Health systems hope social initiatives will produce better health outcomes and lower costs

A tour through the "Body Metrics" exhibit at the Tech Museum of Innovation in San Jose, Calif., requires visitors to don bulky biosensors that measure brain waves, heart rate, breathing rate and muscle tension.

After suiting up, visitors stop by the interactive “Data Pool,” the museum's centerpiece, which displays the visitor's photo and describes his or her personal attributes, such as “active,” “ecstatic” and “engaged.” Then it offers a summary description, like “confident doer.” The goal is to create self-awareness about health, said Romie Littrell, lead curator for the exhibit.

The $3.5 million exhibit, which opened in 2014, has Kaiser Permanente as a supporter. It's free to schoolchildren, and 60% of visitors are from low-income schools. The program is one of the many community benefit initiatives that not-for-profit Kaiser supports.

In 2014, Kaiser spent $2.2 billion, or 3.9% of operating revenue, on community benefit programs. Some of its efforts stay close to traditional healthcare, such as supporting community health centers in their stroke and heart attack prevention programs. Others, such as the “Body Metrics” exhibit, are about encouraging healthy lifestyles. Many of its programs are focused on children. It also has a fitness partnership with pro hockey's San Jose Sharks to get underprivileged sixth-graders to become more active.

Kaiser has powerful reasons for wanting to keep its population healthy, since it runs both a 10.2 million-member health plan and an integrated healthcare delivery system including hospitals. The healthier its enrolled population, the lower the medical costs for its insurance arm. In Santa Clara County, where the Tech Museum is located, one-third of residents are Kaiser members, and many more could be future Kaiser members. So initiatives to improve community health could have a return on investment.

Kaiser's population-health improvement efforts are working, said Loel Solomon, vice president of community health. In 88% of its communities, there's evidence that people are making at least one positive health-related change, whether that's reducing consumption of sugar-sweetened beverages or increasing physical activity, he said. But Kaiser can't do it alone. Its programs must complement what other groups are doing, and they have to be sustainable. “This kind of community change work is a team sport,” he said.

A small but growing group of not-for-profit hospitals and health systems are spending more money on nontraditional community benefit programs designed to address social determinants that affect health, including crime, education, housing, hunger, jobs, poverty and violence.

Many of these projects fall outside the conventional range of community benefit activities, such as free clinics and health screening events. Instead, their focus is on building healthier communities by bettering people's lives.

Besides carrying out their not-for-profit charitable mission, these systems hope that their efforts will pay dividends under value-based payment models that reward providers for keeping people healthy. They also see these initiatives as a way to demonstrate that they are providing community benefit to justify their tax-exempt status, at a time when the Affordable Care Act is reducing the need for them to deliver their traditional community benefit of charity care, particularly in states that have expanded Medicaid under the ACA.

This month, Trinity Health announced it will invest $80 million in six communities it serves over the next five years to improve public health, with a particular focus on obesity and tobacco use. The Livonia, Mich.-based Catholic system, which operates 88 hospitals across the country, will work with community groups, local health departments, and technical advisory organizations in the six communities, to be named in January, to implement policies and programs to decrease obesity and smoking rates.

“As a health system, it is not enough to just treat illness,” said Dr. Bechara Choucair, Trinity's senior vice president for safety net and community health. “We need to be part of the business of creating health in our communities.”

A number of urban hospitals are trying to address their communities' economic needs by stepping up local hiring, recognizing that employment is related to good health, said Erika Poethig, director of urban policy initiatives at the Urban Institute. Such systems include University of Chicago Medicine, Penn Medicine in Philadelphia, and Johns Hopkins Hospital and Health System in Baltimore.

But some researchers question whether these efforts by health systems will be big enough to dent broad societal problems such as poverty and income inequality, and whether the systems are willing to step into controversial political fights that could involve government spending and regulation. Health systems are still trying to gather the evidence that their programs are having the intended impact.

Increasing access to medical care is less important to health outcomes than addressing social factors such as income inequality and support for parents during the first year of a child's life, said Dr. Stephen Bezruchka, a senior lecturer in the health services department at the University of Washington. “You have to recognize that nonmedical factors are what produce health,” he said. But, he added, “I don't see any hospitals trying to advocate for social change.”

