March, 2012

1. Community Health Centers Leveraging the Social Determinants of HealthA Project of the Institute for Alternative Futures & NACHCFunded by At the GIH Health + Equity for All 2012 Annual MeetingPhyllis Meadows, Kresge FoundationClem Bezold, Institute for Alternative FuturesDavid Stevens, National Association of Community Health Centers (NACHC) March, 2012

2. Primary Care 2025 Scenarios & CHCs Leveraging the Social Determinants of Health • IAF and NACHC Projects funded by the Kresge Foundation

3. Primary Care 2025 Scenarios • Major forces shaping health care likely to lead to very different primary care in 2025 – including the community centered health home (CCHH); broadened primary care team, including Community Health Workers; advanced, personalized health & disease knowledge; digital health coaches; evolved payment forms; & self care • Scenarios have relevance for all health care development and funding (How likely do you think each scenario is?; which of the scenarios do you prefer?) • For Leveraging Social Determinants – this is likely to be a more conscious part of health care, and this is explored in scenarios 3 and 4. see www.alfutures.org/primarycare2025

4. CHCs Leveraging the Social Determinants of Health • Health is shaped by many factors, particularly the social determinants of health • Growing focus on the Triple AIM and Population Health • Population health requires going beyond the clinic to shape community conditions. • CHCs routinely do this in a many ways as they “leverage the social determinants of health” • This project identifies & summarizes CHCs’ efforts

5. The Project on Community Health Centers Leveraging the Social Determinants of Health • Partnership with the National Association of Community Health Centers • Kresge Foundation grant to the Institute for Alternative Futures • National Workshop of leaders considering state of knowledge, state of the art, and recommendations

6. What are Social Determinants of Health? • WHO:“…the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices.” • CDC: “…the complex, integrated and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services and structural and societal factors.” • RWJF: “Health starts where we live, learn, work and play.”

7. Major Factors Shaping Health Source: 1993 – M = McGinnis and Foege, JAMA, 1993, 270, 2207-2212; 2002 - McGinnis, Russo, Knickman, 2002, Health Affairs, 21,3,83; HPC – “Healthy, Productive Canada, Final Report of the Senate Subcommittee on Population Health. June 2009; CHR = County Health Rankiings, 2010 www.countyhealthrankings.org/

8. Why is Leveraging the Social Determinants of Health Important? • COPC Origins of CHCs • HRSA Program Expectations:“facilitate access to comprehensive health and social services…and additional services if critical to improving the health status of a specific community or population group” • SDH in Emerging Models of Health Care: Chronic Care Model, PCMH, Comprehensive Health Home, Community Centered Health Home • Healthcare Quality (the Triple Aim) requires improved population health • Hippocrates & Flexner

9. Defining CHCs Leveraging SDH • A clinic is leveraging the social determinants of health (SDH) when it moves beyond providing health care to address or change the built environment or social and economic conditions that affect health and wellbeing.

10. Research Approach • Create Database • Website www.altfutures.org/CHC-SDH • PCA Surveys • Key literature; online searching; announcements • CDN literature review of cases in peer reviewed journal • Conference sessions NACHC 2011 P&I, CHI, CDN Webinar • Specific network requests

11. The CHCs Leveraging SDH Knowledge Base • Data Base: 176 Efforts/52 CHCs (50 FQHCs, 1 Look-Alike, 1 Social Service Agency) • Limitations: not random sample, not exhaustive • But indicative • and supplemented by • CDN literature review, • 10 case studies, and • data from HRSA/BPHC Universal Data System

12. 10 Case Studies • Beaufort-Jasper-Hampton Comprehensive Health Services,Ridgeland, South Carolina • Centro de Salud Familiar La Fe, El Paso, Texas • Community Health Partners, Livingston, Montana • Hudson River HealthCare, Peekskill, New York • Joseph P. Addabbo Family Health Center, New York, New York • Kokua Kalihi Valley Comprehensive Family Services, Honolulu, Hawaii • La Clínica de La Raza, Oakland, California • La Maestra Community Health Centers, San Diego, California • Sea Mar Community Health Centers, Seattle, Washington • Sixteenth Street Community Health Center, Milwaukee, Wisconsin

