BY: MARICE ASHE, JD, MPH AND LESLIE ZELLERS, JD
Increasingly, health care providers have recognized the importance of patients' local environments and how those environments can affect their health outside of the hospital setting. Evidence suggests clinical care alone explains only a small amount — perhaps 20 percent — of improved health outcomes as compared with other factors, including social context, environmental influences and personal behavior.1
Preventing disease requires more than medical care or simply providing patients with information to make healthy choices. To be most successful in preventing disease, clinical care must be integrated into the policies, systems and environmental (PSE) conditions that influence the social determinants of health in a community setting. In other words, public policies — such as land use and zoning, school wellness, tobacco-free public places and healthy food procurement — must be aligned with desired clinical outcomes in order to reduce the burden of chronic disease in a community.
INTEGRATING STRATEGIES
Hospitals can support a PSE approach to disease prevention as they implement their community benefits programs.
By employing a three-step method, hospitals can encourage standards of behavior that can prevent disease and create lasting changes in the communities they serve.
Step 1: Ensure that internal hospital policies model and encourage healthy choices.
Hospitals recognize that internal policies such as maintaining smoke-free campuses and providing open stairwells for use between floors promote health as they also model and support healthy choices for patients and staff. Indeed, most hospitals have instituted smoke-free campuses even if state law does not require them to do so.2 Increasingly, hospitals also are adopting healthy food and beverage programs to align their institutional practices with medical advice and health education messages. In a large hospital system in the Northeast, for example, a pilot program discouraging sales of sugary beverages and encouraging sales of healthier beverages proved so successful that hospitals have started to ban sugary beverages altogether.3
Step 2: Partner with community-based networks and organizations to provide early intervention and monitoring of chronic conditions.
Hospitals can help improve population health by partnering with community-based organizations and clinics to extend clinical care into community settings. As an example, Akron, Ohio, received a community transformation grant from the Centers for Disease Control and Prevention that funded a project to coordinate health care and support Type 2 diabetes patients inside and outside the doctor's office. The local accountable care community initiative, which includes dozens of community partners, has resulted in a measurable decrease in diabetes-related emergency department visits, thus both improving health and saving money.4
Step 3: Leverage the professional expertise and influence of the hospital to support lasting change through public policies that influence the social determinants of health.
Perhaps the most important way that hospitals and health care systems can improve community health is by leveraging their power to support policy change in the cities and counties in which they are located. Through their community benefit programs, hospitals can participate in local coalitions advocating for policy change to create the conditions necessary for patients to make healthy choices.
Hospitals can develop these relationships through their community health needs assessment process and then, as part of their implementation strategy, can partner with local government and community-based organizations to set priorities for the policy strategies that will lead to the greatest improvement in community health.
Step 3 is the key to long-term success of hospital community benefits programs. Hospitals most likely to reduce the incidence of disease in the communities they serve are those that focus the use of community benefit resources — specifically in policy areas that are proven to have the greatest impact on improving community health outcomes.5
PUBLIC POLICY CHANGES
While learning to work in a policy context may be a steep learning curve for some hospitals, the fact is that hospitals across the nation are partnering with community-based organizations and local governments to create lasting changes. Either through direct participation or through funding relationships with community-based partners, hospitals have supported evidence-based public policy changes on issues such as:
Tobacco-free places: More and more communities are extending protections from secondhand smoke to include outdoor areas. For example, New York City requires smoke-free parks, beaches and pedestrian plazas.6 Additionally, local and state governments from California to Maine are taking steps to protect tenants from secondhand smoke drifting in from neighboring units, such as by requiring landlords to disclose the smoking policy to new and potential tenants. Nationwide, more than 230 housing authorities have adopted smoke-free policies for some or all of their units. One of the largest is the Boston Housing Authority, which prohibits smoking in all of its approximately 14,000 housing units.
Healthy food: Communities have successfully used a combination of proverbial carrots and sticks to encourage greater access to healthy foods and discourage unhealthy foods. Rockford, Ill., used a loan from the U.S. Department of Housing and Urban Development to develop a supermarket in a low-income neighborhood, and Cleveland updated its zoning code to allow urban agriculture (such as community gardens and pocket parks) in residential districts. To encourage healthier neighborhood dining options in a community saturated with fast food, the city of Los Angeles banned new fast-food restaurants in South LA and financed a full-service grocery store in the same neighborhood to serve the extremely low-income community.
