmony & Health conference, sponsored by the non-profit Institute of Health Air Water & Soil. But there is plenty else to be excited about in Louisville. Under the leadership of Mayor Greg Fischer, city agencies have collected reams of data on air quality, health outcomes, life expectancy, income inequality, and unemployment, among many other measures. What has emerged is a far better picture of the tough environmental and socioeconomic issues impacting the health and wellbeing of Louisville’s 600,000 residents, and a serious and concerted commitment to build a culture of health.

Airbare air quality installation in Louisville, Kentucky

The numbers, contained in the Louisville Metro Health Equity Report, paint a clear picture of the city’s challenges. More than 63 percent of Louisville residents live in neighborhoods with a life expectancy below the national average, and people can experience an 18-year gap from one neighborhood to the next. Almost 32 percent of African-American residents are in fair or poor health, and one in five residents lives in poverty; unemployment is high. And then there is the air quality problem. Louisville sits in a valley where toxic pollutants generated by nearby coal and oil-burning power plants and other industrial facilities collect in the stagnant air. As a result, asthma is the third leading cause of hospitalization in Jefferson County—which includes Louisville.

Still, this is a community that is fully committed to taking the steps necessary to bring about sustainable change. Air Louisville, the city’s multi-stakeholder clean air initiative, is a great example of what it takes for a community to really move toward building a healthier culture. It all begins with documenting the problem. The city had air quality sensors placed around various Louisville neighborhoods to collect and record real time data on levels of particulates and other toxic chemicals. At the same time, some 350 asthma sufferers were given high-tech inhalers that used GPS to relay the time and geographic location of asthma symptoms. The tracking device—which can sit on top of any inhaler, was developed by a former RWJF Health and Society Scholar, who also started Propeller Health. The devices are being made available at no cost to members of the community who participate in the research. Interestingly, the AirBare installation utilizes data from both the neighborhood sensors and the high-tech inhalers to raise awareness about the connection between air quality and asthma in community members.

This month the Air Louisville initiative is expanding. In a collaboration between the Institute for Healthy Air, Water and Soil, Propeller Health, local health plans, and other groups, 1,000 more Louisville citizens are being equipped with sensors for their asthma inhalers to track when, where, and how often they use their devices. This data-driven initiative uniting public, private and philanthropic organizations is designed to use digital health technology to help patients better manage their asthma symptoms, and aid city leaders in making smarter policy decisions about how to keep the air clean.

Louisville has as its goal to be one of the country’s healthiest cities by 2020. That’s an ambitious aim, but my recent visit convinced me that this city is up for the challenge. The key factor is collaboration: Louisville has enlisted a broad range of partners working in community development, health care, transportation and business—to name just a few—in executing its strategic plan. Along with the Air Louisville program, there are initiatives under way to improve health care delivery, reduce obesity and increase residents’ access to fresh, healthy foods. It’s exciting to see a community resonating so closely with RWJF’s framework for building a Culture of Health.

Alonzo Plough Headshot

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

Wed, 13 May 2015 12:44:00 -0400 Alonzo L. Plough Health Data and IT Built Environment and Health <![CDATA[Nurses and Physicians Need to Learn Together in Order to Work Together]]>

Many practitioners understand the value of interprofessional education—the challenge is to make sure all our nation’s educators and providers do.

Nurse and physicians

Imagine your grandmother or someone you love falls and breaks her hip, arriving at the hospital in excruciating pain. She desperately needs pain medication and the nurse or medical resident on duty calls a senior clinician to request it. But the clinician says she’s busy and can’t see your loved one for at least an hour. How would you feel if the nurse or resident passively accepted this response? Alternatively, what if they challenged it?

Nurses and early career doctors regularly encounter thorny scenarios like these. Unfortunately, many hesitate to challenge senior colleagues, even when a fragile patient urgently needs help. Senior clinicians may even berate perceived subordinates for challenging their authority.

At New York University, we are part of a growing movement that aims to change these pernicious patterns. Marc Triola, MD, and I co-led a project to give nursing and medical students the training they need to work better together.

