Population Health Blog

Population Health Blog

Why It Matters

Primary Care Leads the Population Health Revolution

By Dennis Archambault

Wayne County, which has the lowest health ranking of any county in Michigan and many counties across the nation, has four health systems (actually, three, now that Oakwood Healthcare has joined Beaumont and Botsford hospitals) and one of the nation’s largest medical schools. The quality of medical care is about as good as it gets in Michigan, yet this doesn’t translate into the health of people living in Wayne County. The Robert Wood Johnson Foundation County Health Rankings http://www.countyhealthrankings.org/ repeatedly list Wayne County at the bottom of the state’s county rankings.

Health systems are driven by the “sick care” model, steeped in specialty care, and oriented to emergent and critical needs for an unhealthy population. Most of the health systems in the region train medical residents, and most of these residents look to specialties that allow them to enjoy an affluent lifestyle and practice in hospitals or suburban specialty practices. About 60 percent of the patient visits in the United States occur in hospital specialty practices, resulting in about 95 percent of health care expenditures, which is an unsustainable social expense.

Nothing really new here: Voices crying in the community health wilderness have assailed these misdirected resources for some time. But the time has come for primary care providers, uniquely positioned at the intersection of health care delivery and social determinants of health, to lead “the 21st century revolution,” according to “Primary Care Must Lead on Population Health,” written by Theodore Long, Ali M. Khan, and Nav Chana, published this summer in the journal Postgrad Med (http://pmj.bmj.com/site/about/).

If the call to leadership isn’t enough, the authors bemoan the “disturbingly high lack of engagement” and burnout of primary care providers. In the United States, “even in the face of a looming shortage of up to 44,000 adult care generalists by 2025, nearly two-thirds of primary care internal medicine residents do not report an interest” in primary care specialties.

Young physicians need to realize that the times are changing and that “the whole of the health care community needs to listen and support the shift to population health.”

The physicians training in the Authority Health teaching health center program have heard the call and are learning community-based practice skills, steeped in population health knowledge, reinforced by a population health certification program provided through the University of Michigan School of Public Health. Six primary care specialties — family medicine, internal medicine, pediatrics, obstetrics and gynecology, psychiatry, and geriatrics — are leading the revolution.

But it will take more than primary care providers upending the system — and commanding their just fiscal reward. Specialists will need to learn to become consultants to primary caregivers, rather than the dominant providers they have been. “This might mean, for example, that the responsibilities of a consultant respiratory physician would include not only caring for patients with respiratory disease…but also the respiratory health of the people in their locality… A new style of (collegial) leadership is called for to promote effective networking and federation, with perhaps less emphasis on the adversarial and competitive style of leadership,” according to the authors.

The revolution is under way, and the revolutionaries are likely to be found in the Authority Health teaching health center program, and other similar programs throughout the country.

Dennis Archambault is director of Public Affairs for Authority Health.

Helping vulnerable people embrace their vulnerability without shame

By Esperanza Cantu

In her 2010 TED Talk, Brene Brown, a researcher who studies vulnerability, courage, authenticity, and shame, delves into a personal experience that helps her to better understand humanity. Brown shares that although people crave social connectedness, shame can prevent us from feeling part of a group of people or a relationship. We can be so afraid of rejection from others that we inadvertently keep ourselves from truly connecting with others. The underpinning of shame, which she describes as the fear of disconnection, is excruciating vulnerability. She shares that to truly connect with others, we must allow for ourselves to be vulnerable and be truly seen.

In her research, Brown encountered many individuals who she eventually referred to as “wholehearted.” These folks shared four common characteristics:

1) They had the courage to be themselves;

2) They had the compassion to be kind to themselves and others;

3) They lived by authenticity, understanding that they had to be true to themselves and let go of who they thought they “should” be; and

4) They fully embraced vulnerability.