There's broad agreement that social factors affect health and that healthcare organizations need to pay more attention to them in working with their populations. Last year, the Minnesota Health Department reported to the state Legislature that clinical care determines only 10% of health outcomes, social and economic factors determine as much as 40%, and healthy personal behaviors influence another 30%. “The leading conditions bringing people into these (health) systems are very much patterned on social conditions,” said Dr. Steven Woolf, director of Virginia Commonwealth University's Center on Society and Health.

But what's less clear is the role that health systems can play in changing those social determinants of health.

In Minnesota, HealthPartners, like Kaiser Permanente, operates as both an insurer and a provider, with more than 1.5 million people in its health and dental plans. So it has the same incentives for keeping members healthy. Also, like Kaiser, it has put a major emphasis on children.

One of its core initiatives is a 10-year program called PowerUp for Kids, which tackles childhood obesity. About 10,000 children in 26 elementary schools have participated in the six-week challenge, which focuses on eliminating sugar-sweetened beverages, getting them to eat more fruits and vegetables, and encouraging them to be more active.

The program has a greater than 90% participation rate, and it eventually will quantify health outcomes, said Nico Pronk, HealthPartners' chief science officer. One of the challenges is the lack of good data allowing the health system to assess program effectiveness. “We're getting some data, but at this point in the process, it's still very young,” he said.

In the U.S., most attention and funding is still devoted to providing clinical services to people with medical conditions rather than improving health conditions for the larger population. The U.S. in 2009 spent 16% of its gross domestic product on healthcare but only 9% on social services, according to a 2011 study in BMJ by Elizabeth Bradley, a Yale University public health professor. In contrast, many European countries that score higher on population health outcomes spend more on social services and less on healthcare. Switzerland, which has one of the highest life expectancies in the world, spent 11% of GDP on healthcare and 21% on social services in 2009.

Bezruchka argues that if hospitals want to be effective in improving population health, they need to advocate for public policies such as a higher minimum wage and paid maternity and paternity leave.

Trinity's program will include working with community leaders to pass laws that improve public health, said Marice Ashe, CEO of ChangeLab Solutions, an Oakland, Calif.-based not-for-profit that is partnering with the system on its new community health improvement initiative.

But Bezruchka acknowledged that it could take a generation for community health improvement initiatives to make a demonstrable impact, including a return on investment for health systems.

Some health systems are starting to gather the data themselves. ProMedica in Toledo, Ohio, is one of the founding members of the Root Cause Coalition, a group launched last month to find solutions for reducing hunger and food insecurity. A key area of focus will be supporting research that explores the link between illness and social determinants such as food and housing insecurity.

ProMedica and its CEO, Randy Oostra, have become prominent voices on the issue of hunger and health outcomes. The system has partnered with the Alliance to End Hunger to host an annual Come to the Table summit to encourage other organizations to address the issue. In its hospitals, ProMedica screens patients for food insecurity. In April, it opened a “food pharmacy” at ProMedica Toledo Hospital. Doctors can write a referral for patients to visit every 30 days to receive food items based on their unique health needs, for up to six months.

The system soon plans to open a grocery store at the site of the ProMedica Ebeid Institute for Population Health in Toledo, in a neighborhood that's considered a “food desert” because residents lack access to fresh food. It will include a local market selling fruits and vegetables and offer cooking classes, nutrition education and job training for local residents who will rotate through various positions.

Other hospitals and health systems are tackling the issue of quality and affordable housing, since there are solid data showing the link between housing security and health outcomes. In Baltimore, St. Agnes Hospital, owned by the large Ascension Health system, has partnered on an ambitious project to convert a nearby former high school into an apartment complex for low-income residents. It will feature an adjacent green space, a fresh food market, a restaurant and a fitness center.

Some of the apartments will be reserved for grandparents raising their grandchildren, who are often in that position because the parents are incarcerated or incapacitated. St. Agnes' congressional district has a high concentration of these intergenerational families. Studies of similar housing programs in the Bronx have shown that they lead to children having better school readiness, higher attendance rates in high school and college, and greater family stability—all of which contribute to better health outcomes, said Bill McCarthy, executive director of Catholic Charities of Baltimore, another one of the partners on the project.

“Stable housing is a missing resource for grandparents raising grandchildren,” he said. “What Ascension and St. Agnes saw is that community wellness is critical.”

Such partnerships between health systems and communities will continue to grow, said Jack Nelson, a law professor emeritus at Samford University who specializes in healthcare. “The line between public health and medical care has blurred,” he said.

—Maria Castellucci contributed to this article

This Modern Healthcare reporting was supported by a fellowship from the Association of Health Care Journalists and the Commonwealth Fund.