March, 2012
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IAF and NACHC Projects funded by the Kresge Foundation
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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
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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?)
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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
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Health is shaped by many factors, particularly the social
determinants of health
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Growing focus on the Triple AIM and Population Health
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Population health requires going beyond the clinic to
shape community conditions.
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CHCs routinely do this in a many ways as they “leverage
the social determinants of health”
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This project identifies & summarizes CHCs’ efforts
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Partnership with the National Association of Community
Health Centers
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Kresge Foundation grant to the Institute for Alternative
Futures
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National Workshop of leaders considering state of
knowledge, state of the art, and recommendations
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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.”
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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.”
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RWJF: “Health starts where we live, learn, work and play.”
Behavior
Socioeconomic
conditions
M2002
40%
HPC
CHR
30%
50%
40%
10%
15%
25%
10%
Environment
Social
Physical
Genes
Healthcare
15%
5%
30%
10%
20%
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/
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COPC Origins of CHCs
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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”
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SDH in Emerging Models of Health Care: Chronic Care
Model, PCMH, Comprehensive Health Home, Community Centered Health
Home
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Healthcare Quality (the Triple Aim) requires improved
population health
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Hippocrates & Flexner
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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.
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Create Database
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Website www.altfutures.org/CHC-SDH
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PCA Surveys
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Key literature; online searching; announcements
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CDN literature review of cases in peer reviewed journal
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Conference sessions NACHC 2011 P&I, CHI, CDN Webinar
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Specific network requests
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Data Base: 176 Efforts/52 CHCs (50 FQHCs, 1 Look-Alike, 1 Social
Service Agency)
◦ Limitations: not random sample, not exhaustive
◦ But indicative
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and supplemented by
◦ CDN literature review,
◦ 10 case studies, and
◦ data from HRSA/BPHC Universal Data System
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Beaufort-Jasper-Hampton Comprehensive Health Services, Ridgeland, South
Carolina
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Centro de Salud Familiar La Fe, El Paso, Texas
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Community Health Partners, Livingston, Montana
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Hudson River HealthCare, Peekskill, New York
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Joseph P. Addabbo Family Health Center, New York, New York
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Kokua Kalihi Valley Comprehensive Family Services, Honolulu, Hawaii
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La Clínica de La Raza, Oakland, California
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La Maestra Community Health Centers, San Diego, California
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Sea Mar Community Health Centers, Seattle, Washington
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Sixteenth Street Community Health Center, Milwaukee, Wisconsin
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Most CHCs Leverage the SDH
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CHCs pursue a wide range of effort areas
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CHC Leadership is key
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Variety in how SDH efforts are managed
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Partnership, partnerships, partnerships
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Funding is often a challenge, most programs are not selfsustaining
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Unclear about impact/effectiveness beyond anecdotal
results (which are impressive)
In 2007, CHCs reporting to HRSA/BPHC provided or made referrals for:
98.7% - health education
98.3% - eligibility assistance
94.8% - WIC services
92.4% - parenting education
91.1% - nursing home and
assisted-living placements
90.1% - food banks or delivered
meals
90.1% - obtaining suitable
shelter
89.7% - Head Start services
89.0% - employment and
educational counseling services
82.9% - environmental health
risk reduction programs
68.1% - child care during a patient's visit to the center
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HRSA program expectations call for it
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It’s in the DNA of CHCs
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Models of primary care and health quality increasingly
require improved population health
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Believe that sustainable impact on health requires
community-level interventions.
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Are well-positioned for it (know their communities
well; have a stable, long-term presence; employ
community members)
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Education
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Job Skills, Employment, and Workforce Development
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Healthy Eating and Diet
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Physical Activity and Exercise
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Social Conditions, including community safety, wellbeing, and
involvement; family and social support and emotional wellbeing
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Economic Development
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Housing, Built Environment, and Recreational Spaces
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Policy, Advocacy, and Activism
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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)
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Reach Out and Read 18% of all 8,100 CHC sites in 2010
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National Center for Medical-Legal Partnership in 150 CHCs
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Health Leads 660 college volunteers, across 22 sites in 2010,
including 5 CHCs
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AmeriCorps & NACHC Community HealthCorps Nearly 500
members in CHCs often functioning as community health
workers & advancing community gardening
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Women, Infants and Children Program (WIC)
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United Way
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Canyon Ranch Institute to prevent, diagnose, and address
chronic diseases, provide exercise equipment
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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.