For those of us who struggle with living wholeheartedly, she describes how we often deal with vulnerability. To try and not feel vulnerability, we numb. Unfortunately, that means that while numbing sadness and anger, we also numb joy and gratitude. We make the uncertain certain, whether that may be through the denial of religious beliefs and/or political practices of those different from us. We strive for perfection, both for ourselves and for those we love around us. She offers an example regarding children: sometimes, parents sometimes attempt to mold their children into perfection; instead, she says we should be teaching our children that despite our imperfections, we are worthy of love and acceptance. Lastly, we pretend that what we do doesn’t hurt others. We don’t take responsibility of our actions and apologize.

Despite this, she believes that there is another way. She offers four guidelines that will help us all embrace vulnerability:

1) Let ourselves be seen, deeply;

2) Love with our whole hearts;

3) Practice gratitude and lean into joy; and

4) Believe that we are enough.

How is this related to population health? In a 2010 meta-analysis, researchers reviewed the scientific literature related to social relationships and mortality risk. Previous research has shown that people who lack social connections or frequently report loneliness tend to suffer higher rates of morbidity and mortality, infection, depression, and cognitive decline. The meta-analysis, which combines and contrasts results from many different studies using sound statistical methods to identify large partners, indicated that the influence of social relationships on the risk of death exceeded the influence of risk factors such as physical inactivity and obesity.

How many of us have had a doctor or other medical professional outside mental health ask us, “Do you have a reliable support system?” What might our society look like if physicians could prescribe prescriptions for healthy social interactions? A recent 20-year cohort study, sponsored by Robert Wood Johnson Foundation, showed a link between children’s social skills in kindergarten and their well-being in early adulthood.

If shame is what prevents us from having true, vulnerable relationships with others, which can help us live healthier lives, what can do to promote shame resilience? What can we do for ourselves and young people that will help us live longer and more fulfilling lives? In an interview with Spirituality & Health, Brown shared four common traits of people who are shame-resilient

1) They can distinguish shame from embarrassment or guilt, articulate their feelings, and ask for what they need from others

2) They understand what triggers their feelings of shame and can identify it

3) They practice critical awareness; and

4) They reach out to others vulnerably.

If we apply Brown’s research findings and recommendations into our daily lives, we find that at least on a personal level, we don’t need expensive and/or wide-reaching interventions to combat social isolation. We don’t require dozens of friends or a fancy medication—just an understanding of shame, the willingness to be vulnerable, the freedom to advocate for one’s self, and someone to share our feelings with.Importantly, members of different marginalized groups may not feel safe forming true meaningful relationships with others. Perhaps a tool that facilitates healthy social interaction, outside of social media, and results in friendship may be an effective population health intervention to combat social isolation.

Esperanza Cantu is the 2015-16 WK Kellogg Population Health Fellow.





Processing healthier food options that meet taste, affordability, and accessibility

By Dennis Archambault

Eastern Market has long been the nexus of the food distribution system in Southeast Michigan. But until recently, that system hasn’t reached low income and vulnerable enclaves in the region. Through its holistic vision for diversifying its role beyond the traditional retail and wholesale identity to initiatives that are tied to economic development and social justice, the market is poised to be the catalyst to reach disenfranchised markets that need fresh and nutritious processed food.

Eastern Market is in the midst of a strategic planning process in which small and large groups of stakeholders are exploring ways of enhance the effectiveness of the market and propose areas of growth to better serve its mission in the community.

One area of opportunity is economic development. That interfaces with population health objectives of increasing employment opportunities and creating products and services that enhance health. In this case, of course, the businesses would be centered around fresh and processed food.

Eastern Market has been active in helping improve the distribution of fresh fruits and vegetables to sub-communities of Detroit for several years. Through its leadership, and grassroots initiative, neighborhood farm markets have emerged during the growing season.

An opportunity exists to develop businesses that distribute nutritious food products to underserved areas during the off-season. This is a challenge that Hampton Creek www.hamptoncreek.com and other food-oriented social entrepreneurs are addressing. It’s something Eastern Market and its affiliated entrepreneurs.