In our project, NYU3T: Teaching, Technology, Teamwork, we used the scenario above, as well as others, to teach nursing and medical students how vital it is to communicate effectively about patients’ needs. We hope that teaching nursing and medical students together will help them to develop the skills they need in order to work together in a system that is increasingly reliant on team-based care. My colleagues and I believe that this interprofessional collaboration will result in better communication between providers, fewer medical errors, less duplication, lower costs, and greater clinician and patient satisfaction.

What do our students think?

“It’s easy to feel isolated in your own profession...but I don’t think that’s good for the patient,” says Meriel McCollum, one of my nursing students. She says that learning and working together helps to reduce tensions and alleviates anxiety about speaking up when concerns arise. “This project helped me feel more comfortable and know that I really do need to speak up for the patient’s safety.”

In one simulation, Meriel and a medical student each wrote a care plan for a patient with heart failure and other health problems. Meriel’s plan directed the patient to monitor daily fluid intake and report weight changes. Those items were missing from the medical student’s care plan. But the medical student directed the patient to change medications to avoid possible complications, which Meriel had not included in her plan.

“Together, the medical student and I were able to produce a holistic care plan that addressed all aspects of the patient’s ongoing treatment and activities of daily life,” she says. “Had the patient received only my plan, or only the medical student’s plan, he or she would have received only half of the recommendations for high-quality care for heart failure. No one wants patients to be left half-treated, or half-healthy. This exercise reinforced that we are on the same team, with the same goal: to provide high-quality, compassionate, and evidence-based care to our patients.”

Meriel notes that when physicians have a fuller understanding of the roles and responsibilities of nurses, they will be more likely to utilize nurses to the full extent of their training and expertise—and that will benefit both nurses and the patients they serve.

Another participant, Brent Dibble, an MD/MBA student, found interprofessional education so critical that he believes it should be mandatory for all medical students at all schools. “As a physician, I’m going to be working in teams for the rest of my life,” he says. “Often I’ll be the team leader, but sometimes I won’t be. Understanding each team member’s capabilities is a really useful skill. I can’t imagine treating a patient without that knowledge.”

Before taking our course, Brent had worked with students from other health professions but had not developed a full understanding of how “the different cogs in the wheel work together.”  For example, he didn’t fully understand which levels of education nurses need in order to assess and evaluate patients, write prescriptions, and more. He said that having that knowledge will enable him to function better on a health care team.

New Ways and New Programs

Interprofessional education, of course, is nothing new. More than four decades ago, the Institute of Medicine (IOM) called on educators to train health professions students to practice as members of health care teams. In 2010, the IOM released a report on the future of the nursing profession that echoed that call. The same year, the federal government enacted the Patient Protection and Affordable Care Act, which pointed to interprofessional collaboration as a way to improve the quality of care while containing costs.

All along, innovative educators have been coming up with new ways and new programs to prepare health professionals to work as members of high-functioning health care teams. My colleague, Judith Haber, PhD, APRN, FAAN, is one stellar example; she is overseeing a pioneering program called Teaching Oral-Systemic Health (TOSH) that teaches advanced practice nursing, medical, and dental students about the interconnection between oral and general health.

RWJF is committed to spreading the word about the importance of collaborative practice, and released a white paper in March that aims to do just that. Many of us understand the value of interprofessional education. Our challenge is to make sure all our nation’s educators and providers do. Not nearly enough health professions schools are teaching students to work as members of teams—to work, in other words, in the health care system of the future.

Maja Djukic, PhD, RN, is an assistant professor at the New York University (NYU) College of Nursing and a Robert Wood Johnson Foundation (RWJF) Nurse Faculty Scholar (2012-2015).

Please share your views on educating physicians, nurses, pharmacists and other health professionals together by leaving a comment below or joining the conversation underway on the RWJF Leadership Network, an exclusive, online community of over 10,000 leaders in health. If you’re not yet a member of the Network, please click the yellow “Join” button in the upper right corner of the page.

Mon, 11 May 2015 09:34:00 -0400 Maja Djukic Nurses and Nursing <![CDATA[Retail Clinics Are Expanding Their Role Within the Health Care System]]>

With convenient weekend and after-hours care, retail clinics have the potential to expand access to basic primary care and help address some non-clinical needs underlying the social determinants of health.

A CVS Retail Clinic at the corner of a street.