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TimeBanks USA to promote equality and build caring
community economies through inclusive exchange of time and
talent.
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States' Department of Education or a State agency serving the
same function may assist with planning, designing, or
implementing new charter schools.
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Most Frequent: obesity, diabetes, hypertension,
cardiovascular disease and asthma
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Behavioral or psychiatric problems among community
members, e.g., depression among socially isolated
seniors
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Less Frequent: parasitic worms; depression; mercury
content in local fish
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Anecdotal observations by CHC personnel or community
members
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Grant opportunities
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A non-CHC organization approaches the CHC or provides the
opportunity, e.g. national programs
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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
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Less frequently: stepping in to enable the survival of existing
programs or efforts by others
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.
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Distributed among several departments.
◦ Several CHC departments engage in specific efforts that address the SDH, along with
their respective clinical programs and services.
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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.
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Project-based management teams.
◦ Consist of personnel from across the organization and form and disband according to
funding opportunities.
CHCs are great at partnerships.
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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
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Community support and enthusiasm is essential and
community input affects program design
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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”.
Funding is often a challenge.
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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.
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Among 176 efforts, grants range from $2,500 to more than
$8 million.
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Estimating the share of a CHC’s total work or funds that go
to leveraging SDH is challenging.
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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.
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28 or more (16%) rely on internal funding (including
donations) to varying degrees
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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
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Meet performance requirements at each renewal to maintain
government sponsorship, e.g., charter schools, WIC, and government
subsidies for low-income housing.
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Relatively heavy initial investment and then become selfsustaining, 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 selfsustainable.
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Use donations and/or CHC operating budget if cost is small,
e.g., for students to shadow health professionals, providing nonpartisan
voter registration forms
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Create and later transfer efforts to other organizations or turn into
small businesses.
Most programs, however, are not entirely self-sustaining.
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Often require outside funds & continually subject to
changes in funding levels.
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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.
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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)
o Dropped the prevalence of
lead poisoning among
children from 34 percent in
1996 to 1.8 percent in 2011
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.
◦ Housing
 ~200 beds and
adequate/safe housing for
farmworkers
 20 rental apartments for
low-income families plus 5
units for families
transitioning from
homelessness (all fully
occupied since 2010)
◦ Scholarships ($1,000@)
 140+ scholarships in 2010
 1,600 students since 1995
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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
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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
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Helped organize water systems and fire protection for two
counties
Worked with state government to change policy and mandate
better sanitary services
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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.
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From 1998 to 2003, trained over 560 community members to
work as medical assistants, pharmacy technicians, eligibility
workers, outreach workers, and referral clerks
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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
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CHCs meet all grant reporting requirements
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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)
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5 of 52 CHCs partnered with a third-party evaluator,
paid through the grant for a particular program/effort
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Most reports of successes are anecdotal
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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
What CHCs Should Do
Spreading the leveraging of the social determinants of health among community
health centers
1. 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.
2. 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.
National Leadership and Funding
Developing an evidence-base for leveraging the social determinants of health, and
identifying and disseminating best practices
6. 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
7. To create a national learning community, HRSA should include
the leveraging of the social determinants of health in existing
national breakthrough collaboratives.
National Leadership and Funding
Incentivizing engagement of the social determinants of health
12. 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
13. 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.
14. Pass on the legacy of community aspirations and the social
determinants of health.
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CHCs generally and efforts to “leverage the social
determinants of health” provide important opportunities
in your communities
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Are there efforts to leverage the SDH in your community
that your CHCs should be involved in?
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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
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Next steps include working to develop recognition and
awards for best practices in leveraging the SDH, and CHC
training.