In Your Neighborhood

Why it takes a community to address health, not just health care

South County Hospital President and CEO Louis Giancola shares the work underway to build a collaborative, community approach

Courtesy of South County Hospital

Louis Giancola, the president and CEO of South County Hospital Healthcare System, has embarked on a new community-based strategy focusing on health and not just health care.

By Louis Giancola
Posted 4/27/15
South County Hospital Healthcare System President and CEO Louis Giancola discusses the community-based approach his hospital system is taking with the focus on health, not just health care.
What kinds of research will be undertaken to quantify the economic, health and cost benefits of this approach to health? How does this effort intersect with the community health care teams being set up under the framework of the Care Transformation Collaborative in South County and in Pawtucket? Can this kind of health innovation be mapped in Rhode Island as a competitive advantage? What kind of story telling is being created to help shape and to share the narrative of what happens with this effort?
By broadening the definition of what health means in a community, and how the local community hospital responds to the community’s needs, South County Hospital is taking a different tack in its approach to the future of health care in Rhode Island. It moves the equation from the popular term of patient-centered care toward a broader common denominator, community-directed care. And, it can provide new metrics for engaging with patients and communities beyond patient satisfaction surveys as a way to measure health.

WAKEFIELD – While visiting New Zealand last year, I experienced first-hand that country’s effort to reduce traffic fatalities caused by speeding: I was stopped by police for driving 10 kilometers per hour (about 2 miles per hour) over the speed limit on a rural road.

Fortunately, I got off with just a warning. I later learned that, after a series of fatal accidents in which alcohol and/or speed was a factor, coordinated community action resulted in a zero-tolerance law. It’s working: New Zealand has seen a reduction in traffic deaths and injuries.

My New Zealand experience is an example of how community efforts to solve a difficult and important health problem – one that is beyond the reach of the “health care” system as we know it today – can make a difference.

How is Rhode Island doing?
How are we doing in Rhode Island on similar challenges? It’s a topic I think about often. And, lately, I see community-based initiatives that hold promise. Here’s a recent example.

Forty people crammed into a basement conference room of the Peace Dale Library on March 23 in response to an invitation to provide input to the Reinventing Medicaid Task Force created by Gov. Gina Raimondo.

Each speaker approached the proposed reductions to the Medicaid Program from his or her own perspective.

There were advocates for senior citizens arguing on behalf of efforts to keep people in their homes rather than institutionalize them in nursing homes.

There were advocates for the creation of a single-payer system to reduce duplicative administrative costs.

There were parents of children with disabilities who provided heartfelt testimony on how Medicaid had a huge impact on the care their offspring had received.

There were social service workers who spoke passionately about how they had helped people with addiction and mental health problems get their lives together by finding them housing and other social supports.

There was a labor leader advocating for paying health workers a living wage, particularly home health aides.

The common theme
The common theme for me is that health, not health care, can only be addressed when communities unite to promote the common good. Whether it is through advocacy, volunteering to help those in need, or promoting healthy behaviors, the health of individuals requires the mobilization of the entire community to understand and attack the underlying societal factors contributing to ill health.

It was not lost on me that these strong advocates for their fellow citizens were speaking in a turn-of-the-century building devoted to strengthening the community by giving everyone free access to knowledge through access to books.

We have known for some time that, at most, health care contributes 20 percent to the health status of individuals; genetics contributes an equal portion.

The biggest drivers of health – what are often referred to by public health experts as the social determinants of health – are poverty, education, and healthy relationships.

Yet, we focus most on health care because it is tangible and we often, if only temporarily, fix people or at least make it possible for them to function.

The so-called health care system has not seen its mission as addressing the underlying causes of ill health, and it has even complained that it is being held accountable for things outside its control.

Health promotion, not health delivery
Although I have a Master’s in Public Health, and I am aware that the major improvements in life span, infant mortality and the prevention of communicable disease have resulted from improvements in nutrition, sanitation and mass immunization programs, I have devoted most of my 45-year career to health care delivery, not health promotion.