My husband had been suffering from a very painful sore throat for a couple of days when he finally decided to call his doctor. Just one problem: It was a Friday morning and the office was booked for the day. The doctor called back later in the afternoon and told my husband it sounded like a virus and he should simply “wait it out.” With the weekend approaching, the next available appointment—if needed—was on Monday. Rather than suffer all weekend with a raw throat, my husband followed the advice of a relative (who also happens to be a physician) and went to a clinic at our local CVS. Less than an hour later he was diagnosed with strep throat and started on antibiotic therapy he picked up at the pharmacy. By Saturday evening he was feeling a lot better.

Access to quick, convenient care on nights and weekends is one of the prime selling points of “retail clinics” based in pharmacies, groceries, and big-box retailers. With longer operating hours and no need for an appointment, these clinics, sometimes called “doc-in-a-box,” give patients more flexibility to avoid time away from work and family. Plus, a trip to a retail clinic costs about one-third less than a visit to a doctor’s office, and is far cheaper than an emergency room. Retail clinics usually accept private insurance, Medicare, and, in many cases, Medicaid; yet people without insurance or a personal physician also are using them for treatment of routine illnesses, basic health screenings, and low-level acute problems like cuts, sprains, and rashes.

New shopping list: Pick up milk, breakfast cereal, and toilet paper; get a flu shot and that weird rash checked out.

This kind of convenience is definitely a plus. But what is even more interesting to us at the Robert Wood Johnson Foundation (RWJF) is the potential role retail clinics can play in our larger vision of building a Culture of Health. Since 2006, the number of retail clinic sites has increased almost 900 percent from 200 to 1,800, and in 2012 they recorded some 10.5 million patient visits. A new study, “The Value Proposition of Retail Clinics” prepared by health care consultant Manatt Health with funding from RWJF, finds that retail clinics that are embedded in high-volume retailers, large groceries, and big chain pharmacies can potentially serve tens of millions of people each week.

The study identified key steps these clinics can make—and in some cases, already have—that can connect patients to health, wellness, and social services that promote public health in the broadest sense. To start, they can forge stronger connections with larger health systems. Ideally, after my husband visited the CVS clinic, information would have been entered into his electronic health record (EHR) and shared with his primary care physician. That rarely happens now, mostly due to poor connectivity between disparate EHR systems. Still, the Manatt study identified more than 100 such partnerships, including one that links the UCLA health system with the MinuteClinic chain of clinics operated by CVS. When a patient under the care of a UCLA primary care physician is seen at a MinuteClinic, the UCLA doctor automatically obtains a copy of the patient’s encounter and it is incorporated directly into UCLA’s EHR system. The plan is to make this flow of information two-way in the near future: UCLA patients will be able to obtain follow-up visits at a MinuteClinic as well as referrals to emergency and urgent care instead of having to make an appointment at their primary care physician’s office.

This table shows the Value Proposition of Retail Clinics. The six largest retail clinics sponsors represent 93 percent of the total number of clinic sites nationwide.

Retail clinics can also be used to connect people to healthy foods, products, and services. Imagine a diabetic visiting a retail clinic for a routine checkup and being prescribed a personalized list of groceries, pharmaceuticals, and medical supplies that can be picked up in the store. The Manatt authors describe just such collaboration between Texas-based RediClinic and H-E-B grocery stores on a 10-week, medically supervised weight management program. The clinic provides patients with physicals and nutrition programs tailored for diabetes, hypertension, and other restricted diets, as well as pedometers and exercise routines. It also gives patients grocery lists, directing them toward healthy food purchases within the store. Patients following the program lost an average of one to two pounds per week, while patients diagnosed as hypertensive decreased their blood pressure readings by 62 percent.

There are encouraging signs that retail clinics can move even further in promoting a healthier culture given the enormous customer volume in their host locations. Walmart alone serves more than 140 million customers each week. Its stores could be used to link lower-income people to a range of programs that address underlying social determinants of health, such as food security and safe and affordable housing.

As an example, look at San Antonio where H-E-B is collaborating with the Texas Health and Human Services Commission to place food bank workers in select stores to enroll eligible customers in SNAP, the federal food stamp program. These food bank workers help approximately 1,500 people each month apply for federal assistance.