Physical activity: Pedestrian-friendly neighborhood design helps people stay active and healthy, and it also can reduce traffic and pollution. Other successful strategies include joint or shared use agreements, as in Merced, Calif., where schools agreed to open up school fields and certain gymnasiums to be used by the community after school hours. In Minneapolis, the zoning code requires at least one bicycle parking space for every 20 automobile spaces. Kansas City, Kan., adopted a complete streets policy in April 2011 that sets new street design standards including narrower streets, wider sidewalks and bike lanes or wide, shared-use travel lanes.
Healthy housing: It is important that individual housing conditions be safe and healthy. A program in Greensboro, N.C., helps low-income homeowners and rental tenants pay for a lead risk assessment to find out if old lead paint is deteriorating and offers assistance in paying for contractors to correct the hazards.7
ADDED EFFICIENCIES
Rather than targeting a single disease or health condition, PSE strategies impact multiple community health needs at once. For example, smoke-free policies curb incidences of lung cancer and reduce asthma rates. Policies that create more bikeable and walkable communities, or policies that increase access to healthy food, simultaneously address a broad range of chronic diseases, including cancer, heart disease, obesity and diabetes, and broader issues such as aging in place, social isolation/mental health and climate change. As a result, PSE strategies are highly efficient because a single strategy can address multiple community health needs at once.
Through community benefit programs, hospitals can participate more fully in improving the environmental conditions that support good health for their communities, to improve patient health and help fulfill the charitable mission of nonprofit hospitals and health care systems.
MARICE ASHE is the founder and chief executive officer of ChangeLab Solutions, a nonprofit organization in Oakland, Calif., providing community-based solutions to prevent disease.
LESLIE ZELLERS is an Oakland, Calif.-based attorney and policy expert specializing in public health and health care.
NOTES
- See, for example, County Health Rankings at www.countyhealthrankings.org/roadmaps/what-works-for-health.
- Scott C. Williams et al., "The Adoption of Smoke-free Hospital Campuses in the United States," Tobacco Control, Aug. 20, 2009, http://tobaccocontrol.bmj.com/content/early/2009/08/20/tc.2009.030494.abstract.
- James Corbett and Manel Kappagoda, "Doing Good and Doing Well: Corporate Social Responsibility in Post Obamacare America," Journal of Law, Medicine & Ethics 41, no.1 (Supplemental Issue, March 1, 2013).
- Trust for America's Health, The Truth about the Prevention and Public Health Fund, June 2013, http://tfah.org/report/106/.
- For additional examples, see Centers for Disease Control and Prevention, "Community Transformation Grants: Accomplishments," www.cdc.gov/communitytransformation/accomplishments/index.htm.
- For model policies, how-to guides, fact sheets, tools and other resources, see www.changelabsolutions.org.
- See http://www.nycgovparks.org/facility/rules/smoke-free.
- For more information, see City of Greensboro, Lead Safe Housing Program, www.greensboro-nc.gov/index.aspx?page=1556.
CHANGELAB SOLUTIONS
Aprivate nonprofit organization, ChangeLab Solutions of Oakland, Calif., partners with health leaders, community stakeholders and local government agencies to assess existing policies that inhibit healthy activities, strategize locally relevant solutions and then develop customized policy tools to create systems that support healthy behaviors and deliver improved health outcomes.
The organization specializes in researching and drafting model laws and policies, providing analysis and recommendations on environmental change strategies, developing educational tool kits and fact sheets and providing training and technical assistance to stakeholders who seek to address the social determinants of health in their communities. It offers the largest library of model laws and policies in the nation. Their tools and resources are grounded in science and are useful in small towns, suburban centers and major cities.
These resources have been developed with funding from the Centers for Disease Control and Prevention, the Robert Wood Johnson Foundation and many other philanthropic and government agencies. For more information, visit www.changelabsolutions.org.