In late January, government officials announced a timeline for Medicare’s shift to paying clinicians based on quality of care rather than quantity of services. As Medicare goes, so go private insurers; this makes the agency’s move toward quality-based reimbursement nothing less than a sea change. It builds momentum for a view of health and health care that is integrated and holistic, rather than comprising discrete, disjointed episodes of treatment.
This shift to quality will make it easier to create a true culture of health, where we widen our focus from the individual to encompass the health of communities. To understand a patient’s health needs, we must consider the context in which she lives, works, plays, and learns. Community environments and related behaviors are the leading factors driving health outcomes, so it’s critical to make space to assess and address these issues in health care settings.
The community-centered health homes model is an example of this broader way of thinking. Expanding on the patient-centered medical home, it links high-quality medical care with prevention strategies for improving community conditions. This approach engages doctors, nurses, and the entire health system in understanding the underlying conditions that contribute to poor health in their neighborhoods and cities — and in changing those conditions for the better. Addressing the root causes of illness and injury will keep patients healthier in the first place, and support recovery of those who are sick or injured.
What does this look like in practice? At St. John’s Well Child and Family Center in Los Angeles, clinicians suspected that substandard housing conditions were the reason why many patients presented with lead poisoning, skin diseases, and rodent bites. Clinicians began asking patients a set of questions about housing conditions during office visits, and worked with a local housing agency and other community partners to form a collaborative that addressed substandard housing in their area. Community conditions, and patients’ health, improved as a result.
Many physicians, nurses, and other health care workers know how important the community environment is, particularly those who work in disadvantaged areas. They see entrenched societal factors, such as lack of green space for recreation, poor access to healthy foods, and unsafe neighborhoods that discourage social bonding, take a heavy toll on their patients’ health. They become frustrated by their perceived inability to influence their patients’ health beyond the exam room or the walls of the hospital.
It doesn’t have to be this way. Clinicians can use their influence and expertise to effect real change in their patients’ communities. For example, at Cincinnati Children’s Hospital, physicians and nurses noticed a persistent high rate of asthma in children from poorer parts of town, and partnered with local entities to organize home inspections to look for contributory conditions. Kaiser Permanente Health System has helped to create dozens of farmers’ markets around the country, to ensure community members have access to fresh, healthy food. And in a densely populated area of Honolulu, providers at the Kokua Kalihi Valley Health Center are transforming a 100-acre parcel of land into a nature park so residents have a safe, welcoming place to exercise and grow food.
These are just a few of the examples where community-centered principles are being put into action. Paying clinicians based on quality of care encourages these kinds of long-range, prevention-focused strategies. As the benefits become apparent through a healthier population, we can expect to see health care facilities and workers adopt community-centered strategies more widely. A happy byproduct for clinicians is that improving community health conditions will help restore the joy of service that led them to their profession in the first place—the joy of healing and hope.
Larry Cohen is executive director, Prevention Institute.
