We know that factors outside of health care including transportation, housing, and the built environment have a profound effect on individual and community health. It is estimated that only 20% of health outcomes are impacted by clinical care, whereas social determinants of health can impact health outcomes as much as 50%.
Many health care systems are increasingly thinking about their role in addressing social determinants. They are employing practices such as screening tools for social needs or supporting food and transportation services to drive positive change in health outcomes.
While these tools and investments can have an impact on an individual or neighborhood level, upstream solutions can broaden the intended outcomes to entire communities. Unless systemic barriers are addressed, health systems will only be able to mitigate, and not prevent, the root causes of poor health. Particularly for systems that see themselves as anchors in the communities they serve, partnering with local community development financial institutions, elected officials, and coalitions on both policy change and investments can create sustained and improved health outcomes at a broader level than systems can do alone.
CityHealth is partnering with Healthcare Anchor Network (HAN), a national collaboration of more than 70 leading health care systems, and Multiplier Advisors, a national health care impact investing consultant, to explore ways in which health care systems can work with cities to address the social determinants of health. In January, the organizations kicked off a six-month learning cohort for HAN members focused on the alignment of impact investments and policy advocacy at the local level. Cohort participants will have the opportunity to collectively explore the successes and challenges in achieving upstream policy interventions and create their own strategy for calibrating their impact investments with city needs and community organizations.
Kaiser Permanente and the Smokefree Atlanta Coalition
When it comes to the local policy environment, health care anchors can bring a powerful voice through their standing as community institutions and by leveraging their subject matter expertise. In February of 2019, Kaiser Permanente joined the Smokefree Atlanta Coalition as the city council was gearing up to consider a Smoke-Free Indoor Air ordinance. As public opinion was growing increasingly favorable towards indoor smoking bans and momentum was developing in other localities across the country, Kaiser Permanente brought a key health care voice to the local coalition — as well as policy expertise through their partnership with CityHealth.
When the coalition realized that the initial ordinance carved out an exemption for long-term care facilities, Kaiser Permanente quickly organized meetings with elected officials and staff. They explained the harmful impacts the exemption would have on residents and staff and arranged for their chief pulmonologist to testify in front of the council. Not only was an amendment passed to include long-term care facilities, a complete, comprehensive ordinance was signed into law in July 2019 and covered the Atlanta Hartsfield Airport. The impact of this local policy, which addresses both health behaviors and the built environment, means that millions of people will be protected from secondhand smoke. The Center for Community Health and Evaluation at the Kaiser Permanente Washington Health Research Institute (KPWHRI) — a non-proprietary, public interest research center within Kaiser Permanente Washington — researched and collected data on the impact of these policy implementations.
While indoor smoking bans are a direct example of how local policy interconnects with the work of health systems, issues like Greenspace, High-Quality, Accessible Pre-K, and safe and affordable housing also have impacts on health outcomes. Additionally, working with local coalitions to advocate for increased investments in these areas can have a profound change on the reach and sustainability of these policies.
UMass Memorial Health: Community Investments Coupled with Advocacy
UMass Memorial Health (UMMH) in Worcester, Massachusetts, has committed 1% of their investment portfolio — $4 million — to addressing social determinants of health in the community through targeted place-based investments, with an expected return on investment. By leveraging community partnerships, UMMH has been able to support a number of housing and community development projects focused on improving community health, including vacant property rehabilitation for first-time homeowners and the development of housing units for individuals experiencing homelessness.
Alongside their community investments, UMMH joined with a local coalition to push for additional city investments for housing. The coalition, which included community development corporations, the Central Mass Housing Alliance, and Black Families Together, successfully advocated for the city of Worcester to invest approximately 20% of its ARPA funds for housing — almost double what the city manager had originally proposed to spend.
These funds have been allocated towards establishing an Affordable Housing Trust fund and funding for a variety of other initiatives such as housing rehabilitation, first time homeowner assistance, and “Housing First” homelessness support. Although this work was not centered around a specific policy or legislation, UMMH’s advocacy efforts, in alignment with their own community investments, allowed for the advancement of housing stability and better health for the community of Worcester.
With so much of an individual’s health being shaped by factors outside of the walls of a hospital or clinic, health systems must look beyond their clinical tools of tests and treatments. Through partnerships, coalitions, and more comprehensive approaches, they will be better positioned to promote community health. As research continues to show the link between both physical and mental health to areas such as housing stability and quality or access to educational opportunities, there is a legitimate role for health systems to play in informing these issues.
Lauren Talley is a program assistant with CityHealth.