Profiles in Innovation: part two in a series
Across the country, health providers and public health leaders are developing cutting-edge ways to address the underlying conditions that play a huge role in determining the health of a community and its residents. This is part two of Profiles in Innovation, a weekly series of interviews with health leaders who are pioneering new methods centered on capturing data, creating partnerships, transforming payment systems, and creating interventions that improve the health of whole populations, as well as individual patients.
Five years ago, San Diego County’s newly named Health and Human Services Director Nick Macchione decided to take a look around his county and explore some basic questions: Why was San Diego, like so many places, spending so much on health care and getting such meager results? What key factors contribute to poor health in many San Diego communities? And how could he and his colleagues, working with community partners, start addressing these problems?
Macchione and his colleagues convened meetings with futurists, providers, public and behavioral health leaders, hospital executives and leaders of clinics and community organizations. They set out to create a plan to improve medical services and alter the community conditions that give rise to chronic disease and poor health. Out of this process was born Live Well San Diego!, an aggressive 10-year plan that aims to dramatically improve the health of San Diego’s communities and people.
My colleagues from Prevention Institute and I talked with Macchione and Wilma Wooten, the county health officer and director of public health services, about the work they are doing. Here are some excerpts:
Let’s go back to 2008. You were doing this assessment and trying to figure out how to change a very complex health and public health system. What were your insights?
Nick Macchione: There is a tremendous amount of complexity—but sometimes the simplest things have the greatest impact. This was our epiphany: We could focus on three simple things—healthy eating, exercising and smoking—because they have such a huge impact. From a quality of life standpoint, three quarters of chronic diseases are truly preventable. And from an economic standpoint, we did a study and found that those three behaviors were contributing to $4 billion worth of direct medical expenditures in our region. So there was an economic imperative.
Wilma Wooten: We had been working on this construct called the 3-4-50 principle. Three behaviors—poor diets, physical inactivity and smoking—contribute to four chronic diseases: cancer, heart disease and stroke, diabetes, and respiratory conditions. Those four buckets account for over 50 percent of death worldwide and, in San Diego, 57 percent of deaths could be attributed to those four conditions. The focus of the 3-4-50 principle was creating healthy choices and fostering policy and environmental change. Ultimately Live Well San Diego became about changing our culture from within. If we’re recommending XYZ, we have to walk the talk and do it ourselves and promote those strategies and interventions for our employees.
Macchione: We also realized we couldn’t do it alone; if we’re going to really make an impact in the region, we need all corners of the county and all industries. It was important that it was an all-in strategy, that we look beyond county departments to the faith community, business community and schools. When we presented the Live Well San Diego plan to the board of supervisors, it was on behalf of the entire county and became the plan for all 52 county departments, including parks and recreation, county housing, public safety, etc. Our economic development council for the northern region of San Diego, which represents probably a dozen or so chambers of commerce, became our first Live Well economic development council. They said, “We want to stand with you.”
Wooten: Yes, we looked at the American Human Development Index and also Gallup’s five principles of well-being and came up with five areas of influence. We are tying them into all of our programs, our community health improvement plans for accreditation, our county’s strategic plan and the Live Well strategic plan. In health, the leading indicators would be longevity or length of life, and quality of life. The second area of influence is fiscal or economic and we want to look at average household income. The third is education and the number of people who graduated from high school is one of many education indicators. The fourth is community and we’re looking at sense of security, the crime index, as well as the built environment. The fifth is social connectedness—are people taking advantage of services like elderly homes or community centers? That’s just an overview of those five areas of influence which will help us achieve the one vision of Live Well San Diego. We will be tracking specifics elements of each of these areas of influence and using them to guide our programs and interventions.
I gather you’ve had some success making apartment buildings tobacco-free. I just saw some news stories that said one large building will ban smoking January 1. Tell us about it.
Macchione: Second-hand smoke exposure kills 44,000 people every year, according to the Surgeon General. It disproportionately impacts vulnerable populations like children, seniors and low-income residents. It’s an ongoing problem in apartment complexes. One-third of California residents live in multi-unit housing. Many cities have adopted policies to protect residents from second-hand smoke exposure in multi-unit housing complexes. With our partner Social Advocates for Youth (SAY) San Diego, and with funding from the CDC, we are working with landlords, owners and property managers to implement smoke-free policies. A large multi-unit housing complex in central San Diego, the President John Adams Manor, is implementing a smoke-free policy effective Jan. 1, 2014. We expect many more to follow.
How does Live Well San Diego work with health providers and hospitals?
