Population Health Blog

Population Health Blog

Why It Matters

Training a new generation of physicians in population health

By Dennis Archambault

It’s hard for a medical resident to have a sense of history after a long day of clinical training. But most of the primary care residents training in the Authority Health teaching health center program, sponsored by the Detroit Wayne County Health Center, experienced history on Oct. 30 as the University of Michigan School of Public Health initiated its first population health certificate program. A mandatory component of the Authority Health curriculum, the two-year course will enhance the residents’ understanding of the social determinants of health and the potential of community-centered practice.

While there are training programs in preventive medicine and residencies that have public health components, nowhere in Michigan, and probably few training programs anywhere integrate the principles of population health into the primary care experience. As Phyllis Meadows, PhD, RN, associate dean for practice at the University of Michigan School of Public Heath explained, “You’re launching launching something that has never been done before… you are pioneers in health equity.”

The administrative and clinical leadership of Authority Health underscored that in explaining the program to around 50 residents.

David Kindig, M.D., emeritus professor at the University of Wisconsin Institute for Population Health, who co-chairs an Institute of Medicine roundtable on population health (Dr. Meadows is also a member of the roundtable), greeted the residents through a pre-recorded statement. Credited with having defined population health practice in America, Dr. Kindig recalled his days as a medical resident specializing in social medicine and reiterated his observation that progress won’t be achieved until there is reform in the payment incentives for providers. Society, he said, needs to make “paying for health” a goal.

The residents will attend nine sessions annually, each with one hour of lecture and one hour of group interaction. Additionally, there will be selected readings and six hours of independent study in a small group project. While those are the minimum requirements, Dr. Meadows offered a wealth of additional experience for residents who wanted a deeper experience.

“This is wonderful moment for us,” noted Chris Allen, CEO of the Health Authority. He worked with Dr. Meadows for over a year to conceive the program and design it so it works for a school of public health as well as the Authority Health medical training program. He and John Sealey, D.O., director of Medical Education for Authority Health, will present the program to the American Association of Teaching Health Centers in November.

Residents will learn about population health through “contextual reality,” “race and ethnicity,” “personal influences,” and “evidenced-based strategies.” There will be an ongoing assessment of resident progress, on a spectrum from awareness to understanding and action. There also will be assessment of this pilot course, for refinement in subsequent offerings.

In closing the program, Dr. Meadows predicted that “at the end of this experience, you will be different. You will think differently. You will work differently.” He offered a final assignment in advance of the first formal session in November: She asked residents, when they go to their community health setting the next morning, to pay attention to their surroundings. “See what you see, and what you don’t see. It’s not what you see, but what you don’t see.”

Dennis Archambault is director of Public Affairs for Detroit Wayne County Health Authority.

Ebola Death in Dallas Suggests Need For Closer Connection Between Hospitals and Public Health

By Dennis Archambault

Recent questions about the appropriate emergency treatment of an ebola patient in Dallas raised broader concerns about the relationship between public health and the  private hospital system. Nearly two years ago, Hospital Progress magazine, published by the Catholic Health Association, devoted an entire issue to population health http://www.chausa.org/publications/health-progress/issues/january-february-2013, with a specific article on the need to improve the relationship between the local public health department and hospitals. As health systems assume greater responsibility for improving the health of its immediate population, not just those within their patient population or desired market segments, the relationship between public health agencies — and community health advocates — becomes even more important.

The New York Times on Oct. 11, published an account that questioned the appropriateness of releasing Thomas Eric Duncan — a Liberian man who died of the Ebola virus in Dallas — with a temperature of 100.1 http://www.nytimes.com/2014/10/11/us/thomas-duncan-had-a-fever-of-103-er-records-show.html?_r=0. He was prescribed antibiotics and Tylenol for pain, which Duncan identified as eight on a scale of 10. Hospital officials were quoted by the Times as saying that Duncan’s symptoms were “not severe’ on his first visit and that many communicable diseases have the same symptoms as Duncan’s. Except, Duncan had recently come from Africa.

Texas Health Resources, which manages the hospital — Texas Health Presbyterian Hospital, says it is reviewing the case and is making changes in its intake process to better screen for the disease. This case underscores the importance of community-based medicine, specifically when public health issues have an impact on the health of individuals treated in hospitals and private medical practices. A closer relationship between private hospitals and their public health agencies would help identify emerging issues that impact their patients. (Note: MLive has published a report indicating that Washtenaw County and area hospitals have connected on this issues. http://www.mlive.com/news/ann-arbor/index.ssf/2014/10/washtenaw_county_public_health_7.html#incart_m-rpt-2)

In his article, “Introducing Public Health: Your New Partner,” in the January-February 2013 edition of Health Progress, Edwin Trevathan, M.D., M.P.H., asks “Why are public health and health care so separated? Like any two cultures that have grown apart, it is complicated. We have different languages and different terminology. We have different modes of dress… We are different from one another, but we need each other.

