Primary Care and Population Health: Second in a Five-Part Series

Nicholas Stine, MD, and Dave Chokshi, MD, MSc, writing on behalf of the New York Academy of Medicine Primary Care and Population Health Working Group.

The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders in primary care and population health. In the second of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.
file Nicholas Stine and Dave Chokshi

Challenges in the Urban Context: Discussants converged upon care fragmentation and community diversity as the most difficult challenges associated with working in urban settings. There may be enormous heterogeneity within populations in urban areas with respect to racial, ethnic, and sociodemographic characteristics. Subgroups may vary with regard to exposures, behaviors, and values. The sense of community that can be essential to leveraging social groups may not necessarily be present or uniform throughout a geographic area, necessitating multiple tailored communication strategies. Even between cities, there is significant heterogeneity, such that non-clinical interventions may be less transferable than, say, a chronic disease model.

Communities that do exist may not necessarily conform to geographic boundaries, and the geopolitical boundaries and layers of jurisdiction in place may mean little to those communities. This changes how confident clinical systems can be for outreach and aspects of care that might reach beyond the office, and in general it can be particularly challenging to know what services are being provided for a patient, where, and by whom. This accountability problem makes it easier for high-risk patients to fall through the cracks.

John Auerbach, MBA, illustrated this accountability challenge: “I asked the leader of one of our state’s likely ACOs—a large organization, mostly outpatient and led by civic-minded people—if it would be willing to invest resources in the surrounding community to promote public health activities for the larger population.  He said, ‘We’d love to, but we have only 20% of the market share for our catchment area and it’s not fair to ask us to invest in the health of a population, 80% of which is not our patients. We can only contribute if all the other providers are willing to contribute.’ This was the opinion of one of our most enlightened health care organizations, and it illustrates the challenges we face in focusing on population health.”

Urban settings may also experience more rapid shifts in demographics. For example, in Seattle, David Fleming, MD, described a recent influx of affluent white residents into the urban core who have displaced poor and minority communities to “peri-urban” communities in the southern part of the city. And while overall health status has been improving, disparities have been increasing, so there is an imperative to invest in these multiple new communities, creating a moving target for community-level investment.

There are unique social and environmental determinants of health in urban settings. Safety may be a significant reason why some people don’t access services, or don’t walk or exercise. Alternatively, urban crime may be a deterrent to health professionals attempting to reach out to communities. Meanwhile, air pollution from vehicles and industrial emissions has a geographic effect on respiratory diseases.

Opportunities in the Urban Context: Discussants also identified multiple aspects of urban communities that may confer a strategic advantage when addressing population health. Many of these opportunities have to do with geographic density of people, services, and expertise such that certain advantages of scale and clustering can be realized.

Population density creates the opportunity to embed providers within high-risk communities. Whereas rural settings may provide more clinically-based outreach services, urban providers often have a wider array of partners already embedded in the community. Boston’s Breathe Easy at Home program, for example, provides a link in the patient’s electronic medical record for the health care provider to initiate referrals to Boston Inspectional Services Department for an inspection and initiation of addressing environmental factors that exacerbate asthma.

Regarding the opportunity to align community development resources and health, David Kindig, MD, PhD, notes that “this is uniquely urban… and the scope of resources in play is dazzling. These entities are still learning each other’s language, but there is much shared purpose.” Clinical services themselves may be able to take advantage of densely populated settings, as evinced by the case of Duke placing nurse practitioners and other health team members in public housing projects and areas of subsidized elder housing.

Thinking even more broadly about community resources in densely populated settings, churches are sometimes the most respected and socially powerful organization in low-income neighborhoods. The Congregational Health Network (CHN) in Memphis has demonstrated that clergy and other church representatives can promote better health by serving as role models, creating and encouraging use of community-based activities and programs, helping individuals adopt healthier lifestyles, and serving as a link between congregants and the health system.

“The real actionable edge in CHN is not hospital employees or clergy, it’s the informal caring networks within congregations,” notes Gary Gunderson, M.Div., D.Min., D.Div. Enrolled congregants are flagged by the health system's electronic medical record whenever admitted to the hospital. A hospital-employed navigator visits the patient to determine his or her needs, and then works with a church-based volunteer liaison to arrange post-discharge services and facilitate the transition to the community.

Most discussants agreed that urban settings faced some of the most significant population health challenges, and that they weren’t aware of existing frameworks and best practices specifically oriented around these challenges. David Kindig mentioned ongoing work with George Isham, MD, MS, calling for the development of a collective business model for multi-sectoral solutions—an “Accountable Health Community”—which might be particularly suited to mapping and better understanding the complex urban setting. With so many diverse stakeholders, incentives, and communities, many expressed enthusiasm for such organizing propositions.

Visit the RWJF Human Capital Blog tomorrow for Part Three in this series, which will look at local and state health department collaboration. See Part One of the series, which includes a list of the thought leaders interviewed for the survey, here.