Communities of Solution: Partnerships for Population Health

Engaging Stakeholders: Crossing Boundaries

In “Advanced Primary Care in San Antonio,” Ferrer et al³ utilize health promotion promotores to create relationships with patients in the community, and they engage city planners to map community resources and community partners for each patient's neighborhood and thereby tap into community resources to maximize health (grand challenges 2, 7, 8, and 10, presented in Table 1). The essential tracking of health outcomes, although early, is an essential piece of the COS. The Brazos Valley Health Partnership COS involves the establishment of “one-stop shops” that provide patients with services ranging from health care to Senior Meals to legal aid. Because of the difficulty accessing services experienced by these rural community members, Garney et al⁴ explain that “county boundaries are irrelevant with regard to social and health issues that residents face” (grand challenges 2, 4, 8, 10, and 11). This COS reveals the importance of involving numerous sectors of the community, including community-based organizations, governmental leaders, and health care providers (Figure 1).

• Download figure
• Open in new tab

Figure 1.

Example of a community of solution to address a specific problem shed. Reprinted with permission of the publisher from Health Is a Community Affair, by the National Commission on Community Health Services, p. 3, Cambridge, MA: Harvard University Press,C 1966 by the President and Fellows of Harvard College.

In “Boot Camp Translation” the High Plains Research Network⁵ describes the process for identifying health problems and then building a COS to translate the best medical evidence into locally relevant and actionable projects. The High Plains Research Network brings together patients, community members, health care providers, public health agencies, and community-based organizations to address the important health issues of their populations. This process relies on the expertise of everyone, in both academia and the community, to develop a local solution (grand challenges 2, 4, 8, 9, 10, 12).

Lagom

Lennon et al.⁶ present a military health system COS for medical education, health care delivery, and public health. This article highlights the relative ease of creating meaningful COSs in the cohesive military communication structure. The authors also propose a compelling definition for the correct size of a COS: lagom—“while there is no direct English translation, lagom essentially means ‘just the right amount'|PO. The local COS is an organic entity that will expand and contract in scope until it reaches the right size for the patient community it serves, as measured by the outcomes it chooses to achieve”⁶ (grand challenges 2, 8, 9, 10, and 13). In contrast, the OCHIN Community Information Network⁷ identifies “problem sheds through surveillance of network-wide data” by facilitating locally relevant data sharing among public health partners, community health stakeholders, informatics, and policy. This place-based data component of a COS, although on its face less relationship-based, also enables understanding and outcomes measurement of any identified community health problem (grand challenges 1, 10, 11, and 13).

COSs are indispensable to the mitigation of health disparities because of social determinants of health. A collaboration between the Jefferson Department of Family and Community Medicine and Pathways to Housing-PA creates a jurisdiction crossing lagom COS for a homeless and mentally ill population (grand challenges 2, 3, 9, and 10). Weinstein et al⁸ highlight the current reality that many of these COS roles are “not about to be reimbursed under current insurance mechanisms.” This program provides evidence for the ongoing relevance and breadth of the Folsom Report and the COS framework in addressing the needs of individuals and communities.

Rural and Urban Lagom

In “HeartBeat Connections” (grand challenges 4, 7, 11, 12, and 13), Benson et al⁹ describe a rural program using participatory methods. Recognizing “common barriers to clinical CVD prevention (eg, lack of time and lack of patient follow-up)”,⁹ the project utilizes a multidisciplinary team for counseling and medication management through telephone outreach. Participants also are linked “to other resources within the community (eg, weight management classes, fitness facilities, and farmers' markets), thereby integrating medicine and public health.”⁹

Sanders et al¹⁰ focus on social determinants of health through their inner-city chronic disease management program with “nurse-led teams using protocol-driven clinical decision-making situated in 2 neighborhood food pantries” to focus on hypertension, hyperlipidemia, and diabetes (grand challenges 4, 7, 8, 12, and 13). Their Milwaukee model incorporates a network formed by volunteers, community health workers, local parishes, and strong faith-based connections. In a wider community focus, Baird Kanaan¹¹ describes the Healthy Mendocino COS as a “broad-based coalition” consisting of 20 community stakeholders with pooled funding to launch a web-based tool that will enhance the quality and utility of data for improving local health (grand challenges 7, 8, 11, 12, and 13).

These 3 examples focus on specific community problem sheds: urban, rural, and community wide, emphasizing the utility of Figure 1.

COS: Back to the Future

Can the U.S. public school system serve as a roadmap for health system reforms? (grand challenges 1–13) DeVoe and Gold¹² pose this question in a future-forward essay exploring how a neighborhood-based COS might use community health centers, public health outreach, information technology, and citizen-driven district health boards to deliver coordinated, efficient care.

Influences of the Pharmaceutical Industry

Two final articles discuss the influence of the pharmaceutical industry and the impact of physician disclosure under health care reform—the “Sunshine laws.” In “Physician Payment Disclosure Under Healthcare Reform: Will the Sun Shine?” (grand challenges 8, 10, 11, and 13), Mackey and Liang¹³ illustrate the intent of regulation efforts to control pharmaceutical costs and mitigate conflicts of interests for providers. Evans et al¹⁴ (grand challenges 10, 12, and 13) have an answer to the pharma dilemma: engage in a pharma-free practice redesign. Their clinic transformation includes consensus agreement by clinical and front office staff, detailed cost data on drug samples, and monitoring of pharma visits, all done as part of a quality improvement initiative.

The Payer Conundrum

It is interesting that none of the articles presented include a defined role for insurance companies within the COS; ideally payment would be a powerful incentive to create effective problem-solving structures for problem sheds. However, coverage guidelines from insurance stakeholders may confuse patients about whether the clinician or the insurance provider is actually making care decisions, which creates an inherent conflict within a COS. We believe that payers will become involved in development and support of COSs because their patients derive benefit from living and working in a community that values healthy living. Could an effective accountable care organization actually be a COS with payers included? We hope that visionary payers will accept the grand challenges of the Folsom legacy and begin immediately supporting the development of true COSs in their neighborhoods, catchment areas, and states.

Folsom Forward

These articles illustrate exciting opportunities and COS models and highlight persistent health disparities that plague our nation. COSs may be crucial steps toward addressing social determinants of health. Positive change is anchored to sustainable community approaches that link public health and primary care in explicit partnerships to address the needs of the individual and community. Together, when we build a COS, an environment and a neighborhood that supports healthy living, we contribute to the health of the whole population.

The Folsom Group: Sarah Lesko, MPH, Center for Researching Health Outcomes, Mercer Island, WA; Kim S, Griswold, MD, MPH, University of Buffalo, SUNY School of Medicine and Biomedical Sciences, Buffalo, NY; Sean P. David, MD, SM, DPhil, Stanford University School of Medicine, Palo Alto, CA; Andrew W. Bazemore, MD, MPH, The Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC; Marguerite Duane, MD, MHA, Spanish Catholic Center of Catholic Charities, Washington, DC; Thomas Morgan, MD, Vanderbilt School of Medicine, Nashville, TN; John M. Westfall, MD, MPH, University of Colorado School of Medicine, Aurora, CO; C. Everett Koop, MD, SciD, The C. Everett Koop Institute at Dartmouth, Hanover, NH; Betsy Garrett, MD, University of Missouri School of Medicine, Columbia, MO; James C. Puffer, MD, The American Board of Family Medicine, Lexington, KY; and Larry A. Green, MD, University of Colorado School of Medicine, Aurora, CO, and the American Board of Family Medicine, Lexington, KY.