“For decades, U.S. public health and health care have had separate revenue streams, and so operated in relative isolation from each other. In my opinion, this failure to connect health care with public health is the most important reason why we pay more for health care than any nation on earth, with worse outcomes than most of our peer countries. With health care costs soaring, revenues shrinking and, finally, the realization that our current system is not working, now is the time for public health and health care to become acquainted.”

In times of a potential emerging crisis, it’s imperative that public health and health care not only become acquainted but become partners. The community needs assessment process is a good opportunity for public health and health systems to collaborate to determine need and assemble the resources to meet it.

Dennis Archambault is director of Public Affairs for the Detroit Wayne County Health Authority


Senior housing advocates consider ‘preservation’ of existing residences in urban core

Federally subsidized housing programs specifically designed for seniors with low incomes began in 1959 with the Section 202 program. The Section 8 rental assistance program, with 15 to 40 year project based Housing Assistance Payment (HAP) contracts followed in 1974 and was responsible for the construction of most of the privately owned, subsidized housing presently available for low-income seniors in the United States. The elimination of this program has led to a decline in the housing built specifically for seniors from 40 percent of the units in low income housing with project based rent subsidies to 13 percent (AARP Public Policy Institute). It is projected that within 10 years, all of the original project-based Section 8 HAP contracts will have expired. If Section 8 contracts are not renewed, the ongoing rental assistance it provides is lost for both current and future low-income seniors. For those who are likely disabled or have multiple chronic health conditions, the impact of relocation can be devastating. Consequences can be a decline in physical and mental health, homeless, and even death. Given the aging of the population, it is imperative that a strategy be developed to preserve housing for low-income seniors.

Senior Housing Preservation – Detroit, a coalition that has arisen out of the eviction of 115 seniors from the Griswold Building in downtown Detroit, has developed an issue brief on “Preserving Housing for Low Income Seniors.” The document provides background on the issue, an analysis of the threat to low income senior housing, and options for preservation, a strategy which has worked in other urban areas of the country.

According to the National Low Income Housing Coalition (NLIHC), there are approximately 1.2 million project-based rent subsidized units nationally. When the original Section 8 HAP contracts for these units expire, owners are allowed to renew for terms of one to five years, or not to renew. It’s projected that within 10 years, all of the original project-based Section 8 HAP contracts will have expired. This means hundreds of thousands of low income seniors will be evicted and possibly homeless.

Senior Housing Preservation – Detroit is primarily focused on identifying properties at risk, developing early response to engaging owners, and assisting residents in transition. However, it is concerned with educating opinion leaders on not only the issues of preserving housing for low income seniors, but the principle of inclusion of low income seniors in the lifeblood of the emerging Detroit.

One of the strategies adopted by the coalition is housing preservation – the strategic effort to preserve existing buildings that house seniors and may convert to market-rate housing. According to NLIHC, preserving the existing building is approximately 40 percent less costly than constructing a new one. Housing preservation breaks down into three categories:

  1. Sale of the building to a new owner, likely a nonprofit, who agrees to retain it as housing for low income seniors.
  2. Retention of some of the units covered by the project-based Section 8 HAP and transferring the remainder to one or more newly constructed or substantially rehabilitated buildings.
  3. Transfer the entire project-based Section 8 HAP contract and corresponding rent subsidies for all of the units to a newly constructed or substantially rehabilitated building.

The strategy employed by Senior Housing Preservation – Detroit follows these tactical points:

  • Develop a coalition
  • Identify and analyze the problem
  • Communicate the problem
  • Organize seniors and others impacted by the situation

Tim Wintermute, executive director of the Luella Hannan Memorial Foundation, has written an comprehensive issue brief on this topic. For a copy of the document, contact him at twintermute@hannon.org.



California offers a glimpse of life without water

While the new Regional Water Authority promises to arrange financial support for customers with low incomes, the prospect of households being without clean water — however unintended by the water authority — remains a concern for population health advocates. The New York Times last week published an article on how the drought in California is impacting lives: “With Dry Taps and Toilets, California Drought Turns Desperate.” One of the subjects of the story, Angelica Gallegos, an employee of a citrus packing plant, hasn’t had running water for more than five months. She is one of 500 others who can’t flush toilets or drink water from a faucet, much less wash dishes or clothing. The Gallegos family’s drinking water comes from bottles received through charity. They are able to get water from a county fire station reservoir, which often runs out. The State of California has acknowledged that 700 households in the state are without running water. However, it’s believed that the number is likely higher.