Eastern Market’s Shed 5 now offers processing capacity in its community kitchen. Collaboration with FoodLab-Detroit’s https://foodlabdetroit.com/ Detroit Kitchen Connect http://detroitkitchenconnect.com/ is an example of the market’s capabilities.

Authority Health envisions the potential from a social enterprise perspective. Creating an environment that promotes innovative thinking around nutritious food processing and distribution methods that can meet the needs and wants of low income and vulnerable communities will play an instrumental role in improving the health status of Wayne County.

Dennis Archambault is director of Public Affairs for Authority Health.

Examining the Spiritual Determinant of Health

By Stephen P. Kliewer, MS, DMin, LPC

I will never forget the moment, when, walking down the hallway of a large university hospital I heard two “white coats” refer to the “liver in room 10”.  It had never occurred to me, until that moment, how profoundly disease-oriented healthcare divided human beings into distinct “pieces” or dimensions, thereby rendering them less human.

At that point we were just beginning to study, and promote, an approach to health care that not only sought to be wholistic in nature, taking into account such things as spirituality, but also sought to be contextual, recognizing that such things as the social context in which a person lived each day had a profound impact on wellness.

Today, social determinants of health are taken seriously, and it is understood that no approach to health care would be complete without addressing those factors.  We know that such things as food security, adequate housing, and transportation have a profound impact on a person’s physical and mental health.

Another important shift means that now, instead of thinking simply in terms of “cure”, the eradication of a disease, we think in terms of wellness.  Wellness, according to the Substance Abuse and Mental Health Services Administration (SAMHSA) “concerns maintaining an overall quality of life and the pursuit of optimal emotional, mental, and physical health” (http://www.samhsa.gov/wellness). It is not just the absence of disease, it is the “presence of purpose in life, active involvement in satisfying work and play, joyful relationships, a healthy body and living environment, and happiness (SAMHSA).”

How can you talk about wellness without including spirituality is part of the equation?  Spirituality can be defined in many ways. Many simply see it as a search for “the Sacred” or even a search for meaning and purpose.  It is considered distinct from “religion” which is often the manner in which people attempt to pursue spirituality – using specific sets of teachings and rituals. I like to think of spirituality as the act of connecting with something larger than myself.  This is echoed by Kaiser who suggests that spirituality “refers to a broad set of principles that transcend all religions. Spirituality is about the relationship between ourselves and something larger. That something can be the good of the community or the people who are served by your agency or school or with energies greater than ourselves. Spirituality means being in the right relationship with all that is. It is a stance of harmlessness toward all living beings and an understanding of their mutual interdependence” (Kaiser 2000).

The focus on wellness rather than cure has led SAMHSA to promote what they call the “eight dimensions” of health.  There are emotional, environmental, financial, intellectual, the occupational, physical, social, and spiritual dimensions (http://www.samhsa.gov/wellness-initiative/eight-dimensions-wellness)

These dimensions are now considered as critical as the traditional social determinants of health, and open new opportunities for working with patients in meaningful ways.  We can now add a new layer of richness to the traditional concept of social determinants, which include economic stability, education, social and community context, health and health care and neighborhood.

This is a very exciting development which will allow physicians, nurses, mental health professionals, and other service providers to move more deeply into those factors that impact health.  We have much to learn about how to apply this new agenda to actual care, but this new emphasis is likely to have a profound impact on the art of healing.

Stephen P. Kliewer, MS, DMin, LPC, is the executive director of Wallowa Valley Center for Wellness in Oregon. He has written Creative Use of Diversity in the Local Church, and was the primary author of Healthcare and Spirituality, a basic text for health care providers. He will speak on “Spirituality as a Social Determinant of Health,” at the 2015 Interfaith Health & Hope Coalition Prayer Event, Sept. 24. Contact Ron Beford at rbeford@yahoo.com or 810-923-6940 for information.