The Manatt study makes it clear that retail clinics can be key players in the ongoing effort to create a higher-performing, more equitable health care system, but it also suggests room for improvement. Right now most clinics are located in relatively well-to-do locations—including major cities and affluent suburbs—rather than in the underserved areas where they might be needed most. Assessments of the quality of care could also be better. Insurers and licensing agencies collect and often make public data on how large practices, individual doctors, hospitals and other health care providers perform on quality measures, but retail clinics have mostly avoided this kind of scrutiny. Collecting quality data would increase transparency and accountability, giving consumers and insurers better information to consider when choosing a clinic over another provider.

As more big-box retailers and pharmacy chains expand into health care, there is real potential for clinics to provide services well beyond a simple throat swab, prescription refill, or quick diagnosis of a child’s ear infection. By connecting with larger health systems; steering customers to healthy foods, medications and lifestyle changes; and providing access to food stamps, affordable housing and mental health services (to name a few), these “doc-in-a box” clinics can contribute in a real way to building a Culture of Health.

Tara Oakman

Tara Oakman, PhD, is a senior program officer at the Robert Wood Johnson Foundation focusing on strengthening vulnerable children and families and working to improve the value of national investments in health and health care. Read her full bio

Wed, 6 May 2015 15:38:00 -0400 Tara Oakman Health Care Access Social Determinants of Health <![CDATA[Opening the Care Conversation through OpenNotes]]>

More than 30 health systems have adopted the practice of sharing clinicians' notes with patients, making OpenNotes more than just a revolutionary idea but a movement in health care.

Open Notes_20120530_01007

It’s a memory aid. It’s truth serum. Using it can transform relationships forever. These may sound like come-ons for the type of product typically hawked on late-night television. But in fact, they’re some of the things people are saying about OpenNotes.

OpenNotes isn’t a product, but an idea: That the notes doctors and other clinicians write about visits with patients should be available to the patients themselves. Although federal law gives patients that right, longstanding medical practice has been to reserve those visit notes for clinicians’ eyes only.

But Tom Delbanco and Jan Walker, a physician and nurse at Beth Israel Deaconess Medical Center in Boston, have long seen things differently. Their personal experiences with patients, and inability to access care records for their own family members, persuaded them that the traditional practice of “closed” visit notes had to change. So, with primary support from the Robert Wood Johnson Foundation, they launched what has now become a movement.

A nurse writes notes in a patient record.

In 2010, Delbanco, Walker and colleagues led a study in which more than 100 primary care doctors from three health systems began sharing notes online with patients. Patients got secure messages prompting them that the notes were available, and reminders to read notes before their next appointments.

Many of the doctors who participated were nonetheless skeptical. They worried that patients would overwhelm them with questions, or that the process would result in longer visits. But the study’s results were overwhelmingly positive: Of roughly 5,000 patients who looked at a visit note and completed a survey, most reported that they felt more in control of their care, and that reading the notes made them more likely to take medication that their doctors prescribed. And for nearly all doctors, longer visits or the feared deluge of questions from patients didn’t materialize.

OpenNotes has since spread like wildfire: More than 30 health systems, collectively treating some 5 million patients, have adopted the practice. They include such preeminent systems as Mayo, Geisinger, Cleveland Clinic, the Veteran’s Health Administration, the University of Texas M.D. Anderson Cancer Center, and Kaiser Permanente Northwest.

The primary reason OpenNotes is catching on, Delbanco and Walker say, is that once notes are open, patients and clinicians discover that they really like it. Here’s why:

Cognitive aid: Reading and reflecting on visit notes can sharpen thinking for both clinicians and patients. “Doctors tell us that their patients come to visits better prepared,” says Walker. “They ask better questions. They’ve thought about the visit and they’re more ready for the conversation.” OpenNotes can also jog memories: At a recent foundation-sponsored conference on transparency in health care, one patient, Candice Wolk of Weston, Massachusetts, told how re-reading a note six weeks after a visit with her primary care doctor reminded her that the physician recommended she see a dermatologist about a growth on her back. She did, and the lesion was removed while still precancerous. “I’m indebted to OpenNotes for that,” Wolk said.

