Monday, April 28, 2014

Health Disparities

I am going to write about an event that occurred recently in Alma in Gratiot County, Michigan.  As part of that, I am going to mention some of the sobering facts of life about that part of the state. So before I get into that, I want to say how beautiful Gratiot County is.  Visit the Parks and Recreation website for some Gratiot eye candy. And has a great photo essay on the Gratiot County wind farms which, in addition to being beautiful, are helping to propel economic recovery.  Beauty is also in people’s hearts.  Whether you are talking about the folks who volunteered to develop the Great Plan, or the ones who turn out every week to volunteer at the Gratiot County Free Clinic, it seems like there is no limit to their giving.

The last week of March I attended Michael Vickery’s Health Communication class at Alma College with Dr. Rakesh Saxena from MidMichigan Medical Center – Gratiot, to talk about community health. The discussion turned to the Gratiot County Free Clinic—which had been a focal point of their studies that semester—and students began to challenge us.  The Free Clinic’s target population is uninsured people with chronic health conditions.  It aims to help its patients manage their chronic conditions by connecting primary care with services like counseling, nutrition education and incentives for lifestyle changes, so they can recover their health.  But some of the students were suggesting the Clinic wasn’t doing all it could to accomplish that goal. For example, the Clinic had not yet secured a volunteer dietician to do the nutrition education. The push from the students was welcome.  After the class, Dr. Saxena approached me to ask if the Health Department could help him secure a dietitian ASAP.

But I thought there was another issue that some of the students—like many of us—found difficult to integrate with their thinking about preventive health care services, and that is the fact that differences in health—health disparities—are caused by more than differences in access to care.  People who come to the Free Clinic tend to be much sicker to begin with, and for reasons I will explore below, are less likely to benefit from care than others. Providing care by itself cannot eliminate these disparities.

And Mid-Michigan does have health disparities. A significant proportion of the population of Gratiot County is low income. Eighteen percent live below the poverty line, 18% were uninsured before the role out of the Affordable Care Act, and only 13% have a college degree.  The health outcomes of the low income folks are worse than those with higher incomes. Half of those with incomes below $15,000 have high blood pressure, while only 16% of those with incomes above $75,000 do. The breakdown is the same for obesity. Thirty-two percent of those with incomes below $15,000 have high cholesterol while only 19% of those with incomes above $75,000 do so. It’s like this for every important measure of health status.

It is tempting to believe that the best way to address health disparities is to focus on providing the same kind of health care to lower income people as is provided to folks with higher incomes. Indeed it is difficult not to think that way and we should provide equal care.  The provision of care is part of a heroic narrative that includes Albert Schweitzer’s missions, the establishment of Federally Qualified Health Centers and the Affordable Care Act itself. But while the provision of equal care may improve the health of low income people somewhat, it will not eliminate health disparities.

Our health is influenced by many factors of which care is only one. Here are some examples of other things that affect health which are related to income:

Social support—people in lower income households are more likely to have endured breakups or abuse. Family problems inhibit people from taking care of their own health.
Housing—lower cost housing stock is more likely to be unhealthy, for example having lead contamination, black mold, asthma-causing insects, etc.
Transportation—lower income people are less likely to have their own vehicles, may have poor access to public transportation (especially in rural areas) and have less ability to control their use of time because of the kind of work they do.
Emotional well-being—stress and worry inhibit people from taking care of themselves and economic insecurity is a source of great stress and worry.  A new study from the Michigan Department of Community Health illustrates this nicely.
Health behaviors—lower income people are more likely to do things that harm health like smoking. These behaviors go by many names from dysfunctional coping to self-medication, and while there may be good explanations for why people act this way, the explanations do not remove the harms.

One thing that makes us think about providing more care, rather than dealing with the other things that are the main causes of health disparities, is that it is hard to think about changing social conditions—reducing poverty, increasing community, establishing justice.  But practical examples of ways to make positive impacts are all around us.  Toward the end of the class I told the students my candidate for health hero in Gratiot County would be Don Schurr of Greater Gratiot Development, Inc.  By leading the charge to establish the wind farms, Don has helped to clean up the environment, create jobs, raise the incomes of local families, increase the budgets of the community’s human service agencies and one could go on and on. There are many people in Gratiot County who won’t need health care quite so soon because of Don’s work to improve the fundamental conditions in the community.

Friday, April 25, 2014

Hiring a Community Health Worker

I have written before about the shrinking staffs and budgets of local health departments.  The National Association of City and County Health Officials (NACHO) has published a sobering assessment of the state of the nation’s local public health system which documents layoffs, cutbacks and reductions in programming across the country.    Some local health departments have decided that the verdict from voters and legislators is clear: they do not value public health services.  These departments have reduced their programming to no more the minimum required by law. Other health departments are trying to find new ways to support preventive services in their communities.  Recognizing that funding from local, state and federal taxes will continue to decline, they are becoming social entrepreneurs, trying to identify who benefits financially from preventive services and entering into business agreements with them to sustain these services.

In Michigan, these ideas are part of the State’s plan for improving community health called the State Innovation Model (SIM). The SIM is comprehensive and contains many moving parts, but one piece of it focuses on what are called Community HUBs.  These HUBs may or may not be connected to local health departments, but they share one feature in that they deploy Community Health Workers (CHWs) who work with health care providers to ensure that the sickest and most vulnerable among us get access to preventive care.  CHWs do this by de-duplicating care plans and services and ensuring that clients get all the services to which they are referred, and they follow up to ensure compliance.

HUBs are not supposed to duplicate the care coordination efforts many health care providers are undertaking now.  They are supposed to step in where those efforts fail, with people who fall between the cracks in the health care system—people who frequently and inappropriately use emergency rooms, people with chronic mental health problems that are not under control, etc.

Obviously, there are groups who could benefit from the work of CHWs.  If CHWs are successful in getting people to use emergency rooms more appropriately, health plans would have to pay less for those patients.  And if those people become healthier, physicians and health care systems trying to achieve pay-for-performance goals stand to make more money.

The Mid-Michigan District Health Department has taken one tiny step in this direction.  We have hired our first Community Health Worker!  This person will be working with residents of Clinton County through a HUB located in Lansing.  We are nervous about it, because the HUB doesn’t have any contracts with health plans or hospitals yet.  It is still coasting on grant dollars.  However, we have spoken to some of the plans to find out what their attitude is.  They tell us they love what the Ingham HUB does for their patients and are anxious to see evidence that money has been saved so they can justify signing contracts.

In my opinion, CHWs should not primarily be based in health departments, but should be located in any provider of preventive health services who needs to increase their capacity.  CHWs could help all kinds of community-based organizations improve outcomes for their clients, whether they be substance abuse prevention coalitions, United Ways, mental health providers, etc.

This is an exciting and important experiment.  CHWs could potentially open up a new model for sustaining preventive services and reverse the fraying of the safety net. In five years will human service agencies in Mid-Michigan have a complement of CHWs out in the community?  I hope so.