Better health for those outside the system

Minor interventions yield major improvements

“Health is not only when you go to the doctor,” said Dr. William Paul, director of the Metro Public Health Department, “but how you live your life — in your home, school, work, and in between those places.”

As Middle Tennessee continues to grow, city leaders are trying to align the area’s infrastructure with healthy choices, making it easier for citizens — particularly those in lower economic strata and/or without insurance — to improve their health as part of their daily lives. Transportation and food availability are the obvious considerations, but community health is affected by a range of factors that include education, employment, crime rates, housing and zoning.

“How do you make the world around you healthier? There’s a buzzword for that — ‘health in all policies,’” Paul said. “It’s big-picture planning. How do we go from treating people who are sick to making communities healthier and reducing medical costs through community efforts?”

An ounce of prevention is worth a pound of cure, the adage goes, and it’s an idea with serious implications for the nation’s quality of life. Throughout the health care industry, providers are emphasizing chronic disease prevention and management, making the link between clinical diagnoses and social factors stronger than ever. Stakeholders from every part of the industry are looking at higher-risk communities in a new light and emphasizing the lifestyle elements that help — or hinder — healthy choices.

The most profound influences on a person’s health, Paul said, occur very early in life. Both the health department and nonprofit community clinics like Nashville-based United Neighborhood Health Services contribute a significant percentage of their resources toward healthy pregnancies, infancies and childhoods.

“If I had unlimited resources, they would be loaded in early childhood,” Paul said. “Your health status for your entire life is based on interventions in the first years of life.”

Following that philosophy, United Neighborhood is part of the Strong Start for Mothers and Newborns Initiative, a federally funded three-year program to reduce pre-term births. Providers at United Neighborhood clinics evaluate the risk of pregnant women, providing resources and counseling to high-risk patients to improve health and lower costs, said Mary Bufwack, CEO of United Neighborhood.

The health department also focuses on school-age diseases — the often-chronic conditions that keep children out of school and have long-term implications on education and earning power — that are intrinsically linked to health quality.

“We’re starting a pilot program around asthma,” Paul said. “If kids are out of school with worsening asthma symptoms, we need to make sure their care plan is what it needs to be. And if there are environmental changes we can make, we should.”

Many of United Neighborhood’s chronic disease approaches are rolled into the Patient Centered Medical Home program, a federally certified initiative intended to coordinate primary care. Providers at the nonprofit are emphasizing early identification and good management of conditions like diabetes, and are increasingly evaluating the behavioral factors that affect disease management.

“It is very common for those with diabetes or congestive heart failure to be experiencing a level of depression,” Bufwack said. “If you’re not managing the depression, your motivation to deal with your diabetes may not be there. There is a lot of stigma in mental health and it really stops people from asking for help. But if it’s identified as being part of the medical visit, it doesn’t have near as great a stigma. It becomes about your well-being and your health.”

Increased access to preventive services reduces high-cost, high-acuity emergencies, so from a public health perspective, most expect the federal health insurance mandate to have a positive impact on both wellness and medical spend.

“The more our patients are insured, the more options we have when we want to refer them to specialists or get them tests,” said Bufwack. “We’d love to be able to get people colonoscopies, mammograms. Our people who don’t have insurance have significant financial barriers to getting those kinds of procedures.”

More groups, longer hours

United Neighborhood clinics also will soon begin offering group visits, Bufwack said, encouraging patients to lean on peer support for health management. Diabetic patients and pregnant women will be the first groups to try the program, in which the clinic will host a health education class for a group of patients while the physician visits with each one individually.

The group approach also is at the heart of a recently announced collaboration between Vanderbilt University, the United Health Foundation and Yale University that aims to develop a new model of prenatal care. The venture will combine individual check-ups with group education and discussion session. The pilot program is looking to enroll 400 Nashville-area women in the coming months.

UNHS also is increasing the availability of its services, which has a particular relevance for impoverished patients. While many traditional providers are seeking to increase their after-hours and weekend access, nonprofit clinics have to do the same while also considering the transportation and community issues facing city planners and public health departments.

“If we don’t change our neighborhoods, we won’t change the occurrence of the diseases,” Bufwack said.

But Paul believes Nashville is well situated to improve community health by making changes to how the city’s health care stakeholders can work together. There is great opportunity, Paul said, in being director of the health department in the “health care capital” of the country.

“We’re just starting to find the opportunities where we can collaborate,” Paul said. “We are so rich with health care expertise and resources that we should be the healthiest city in the country. Finding ways to connect all the resources and brains that are devoted to our health in a way that improves the health of our population — that’s the challenge. But I’m confident we’re going to get there.”