Macchione: Hospitals and physician leaders weren’t necessarily gung-ho about our efforts at first. San Diego is a highly innovative place, but hasn’t been known as a visionary leader around broad-scale population improvement. In fact, it’s known to be fiscally conservative and not supportive of the safety net. Yet I’ll fast-forward and tell you that today the hospital association, Council of Community Clinics, medical school, Legal Aid Society and consumer advocacy groups are all on board. They saw our deeds were in alignment with our words. This created trust, partnership and accountability as we began to evolve as what we call an Accountable Care Community (ACC), working to make large population-based improvements, to reduce hospital admissions and to implement the triple aim. (Note: The triple aim describes efforts to improve patients’ experience of their care, improve the overall health of the population and reduce healthcare costs.)
How are you helping residents get access to healthier foods?
Macchione: We’ve been supporting community and residential gardens, through gardening instruction and assistance in policy implementation. For example, recent ordinances adopted by the San Diego City Council made it easier for residents and groups to start community gardens by easing restrictions and fees. Relaxed restrictions on owning chickens, goats and bees are making it easier for residents to grow and sell their own food. Also, we educate residents they can use (SNAP nutrition-assistance benefits) for seeding and growing edible plants. This also provides residents the opportunity for physical activity through gardening. Our San Diego Born & Raised campaign encourages residents to buy fresh, locally grown food harvested at more than 6,000 farms in the county—the most in the U.S.
You’re also making efforts to encourage people, especially school kids, to walk more.
Macchione: Much of the San Diego region wasn’t originally designed for pedestrian ease and safety. Often children are faced with hazards when they want to walk or bike to school. Creating easier opportunities for walking and biking to school not only addresses safety but also creates physical activity opportunities. We worked with the San Diego Association of Governments (SANDAG)—which includes 18 incorporated cities and the county—to provide Safe Routes to School grants to local jurisdictions, tribal governments, school districts, and community groups. SANDAG also developed the Regional Safe Routes to School Strategic Plan that outlined recommendations for making walking and bicycling to school safer and more attractive for families throughout the region. SANDAG also will conduct a countywide assessment to identify areas of high need for physical infrastructure and non-infrastructure projects.
Tell us about your efforts to make a new park safer and to expand it use.
Macchione: Harborside Park opened in 2006 as the first park built on the west side of Chula Vista in over 25 years. Chula Vista is the second largest city in San Diego County, with a population of about 249,000. Many families and their children use the park during the day. But, particularly at night, illegal activities were happening. Our staff members, part of a walking club, raised the issue to the Live Well San Diego leadership team. Working through the city of Chula Vista, the police department and the leadership team, changes have occurred including removing unnecessary fencing, having teams clean and maintain the park, working with the city’s Recreation Department to provide youth sports and activities, working with the police to report illegal activities and bringing in youth to remove graffiti. Today, Harborside Park is filling again with children and families, and 70 members of the walking club walk through the park, monitoring activity and maintaining a presence that discourages illegal activity. Through collective engagement, Harborside Park has been transformed from a danger zone to a healthy and safe place for children, families and employees from nearby businesses.
What kinds of payoffs are you seeing through these collaborative efforts?
Macchione: By working with pediatricians and family physicians, with schools, with businesses, with public health messaging and our public health workforce, we were able to reduce childhood obesity in San Diego by 3.7 percent from 2005 to 2010, as confirmed through research being done with UCLA. We’ve been able to reduce heart disease and stroke from the first and second leading cause of death to the second and third leading cause of death. We’ve been able to reduce our rate of infant mortality. We are looking at markers of large population-based improvements. We are partnering with RAND to measure the cost-benefit of reducing childhood obesity, reducing asthma in hard-hit areas, and increasing access to healthy foods.
Here’s another example: Sharp Memorial Hospital was facing challenges with a difficult population that was experiencing congestive heart failure and had nearly a 25 percent readmission rate that was preventable. They were at wit’s end because they were looking for solutions within the confines of their hospital. We work with the same population through programs like home-delivered meals. We asked if there’s a way to work together. We know what we do best in the community and they know what they do best in the walls of the hospital. We developed a concept called Care Transitions Initiative, to test models of care coordination. We aligned forces of public health workers and discharge nurses. We made sure there wasn’t disruption in handoffs, helped patients transition to home, adapt to their environment, understand their medications and learn to use the Internet. We helped them designate caregivers that are tied directly with medical providers and elevate when they were not feeling well—before they needed the hospital. We reduced hospital readmission rates from 25 percent to 9 percent—a return on investment of $560,000 for 88 lives in a 12-month period.
Any parting words?
Macchione: As I said earlier, sometimes simple things have great impact. Today you can’t install an air conditioner for an asthmatic person through Medicaid, even though an air conditioner can prevent many costly ER visits. We want to change that. That’s the ingenuity, the innovation of bringing everyone in to look at the bigger picture.