13. Patterns & Observations • Most CHCs Leverage the SDH • CHCs pursue a wide range of effort areas • CHC Leadership is key • Variety in how SDH efforts are managed • Partnership, partnerships, partnerships • Funding is often a challenge, most programs are not self-sustaining • Unclear about impact/effectiveness beyond anecdotal results (which are impressive)

14. Most CHCs Leverage the SDH! In 2007, CHCs reporting to HRSA/BPHC provided or made referrals for:

15. Why do CHCs leverage the SDH? • HRSA program expectations call for it • It’s in the DNA of CHCs • Models of primary care and health quality increasingly require improved population health • Believe that sustainable impact on health requires community-level interventions. • Are well-positioned for it (know their communities well; have a stable, long-term presence; employ community members)

16. Areas for Leveraging SDH • Education • Job Skills, Employment, and Workforce Development • Healthy Eating and Diet • Physical Activity and Exercise • Social Conditions,includingcommunity safety, wellbeing, and involvement; family and social support and emotional wellbeing • Economic Development • Housing, Built Environment, and Recreational Spaces • Policy, Advocacy, and Activism

17. Most Frequent Types of Efforts in IAF Database(17 or more out of 176 efforts, among 52 CHCs) • Youth development programs (28% of efforts; 50% of CHCs) • Family and social support (25% of efforts; 31% of CHCs) • Access to healthy foods (23% of efforts; 60% of CHCs) • Job skills, employment, and workforce development (22% of efforts; 40% of CHCs) • Health education (21% of efforts; 50% of CHCs) • Physical Activity and Exercise (19% of efforts; 48% of CHCs) • Community safety, wellbeing, and involvement (19% of efforts; 44% of CHCs) • Nutrition education (16% of efforts; 44% of CHCs) • Healthy, safe, and affordable housing (16% of efforts; 33% of CHCs) • Recreational spaces and improved air and water quality in the community (11% of efforts; 25% of CHCs) • Adult education (10% of efforts; 21% of CHCs)

18. Nationwide Programs among CHCs • Reach Out and Read 18% of all 8,100 CHC sites in 2010 • National Center for Medical-Legal Partnership in 150 CHCs • Health Leads 660 college volunteers, across 22 sites in 2010, including 5 CHCs • AmeriCorps & NACHCCommunity HealthCorps Nearly 500 members in CHCs often functioning as community health workers & advancing community gardening • Women, Infants and Children Program (WIC) • United Way

19. Nationwide Programs among CHCs • Canyon Ranch Institute to prevent, diagnose, and address chronic diseases, provide exercise equipment • Corporation for National and Community Service, including Senior Companions who assist with shopping and light chores, interacting with doctors, or just making a friendly visit. • TimeBanks USA to promote equality and build caring community economies through inclusive exchange of time and talent. • States' Department of Education or a State agency serving the same function may assist withplanning, designing, or implementing new charter schools.

20. Prompting SDH Efforts: Health Issues • Most Frequent: obesity, diabetes, hypertension, cardiovascular disease and asthma • Behavioral or psychiatric problems among community members, e.g., depression among socially isolated seniors • Less Frequent: parasitic worms; depression; mercury content in local fish

21. Prompting SDH Efforts: Identifying Opportunities & Targets • Anecdotal observations by CHC personnel or community members • Grant opportunities • A non-CHC organization approaches the CHC or provides the opportunity, e.g. national programs • Uncommon and significant events: a violent beating of an immigrant, High School shooting, infections, natural disasters, 9/11, high levels of mercury and PCPs in local waters • Less frequently: stepping in to enable the survival of existing programs or efforts by others

22. Organizational Structure for SDH Efforts(10 Case Studies) Depends…and may choose one or more strategy: • A specialized, formal position or division with dedicated staff. • Ranging from program area coordinators, Directors of Special Programs, and specialized CHC departments to subsidiary organizations with their own funding streams and offices to oversee staff and manage SDH activities. • Distributed among several departments. • Several CHC departments engage in specific efforts that address the SDH, along with their respective clinical programs and services. • Seamlessly integrated with clinic operations. • E.g., prescribe and refer to services and resources, ROR, outreach workers providing support and advice, CHCs as businesses and employers. • Project-based management teams. • Consist of personnel from across the organization and form and disband according to funding opportunities.