Transparency tool: Peter Elias, a primary care physician from Auburn, Maine, and OpenNotes adherent, described an “epiphany” he had the first time he wrote a visit note with the intention of letting the patient read it. “I realized that I had been writing a diary for 30 years,” he said—“a very personal, subjective [account of each visit], sometimes with very derogatory comments about the patient and what I thought should happen.” Opening his notes, he said, nudged him to be far more collaborative with patients, sharing more information and engaging them more, especially about sensitive matters like unhealthy behaviors or mental illness. “The openness of the note has made the visit more open,” Elias said. “It’s been transformative for me, [and] changed the way I practice medicine in a pretty fundamental way.”

OpenNotes has now entered a new phase, morphing into OurNotes, a program launched with support from the Commonwealth Fund. Now, patients will “not just passively read notes,” but can also comment on or contribute to them, Walker says. Five health systems, including Geisinger and Group Health, will build prototypes and test them. “We need to learn how to really engage patients through these notes,” Delbanco says. “The point is that they will hopefully join that conversation, and become better consumers of health care.”

Susan Dentzer

Susan Dentzer, Senior Policy Adviser at the Robert Wood Johnson Foundation, former Health Affairs Editor-in-Chief and Health Policy Analyst, The NewsHour with Jim Lehrer, is one of the nation's most respected health and health policy thought leaders and journalists. Read more of Susan’s posts.

Mon, 4 May 2015 10:01:00 -0400 Susan Dentzer Patient-Centered Care First Friday Google Hangouts <![CDATA[No Time to Waste in Battle to Regulate E-cigarettes]]>

The CDC just released alarming data on the new rise of electronic cigarette use among U.S. teens. Unless the FDA acts now, it may get worse with each passing day which is a gamble we can't take.

If the health debate coalescing around e-cigarettes feels familiar, there’s good reason. The uncertainty and questions about this relatively new—and unregulated—product harken back to an age when it was chic for Hollywood stars to blow smoke at the screen, and cigarette brands were plastered all over race cars.  

The tobacco industry knew just what to do to entice young people, and this formula hooked millions upon millions of them and locked in a lifetime of smoking—tragically shortening lives in countless cases.

Even today, just over 50 years since the Surgeon General’s first landmark report on Smoking and Health, tobacco addiction causes a host of cancers and other illnesses. Smoking is still the leading preventable cause of death in the U.S., killing 480,000 people annually and costing over $325 billion in medical expenditures and lost productivity.

E-cigarette graphic

It’s in this sobering context that we should consider the report issued on April 16 by the Centers for Disease Control and Prevention on student smoking in the United States. The latest survey found that the use of electronic cigarettes among middle and high school students tripled in just one year and surpassed youth use of traditional cigarettes. In 2014, 13.4% of high school students used an e-cigarette at least once a month, up from 4.5% in 2013; 3.9% of middle school students used them, up from 1.1% in 2013.

To be sure, much is unknown about these products, and they are evolving rapidly. Even within the health community, there is debate on the value of e-cigarettes in helping people quit smoking traditional cigarettes.

But here’s what we do know, summed up powerfully and succinctly by CDC Director Tom Frieden:

Nicotine is dangerous for kids at any age, whether it’s an e-cigarette, hookah, cigarette or cigar. Adolescence is a critical time for brain development. Nicotine exposure at a young age may cause lasting harm to brain development, promote addiction, and lead to sustained tobacco use.

It’s that last phrase—sustained tobacco use—that stands to haunt this country and millions of families ravaged by the effects of these products, if the FDA does not quickly act within its authority under the Tobacco Control Act to halt this rising tide of e-cigarette use among young people.

The FDA must regulate this product. As the Robert Wood Johnson Foundation noted in comments to the agency nearly a year ago, regulation of the sale, production and marketing of e-cigarettes will be the first critical step. No one younger than 18 should be allowed to purchase these products, and the blatant push to attract young people to e-cigarettes must end.

Today, at least 40 states prohibit the sale of e-cigarettes to minors. In the remaining 10 states and the District of Columbia, e-cigarettes can be legally sold to children. Once young people take the bait, we know how this plays out: the 2012 Surgeon General’s Report found that 90% of all adult smokers first tried cigarettes as adolescents. Three of every four teen smokers continue into adulthood. We know, too, as Dr. Frieden noted, that the adolescent brain is still developing into the mid-20s, so harm done early on will have a lifetime of repercussions.