Of course, people need access to quality health care when they are sick or injured. I’m proud that, particularly when I started my career, I was dedicated to extending access to care to those least able to afford it.

We still have more work to do in that arena, despite the passage of the Affordable Care Act. But it is clear to me that the current health problems we face and their causes – automobile accidents, obesity, mental illness, substance abuse, to name a few – must be addressed at a community level.

Some of these problems are persistent, difficult to solve, and outside the current reimbursement model. There are, however, examples of community mobilization around health issues that can serve as models for addressing seemingly intractable problems.

Now, for example, starting at a very early age, children are educated about the dangers of smoking; the rate of cigarette use has declined significantly. Although automobile fatalities due to drunk driving persist, Mothers Against Drunk Driving has raised awareness, advocated for stronger enforcement and promoted penalties for driving under the influence.

We could come up with many other ideas for communities to address health problems – ones that we spend trillions of dollars to treat, to say nothing of the impact on the quality of lives and lost productivity for those who suffer from them.

But is this approach do-able? Can we truly make an impact on cardiac disease, diabetes, chronic lung disease, substance abuse and mental health by mobilizing communities to address the underlying causes of these problems?

Improving the quality of life
South County Hospital Healthcare System’s mission is to enhance the quality of life for residents of South County.

For some time, the system pursued this mission by making available high quality, affordable health care to all residents regardless of ability to pay; transforming our primary care practices into patient-centered medical homes; providing education on disease prevention and early detection; and conducting immunization clinics and free screenings for selected diseases.

The system has tried to be sensitive to the health care needs in the community through periodic surveys and the review of available data. In most cases, these efforts were carried out by the system on behalf of the community.

It’s clear that many of the problems we see in doctors’ offices, the Emergency Department, and in the hospital can only be addressed if the community rallies to act on the underlying causes.

Toward that end, we have brought together diverse agencies like the YMCA, the five federally qualified health centers, the school systems, the Community Action Program, and community members to harness the resources of the community itself to address the underlying causes of disease.

The hospital is providing seed money and facilitating communications, but the community must decide what conditions will be addressed and how. The concept of “collective impact” forms the foundation of our efforts to address community health.

Collective impact
Collective impact results when actors from different sectors commit to a common agenda for solving a complex social issue. That is why South County Hospital Healthcare System will serve as the “backbone organization,” the convener, not the leader, of multiple entities committed to a common agenda.

When we convened community members to explore strategies for improving the health of the community, we found a dichotomy between those communities that started with a very broad vision for community, health such as Keene, New Hampshire’s Healthy Monadnock 2020, and those that took a more targeted approach, tackling one or two pressing problems.

Our group felt that starting with the health issues of children, and, by extension, their families, made the most sense. As one member said, “The behavioral health problems of children in our community is a crisis no one knows about.”

With funding and support from the R.I. Department of Health, we have launched an effort to extend mental health first-aid to every teacher and policeman in South County.

We had also wanted to mount an educational program for parents, teachers and students on basic social/emotional skills but have had to delay this initiative until we can identify additional resources.

We are promoting the bond between parents and newborns through support of the Reach Out and Read Program in every doctor’s office where children are seen in South County.

In addition, we are starting to tackle the childhood obesity program through the 5210 Program, which promotes five servings of fruits and vegetables per day, two hours or less of screen time, one hour of exercise, and zero sugar-laden drinks.

Most importantly, we’re committed to a common set of metrics to measure our progress and focusing multiple agencies to work toward the achievement of a common set of goals.

Our long-term goal is to inspire the broader community to recognize that health is a community problem and to mobilize government, schools, businesses and citizens at large to rally around efforts to ensure a healthy community.

We welcome your input—what are the health and health-related issues you see that we should be concerned with as we move forward?

Louis R. Giancola is the president and CEO of South County Hospital Healthcare System.

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