By Leslie Mikkelsen and Rob Waters of Prevention Institute
Celebrating 25 years of the Healthy Communities Movement in partnership with the National Civic Review. Read more about Community-Centered Health Homes: Engaging Health Care in Building Healthy Communities.
When children under 12 have an asthma emergency in Hamilton County, Ohio, and need urgent care, there’s pretty much just one place they go—Cincinnati Children’s Hospital. Since severe asthma attacks are generally preventable, researchers from the hospital’s Community Health Initiative decided to track where cases come from to find ways to prevent them.
Researchers reviewed every asthma admission from 2009 to 2011 and found cases were clustered in hotspots, with kids from low-income neighborhoods 88 times more likely to be admitted for asthma emergencies than those from wealthy areas. When they dug further, working with city health and housing inspection departments, they found that the very apartment buildings where large numbers of children were repeatedly experiencing asthma attacks also tended to have code violations for the kinds of substandard conditions that trigger asthma symptoms. The next step was to work with legal aid attorneys to press landlords to make repairs.
Two thousand miles to the west, Asian Health Services of Oakland began focusing on traffic safety after an elderly community member was hit and killed by a car almost outside the clinic’s front door—just one in a series of pedestrian injuries. Working with community partners, the clinic launched a prevention campaign. Youth from the clinic’s leadership program mapped crash locations and took photos of cars blocking crosswalks or turning in front of pedestrians.
They presented findings to the city council and their representative helped obtain state funding for street improvements. Ultimately, a “pedestrian scramble” scheme was implemented at several intersections, stopping all traffic during red lights and allowing pedestrians to cross in any direction, including diagonally. The scramble reduced car-pedestrian conflicts by 50 percent, reducing risk for injuries and deaths.
These examples show the value of partnerships between healthcare organizations and the community. In both cases, clinic staff members partnered with community organizations and local government to address local conditions that lead to illness or injury. In both cases, there are many potential payoffs.
Helping Cincinnati families get their buildings maintained properly reduces the need for their children to be hospitalized, saves healthcare dollars, cuts down on absences from school and reduces lost workdays for parents. Making Oakland streets safer for pedestrians may encourage more people to walk—lowering diabetes and heart disease and boosting patronage of stores and services. These goals are all at the heart of the Healthy Communities movement.
Talking to healthcare professionals who regularly step outside clinic walls to address community health needs inspired us at Prevention Institute to look closely at what many clinics already do spontaneously. We decided to describe, in a more formal way, a coordinated set of practices healthcare institutions can employ, in conjunction with local partners, to facilitate community-level environmental change. We call this approach community-centered health homes.
Community-Centered Health Homes
This concept expands on the idea of the patient-centered medical home, a key part of the Affordable Care Act’s effort to improve care for individual patients. A community-centered health home goes a step further by engaging with partners to address underlying determinants of illness and injury. It recognizes that factors outside the healthcare system affect patient’s health and it works to address those factors through advocacy efforts, focusing on pressing and widespread medical conditions. By working to improve community environments, community-centered health homes also improve the health and safety of patients and residents, advance health equity, and reduce the need for treatment.
We believe healthcare organizations are well positioned to do this work. For patients, clinicians follow a three-part process: collecting data (symptoms, vital signs, tests, etc.), diagnosing problems, and undertaking a treatment plan. A community-centered health home can follow a parallel path to address the health of the entire community. We describe these three stages as inquiry, analysis, and action.
Cincinnati Children’s Hospital applied this kind of practice to prevent childhood asthma attacks. First, staff members used an inquiry process to map the home addresses of patients and identified geographic clusters. Then, the hospital worked with the city’s health and building departments to analyze records and found batches of code violations in the buildings where patients lived, demonstrating the link between slum housing and asthma attacks. Finally, the hospital partnered with the Legal Aid Society to take action to pressure landlords to improve housing conditions.
As a result, the hospital institutionalized the following practice: Staff members are prompted by electronic health records to ask about housing conditions of any patient admitted for asthma-related complications. This helps researchers identify emerging hot spots and develop effective remediation strategies. An agreement between Children’s Hospital and the Cincinnati Health Department allows doctors and families to initiate home inspections. A second partnership with the Legal Aid Society ensures that housing violations can be addressed. One result: hospital readmissions for asthma have been cut by 50 percent.
Today, as we celebrate the 25th anniversary of the Healthy Communities movement, we’re achieving major gains in reforming the U.S. health system. There is growing recognition that we can prevent many of the chronic conditions that account for 75 percent of our healthcare costs. There is also a growing awareness that many of these conditions have their roots in community factors that limit the ability of people to eat healthy food, live and walk safely and breathe healthy air.
We have a singular opportunity to re-envision our national approach toward health and to shape a quality health system that meets the needs of all. To do that, we must provide quality, coordinated healthcare services and we must enable healthcare professionals to work together with community advocates and organizations to create the conditions that foster health and safety for all. It’s a fitting goal for a 25th anniversary.
The Community Health Initiative at Cincinnati Children’s Hospital has put those broad goals into a specific agenda: to focus on four conditions—asthma, unintentional injury, infant mortality, and childhood obesity—and reduce each by 10 to 20 percent over five years.
“‘We have to be about health, not just healthcare,” says Cincinnati Children’s Robert Kahn. “And, clearly, the only way to begin to achieve those goals was for us to understand where the highest levels of need were and who in the community could help join us as partners.”
Rob Waters, a longtime health and science journalist, is chief communications officer for Prevention Institute, where he leads the organization’s communications and media strategy.
Leslie Mikkelsen is managing director at Prevention Institute, where she leads the organization’s work promoting community-level prevention in health reform and the transformation of the U.S. health system.