23. Partnerships CHCs are great at partnerships. • Frequent Partners: public housing, churches, community centers, YMCA, public health departments, hospitals, local social agencies, local police, politicians, schools, local business, government agencies, builders and developers • Community support and enthusiasm is essential and community input affects program design • CDN literature review: “The Community Health Center or other health care providers were a partner in the collaborative planning of the interventions in eight efforts [of 14] and played smaller facilitating roles in four projects”.

24. Financing Funding is often a challenge. • Most often rely on external funding (e.g., grants, donations), often multiple sources; • 1- to 3-year grants are most common. • Sources: Public funds (federal, state), private and community foundations, corporations and small businesses, charities, donations, CHC operating budget and fundraising events, bonds and low-interest loans for housing. • Among 176 efforts, grants range from $2,500 to more than $8 million. • Estimating the share of a CHC’s total work or funds that go to leveraging SDH is challenging.

25. Financing • 64 or more (36%) efforts primarily rely on grants • Most often: public grants, i.e., WIC (USDA); HRSA; Federal Sustainability Grants; American Recovery and Reinvestment Act; Safe Schools/Healthy Students initiative; state pregnancy prevention funds. • Most private grants come from foundations (27 out of 176 efforts [15%]), incl. 20 efforts that received funding from local foundations and 12 efforts that received funding from national foundations. • 28 or more (16%) rely on internal funding (including donations) to varying degrees • 10 or more (6%) include income-generating activities by which the effort is largely, if not entirely, self-sustaining, e.g., housing that produces adequate rental income, farmers’ markets that collect a fee to participate

26. Sustainability(10 Case Studies) • Meet performance requirements at each renewal to maintain government sponsorship, e.g., charter schools, WIC, and government subsidies for low-income housing. • Relativelyheavy initial investment and then become self-sustaining, e.g., housing (with rental income) and community gardening programs (in conjunction with farmers' markets), both of which take some funds or resources to initially establish but thereafter can become self-sustainable. • Use donations and/or CHC operating budget if cost is small, e.g., for students to shadow health professionals, providing nonpartisan voter registration forms • Create and later transfer effortsto other organizations or turn into small businesses.

27. Sustainability Most programs, however, are not entirely self-sustaining. • Often require outside funds & continually subject to changes in funding levels. • May be sustained by renewing the same grants, though often CHCs move a program every 1 - 5 years from one grant to another to sustain the effort, including • temporarily covering the cost of the program through the operating budget and • modifying the design of the program to fit the funder's interests.

28. Results from the project CHC case studies for selected examples of their leveraging the SDH

29. Menomonee Valley, Community Lead Outreach Project / Sixteenth Street Community Health CenterMilwaukee, WI In 10 years: • 300 acres of brownfields developed • 21 companies moved to valley, 7 existing companies expanded • 4,200 family-supporting local jobs created • 900,000+ sq. ft. of green buildings and 7 miles of trails constructed • 45 acres of native plants installed (improved wildlife habitat and water quality) • Dropped the prevalence of lead poisoning among children from 34 percent in 1996 to 1.8 percent in 2011

30. Learning Partners / Community Health PartnersLivingston, MT In 2010: • Supported 37 GED grads (vs. 110 HS grads) • Distributed 200 books each month through the Reach Out and Read • Placed 18 adults in subsidized employment • Provided workplace training for 94 participants. • Served 44 families through its preschool program • Served an average of 45 parents and children through a weekly Open Gym.