Some estimate that as many as 1,000 Detroiters have had their water service discontinued. Theoretically, river water is available a few miles from most residents. Others are illegally tapping fire hydrants. And charities are providing water as needed.

The Population Health Council, in a public letter, is hopeful that state and county officials create a sustainable water service for low income populations who would also qualify for expanded Medicaid health insurance and other forms of social assistance. While water service is a utility, like heat and power, it is also an essential resource for life. Low income households should not have to exist without running water when a natural disaster such as a drought isn’t the cause.

To read the full article in the New York Times, visit http://www.nytimes.com/2014/10/03/us/california-drought-tulare-county.html?_r=0


‘Microbirth’ film examines the future of humanity through a population health lens

By Katie Moriarty, PhD, CNM, CAFCI, RN

Detroit is under the microscope for many reasons, one of which is its extremely, and persistently high infant mortality rate. Especially for those of us whose professions are dedicated to providing a high quality birth experience, this is unacceptable.

As we look for solutions to this dilemma, we are also concerned about impact of poor birthing experiences, not just those leading to death. On Sept. 20, the Detroit Nurse-Family Partnership, a program administered by the Detroit Wayne County Health Authority, hosted the Detroit premiere of the documentary Microbirth http://www.oneworldbirth.net/microbirth/.  Health professionals from around the world spent a Saturday afternoon examining the implications of poor birthing experiences, not only for the infant but for the future of our species.

We need to have these types of gatherings with multiple stakeholders present to discuss issues surrounding women’s health, pregnancy, childbirth, and evidence based care that is driven by data and science for the support of physiologic birth.

Several characteristics of physiologic birth are that women spontaneously enter and progress through labor, the birth of the baby and placenta occurs vaginally, the infant and mother are kept together during the postpartum period and are skin to skin with the support of early initiation of breastfeeding.  The lack of these elements has been, personally speaking, a true elephant in the room and I have felt there has been a cultural blindness to the impact of disrupting these normal processes.

Michel Odent, a famous French physician, has written about cul-de-sac epidemiology whereby there is evidence – however it is shunned by the dominant medical community and hasn’t been adequately covered by the media.  The viewing of Microbirth with multiple stakeholders allowed the beginning of an international discussion from varying perspectives.  It is essential to engage and build multi and interdisciplinary teams with varied and diverse backgrounds and perspectives.  We need to get out of our “echo chambers” and share and be open to accept and hear each other if we want a high quality maternity care system.

The need for this type of discussion is especially urgent in Detroit where we have the highest infant mortality rate (IMR) in the nation.  While the national rate is 6.1 deaths per 1,000 live births the State of Michigan is slightly higher at 7.1/1,000; however, Detroit babies die at a rate that is double the State rate — 14/ 1,000.  If you are African American you will have almost a 3x increased IM rate than a Caucasian woman (15.4 vs 5.5).

We have mapped out IMR by geocode and it shows that your address does matter!  The primary cause of our IMR is preterm birth.  The rate of preterm birth in the USA and Michigan is 12%; while in Detroit 18% of babies are born premature.  The differences in the rate of preterm birth are partially attributed to the significant racial/ethnic disparity that exists between African-Americans and other groups and issues surrounding toxic and chronic stress.    

Microbirth presents elements needed to “seed the microbiome.”  Scientists and maternal health professionals discuss epigenetics and the microbiome.  If there are no medical indications they present a scientific rationale for entering labor spontaneously, the benefits of traveling through the birth canal with a vaginal birth versus a caesarian section, breastfeeding and skin-to-skin contact.  Researchers, scientists, and educators discuss the impact from a population health perspective and a global financial perspective.

There are elements of the film that people agree with and disagree with; however, the fact that we were able to bring together a diverse group of people to consider the critical importance of childbirth and the potential of increasing strategies that promote normal physiologic labor and birth for better birth outcomes and long term health outcomes is notable. We need an ongoing dialogue on this topic.

The potential for improving maternal outcomes through a more careful consideration of birthing options may be one of the most important considerations of this era of dramatic change in our natural environment.

Dr. Moriarty is director of the Detroit Nurse-Family Partnership (NFP). The NFP staff will be scheduling community presentations of this program. For more information, contact Dr. Moriarty at 313-871-3751 or kmoriarty_nfp@dwcha.org.