It’s no wonder, then, that tobacco companies are employing the effective marketing tactics of yesteryear—celebrity endorsements, slick ads and event sponsorships—to capture this next generation.

The flavors of e-cigarettes, too, sound like something ordered off an ice cream truck: cotton candy, banana split and chocolate, to mention just a few. We’ve seen sites, for example, asking (presumably with a straight face), “Love biting into a fresh watermelon or peach? How about vaping flavors that taste like your favorite fruit?”

As someone who has helped wage this battle against tobacco for nearly 30 years—first with the American Heart Association and now with RWJF—this feels like a Sisyphean moment. Just as millions of Americans had left tobacco behind and teen smoking rates had reached their lowest point ever, addictive e-cigarettes are now gaining traction.

At the Robert Wood Johnson Foundation, we firmly believe that we must all work together toward a Culture of Health. That shared responsibility, and a whole generation of Americans, will suffer an astounding setback without swift FDA action on e-cigarettes. Millions of teens could be ensnared in Big Tobacco’s net, and the fight to save their lives will begin anew.

Health experts, not the tobacco industry, should determine how these products are marketed and sold and what health claims are made about them. To say that the industry has a credibility problem on such issues is putting it kindly.

We’ve seen how e-cigarette use among the young can skyrocket in just 12 months. And unless the FDA acts now, it may get worse with each passing day. That’s a gamble we just can’t take—for our kids, our families, and our nation’s future.

Tue, 28 Apr 2015 08:53:00 -0400 Joe Marx Tobacco Control <![CDATA[We Went to Oxford and Got Schooled in Primary Care]]>

As other countries continue to spend far less on health care but perform better on measurable health outcomes, there's opportunity to learn what works abroad and apply those lessons stateside.

Oxford University

It’s a hard notion for many Americans to accept—although we spend more money on health care than any other country in the world, we are far from having the best health outcomes. When you look at measures that include life expectancy, infant mortality rates and preventable illness, other countries that spend far less than the U.S. perform better. But in many of these countries people of all ages and socio-economic status are able to easily access primary care that is comprehensive, patient-centered and rooted in local communities.

One of our goals as program officers at RWJF is to look beyond our borders to identify promising practices that might be incorporated into America’s health care system. Last fall we traveled to Oxford, England, to learn first-hand about promising primary care practices in Chile, England, the Netherlands and Canada—all high and middle income countries that spend less on health care yet have better outcomes than the U.S. We attended a conference organized by the Training and Research Support Centre (TARSC), an organization supported by Charities Aid Foundation of America through a grant from the RWJF Donor-Advised Fund. TARSC provides support and training to government and civic health organizations, and the conference was the next step after its report, “Strengthening primary care in the USA to improve health: Learning from high and middle income countries.” We came away with a lot of insights from both, but were struck by several themes that were constant throughout.

The first, and possibly most important, is that primary care is most effective when it is well integrated into community and population health. In the Netherlands, for example, primary care is local, highly coordinated, and accessible 24/7. Everyone in the country must register with a general practice and select a personal doctor who oversees continuity of care. Primary care providers can only accept patients who live within 15 minutes of their practice. Being local means that, besides knowing their medical history, doctors and their staff have a more robust understanding of their patients’ living, working, and social environment. Most doctors (some 78%) are also part of larger care groups—multidisciplinary teams that combine family practice with nursing and home care, social and mental healthcare, dental and diagnostic facilities—that integrate population-focused preventive services as well as long-term care for people with chronic conditions into the primary care model.

Chile has its own version of this public health-oriented model. The primary care system is built on a network of family health centers in cities, villages and rural settings that serve nearly 75% of the population. Each primary care center is run by municipal health administrators and takes a “biopsychosocial” approach to care—addressing medical, psychosocial and socioeconomic issues. To receive annual financing, center administrators must develop a health plan that includes taking into account local demographics, epidemiological profiles and social determinants of health. For example, one new program targets people in communities who are at risk of diabetes and hypertension. Some 237 primary care centers in Chile serving upwards of 130,000 people provide free medications and offer workshops led by teams of nurses, nutritionists and kinesiologists to teach people how to prevent or control diabetes and hypertension. Another program involves regular workshops at the health centers that are designed to help seniors maintain self-sufficiency and mobility while also addressing mental health concerns like depression and social isolation. This particular program currently reaches 50% of Chile’s senior citizens—over 1.1 million people in total.