31. Scholarships & Housing / Sea Mar Community Health CentersSeattle, WA

32. Septic Tanks, Cluster Wells / Beaufort-Jasper-Hampton Comprehensive Health Services Ridgeland, SC • Eliminated parasitic worm infections among local children • Compared to: at least 50 percent of preschool children in Beaufort County were suffering from parasitic worms in the late 1960s • In 2010 alone, the clinic had 16 septic systems installed and another 16 were anticipated for 2011. • Total of 1,000 cluster wells, including electricity to run the pump • Total of 2882 bathrooms, complete with a commode, sink, toilet, and shower • Helped organize water systems and fire protection for two counties • Worked with state government to change policy and mandate better sanitary services

33. PRYSE / Joseph P. Addabbo Family Health Center New York, NY • Benefited on average over 10,000 children and families per year, for three years • Created positive community trends, including • A drop in crime along with an increasing sense of improvement in the problems of youth violence and substance abuse, • An increase in the percentage of children and teens involved in after-school and summer programs, • A coalition of community residents and leaders, service providers, educators, and law enforcement personnel working collaboratively on solving community problems.

34. Job Training, Micro-Enterprise, and Transitional Housing/ La Maestra Community Health Centers San Diego, CA • From 1998 to 2003, trained over 560 community members to work as medical assistants, pharmacy technicians, eligibility workers, outreach workers, and referral clerks • six months later, 70% of these participants had remained at their jobs. • Today, more than 500 women are participating in the La Maestra Microcredit Program for Women, with a 98 percent repayment rate • 60 percent of transitional housing program residents successfully recover from a variety of issues, including alcohol and substance abuse, and become and remain employed

35. Evaluation of SDH Efforts amongCHCs • CHCs meet all grant reporting requirements • There is little published on impact of programs that leverage the SDH; most efforts have not had rigorous statistical evaluation of program impact (IAF, CDN Literature Review) • 5 of 52 CHCs partnered with a third-party evaluator, paid through the grant for a particular program/effort • Most reports of successes are anecdotal

36. Evaluation of SDH Efforts among CHCs • Monitoring & Evaluation challenges: • CHC clients are in transient communities, so subjects may leave before evaluation completed • Some people benefit from programs but are not necessarily patients of the CHC, so health or SDH records are absent or limited • True program impact may take years, but grants are short (1-3 years) • Prospective studies are expensive

37. Recommendations from the National Workshop on CHCs Leveraging SDH What CHCs Should Do Spreading the leveraging of the social determinants of health among community health centers • Develop and implement a systematic process for identifying community strengths and needs, beyond the clinical needs that individual patients present with at the health centers. • Create and promote the use of a standardized health risk assessment for all patients that goes beyond conventional physical or behavioral health conditions to include social and environmental determinants of health-related needs of the individual.

38. Selected Recommendations National Leadership and Funding Developing an evidence-base for leveraging the social determinants of health, and identifying and disseminating best practices • Pilot learning communities should test ideas and interventions for FQHCs and other organizations engaged in leveraging the social determinants of health. Building the social determinants of health into existing breakthrough collaboratives • To create a national learning community, HRSA should include the leveraging of the social determinants of health in existing national breakthrough collaboratives.

39. Selected Recommendations National Leadership and Funding Incentivizing engagement of the social determinants of health • Engage philanthropy in building a bridge between the social determinants of health and the clinical setting. Communication Strategies for Leveraging the Social Determinants of Health • Frame efforts to leverage the social determinants of health in ways that are intuitively meaningful to multiple sectors, the general public, and the community at large. • Pass on the legacy of community aspirations and the social determinants of health.

40. Implications for Grantmakers • CHCs generally and efforts to “leverage the social determinants of health” provide important opportunities in your communities • Are there efforts to leverage the SDH in your community that your CHCs should be involved in?

41. CHCs Leveraging the Social Determinants of Health • the Project Report, and the full 10 case studies, and the data base are available at www.altfutures.org/CHC-SDH • Other CHCs and health care providers can add their efforts to the data base at this site • Next steps include working to develop recognition and awards for best practices in leveraging the SDH, and CHC training.