Another key lesson we learned from these four countries is that for primary care to really impact quality and cost, it must be highly accessible and simple to navigate. In England, for example, nearly 99% of people are enrolled or registered with a general practitioner in the area they live. Once registered, the National Health Service arranges for all medical records—from hospitals, specialists, previous providers, etc.—to be electronically transferred to the local GP. Patients are contacted within six months of registering to schedule a check-up, while home visits to new mothers and infants, frail elderly, and people with chronic illness are standard services in England. Because primary care physicians are gatekeepers for referrals to specialists, GPs provide 90% of the care for patients. This reduces unnecessary visits to specialists and cuts down on excess or duplicate testing; top drivers of higher cost and poorer outcomes in the U.S.

A law requiring primary care to be available 24 hours a day, seven days a week bolsters accessibility in the Netherlands. To meet demand, physicians formed primary care cooperatives of 40 to 250 individual providers that provide after-hours coverage for 100,000 to 500,000 people within a 30 km radius. On evenings and weekends, a dedicated phone line connects patients with a triage nurse who might recommend self-care, schedule a visit to the doctor the next morning or in emergencies, call an ambulance. In some cases, a doctor will be dispatched to the patient’s home, arriving within 15 minutes in a specially marked car carrying medicine, oxygen and other emergency medical supplies. Even better, the doctor has the patient’s electronic health records in hand. The primary care cooperative system has reduced visits to hospital emergency departments by 89% in the Netherlands and hospital admissions by 34% while winning high scores for patient and provider satisfaction.

The report and the meeting reinforced our belief that we can learn much about primary care from the experiences of other nations. It is worth mentioning that all four countries have universal health insurance—something we haven’t yet achieved here in the U.S. Still, increased support for primary care mandated by the Affordable Care Act is driving momentum toward finding new ways of delivering and paying for care that promotes better coordination, accessibility, and value. It is conceivable that many of the practices we learned about at the conference could be adopted in the United States—and in fact, may already be implemented in some pilot projects.

One U.S. attendee, Lisa Letourneau MD, MPH, Executive Director of Maine Quality Counts, said she finds herself talking about the lessons learned from the Oxford meeting to everyone who will listen. “The meeting really re-lit the fire in me to push for more meaningful, wider, and more sustainable payment reform for primary care in Maine and more broadly,” she said. In April, her team brought together leaders from all of the primary care and medical associations in Maine to gain their support for payment reform. “I’ve been giving a lot of thought to the specific role that regional improvement organizations like ours can give to these efforts,” said Letourneau. “We have a unique role to play regarding connecting healthcare and broader efforts to improve community/population health, and particularly positioning, and supporting, primary care as the intersection of those two worlds."

Over the past three years, another RWJF project, The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP), has identified and visited over 30 primary care practices in 20 states in the U.S. to learn how these practices—like those in the four countries we studied—make primary care more accessible by creatively using their clinician and staff workforce. The LEAP team, led by Ed Wagner MD, Director Emeritus at MacColl Center for Healthcare Innovations and Margaret Flinter PhD, RN, FAAN, Senior Vice President and Clinical Director at Community Health Centers Inc, has developed a great resource for primary care practices, organizations and leaders. Find a description of the project, the findings, a guide to developing effective primary care teams, and other resources at

To keep the exchange of ideas flowing we encourage you to share in the comment section below your experience with promising primary care practices and innovations that are driving greater community engagement and accessibility here at home. Whether the ideas come from a rural village in Cuba, the local councils of Manchester, England or from an American city like Camden, NJ, we will work to leverage the U.S. primary care system to help achieve RWJF’s larger vision—to build communities where all of us have the opportunity to live the healthiest lives we can.

To learn more about RWJF’s efforts to learn from countries around the world, please read Looking Beyond Our Borders for Better Results by RWJF Assistant Vice President Brian Quinn, in Stanford Social Innovation Review.

Thu, 23 Apr 2015 09:00:00 -0400 Maryjoan Ladden Health Care Quality Public and Community Health