summarize the below

\fRecommendation 3: The nation must take a much more health-focused approach to health care financing and delivery. Broaden the mindset, mission, and incentives for health professionals and health care institutions beyond treating illness to helping people lead healthy lives. Problem Health professionals are adept at treatment of a vast range of diseases, injuries, and other medical conditions. But their training and health care delivery incentives do not emphasize addressing the root causes of health problems that occur outside of the health care systemfactors such as education, access to healthy food, job opportunities, safe housing, environment, and toxic stressthat fundamentally shape how long or well people live. Flesearch in this report, as well as the Commission's Obstacles to Health Report issued in 2009, document how great an impact income, education, environment, and other factors can have on a person's ability to make healthy choices and live a long, healthy life. In order to improve the health of all Americans, we must address these factors alongside existing efforts that focus on system changes in how health care is delivered and financed. There is no question that these efforts to change the health care system are needed. America spends more than $2.7 trillion annually on health care, more than any other nation.'32 Health care costs are a rapidly growing part of federal and state budgets. Yet many Arnericans including those with health insurance, a college education, and higher incomesare less healthy than people in other developed countries. A vast portion of those dollars is spent on treatment. Far fewer dollars are invested in initiatives and social supports designed to keep people healthy in the rst place or connecting patients to needed social supports and services. 76 Chapters Health care is critical to health, but health care alone is not sufficient. Patients must also have social and economic resources in the community that address the underlying causes of health. Making patients aware of these resources and how to access them could greatly improve patients' health, as well as the health of the community. Health care researchers, institutions, and professionals are beginning to consider how social factors are impacting their ability to successfully treat patients, as well as their impact on costs. A recent federal Agency for Health Research and Quality report found that 1 percent of those with multiple chronic illnesses accounted for 21 percent of all health care spending in 2010. The top 5 percent of health care utilizers generated 50 percent of all health care spending.53 A great deal of avoidable use of health services and unnecessary health care costs are related to lack of patient access to supports in their own communities and preventable hospital readmissions. For example, if a dialysis patient doesn't have access to transportation or can't pay $20 for a cab ride to a routine dialysis appointment, that patient may face re-admission to the hospital, with thousands of dollars in related treatment costs. Diabetics may need insulin shots, but they can also improve their health with access to healthy food. Community supports and resources could help them access healthful food. Time to Act: Investing in the Health of Our Children and Communities What's Needed? Our nation must take a radically different approach to achieving health. Given the research and emerging evidence, the Commission is calling on health care institutions and those who train, employ, and reimburse health professionals to broaden their approach and establish standards and incentives that reflect how health is shaped by where we live, learn, work, and play. Specifically, we need to: Expand the country's understanding of all the elements including those outside of the health care systemneeded to achieve good health. Broaden the current approach to health care beyond treating disease and injury to addressing the underlying causes of poor health that exist at home, in school, in the community, and at work. Stress closer links or a bridge connecting the work of health professionals and institutions to that of public health and other social and economic resources in the community. The health care system must acknowledge and systematically address those realities of patients' lives that directly impact health outcomes and costs. It must also use all its resources tools, workforce, and physical infrastructureas a gateway to connect patients to the community resources they need to be healthy. And it must create the financial incentives needed to make this new paradigm work. The goals of value-based careimproving quality while reducing costscannot be achieved without addressing patients' social needs. For that reason, momentum is growing to expand new models ofnancing to support better results and greater value that should be expanded even further. These efforts should require health professionals and institutions to work with other organizations in the community to connect patients to social and financial resources that can help improve their health and wellness. The Patient Protection and Affordable Care Act (ACA) creates new opportunities for initiatives to focus on prevention and keeping people well in the first place. This will require developing new indicators of health\"vital signs\" that identify barriers to achieving positive health outcomesas well as incentives to address all factors that affect health. Health professionals, institutions, and payors must start with a clear understanding of how other factors in a patient's life affect his or her ability to be healthy or succeed with treatment. Health professionals should Time to Act: investing in the Health of Our Children and Communities assess their patients holistically, considering all factors that may be aiding or preventing health. For example, for years, health professionals did not assess patient behavior when diagnosing illness, but they now routinely ask patients whether they smoke, drink, or exercise. In addition, health professionals must recognize nonmedical needs that affect a patient's ability to achieve health. For example, a patient may not take insulin as prescribed because he or she has no transportation to get to a pharmacy, or no way to refrigerate it. Other patients may be unable to follow recommendations to eat more fruit and vegetables because they can't get to a supermarket or afford the food. Some health care institutions are leading the way to this broader approach to health. The University of Michigan recently established its Complex Care Management Program, where teams of doctors, nurses and case managers spend much of their time trying to bridge the chasm between inpatient and outpatient treatment systems. Case managers follow patients, sometimes for several years, accompanying them to doctor appointments, helping them obtain food or furniture and connecting them with community resources. The program is generating savings and better health. For example. one 42year-old severely obese patient was able to dramatically change his health. In 2011, that patient spent 327 days in the hospital due to health conditions, but was able to avoid hospitalization in 2013'34 Likewise, Kaiser Permanente has adopted a \"Total Health" approach using clinical, educational, environmental and social actions to improve health. In its medical offices, medical assistants measure exercise as a \"vital sign" and write prescriptions for walking or other physical activity. In its own offices, employees are urged to participate in \"Instant Recess.\" Kaiser Permanente also invests in the communities it serves. For example, it provided a grant to George Washington University Medical school to teach students about social determinants of health. In Portland, Ore, a Kaiser Permanente site has partnered with the local parks and recreation department to allow physicians to write "prescriptions\" for swimming and other exercise. Patients who receive such scrips are contacted directly by department staff. Health care institutions and professionals have a critical role to play in connecting patients to resources and supports Chapter 3 77 that can help maintain health. Questions that address what may be affecting a patient's life outside the doctor's office may lead to a broader \"prescription\" that in turn yields better health and reduced costs. Questions might include: - How can we identify patients' nonmedical health needs as part of their overall care? - How can we connect patients to community services and resources that help people avoid getting sick in the rst place or better manage illness, including physical, behavioral, and mental health needs? - How can we provide strong leadership in collaboration with other sectors to ensure that where patients live, learn, work, and play improves, rather than compromises. their health outcomes\"? - How can we connect people from the community to jobs in the health care sectorwhich typically is one of a community's largest employers? And is there a role for community health workers in providing communitybased services or linking them to needed supports? Approaches to answering these questions are discussed below, along with recommendations for spreading new \"vital signs" to address patients' social needs; spreading models that connect health care, public health, and social services; and strengthening the role of health professionals and institutions in improving community health. Achieving this new model of integrated care will require innovation, incentives to change, and new measures of performance and accountability. ouuououououo nu.u.u..o..o.o.o.oonu.u.u.nounonononooun.u.u.u..uanonononounu.u.u..o..o.o.o.oon.n........o.o.o.o.ou. ............ .u.a.n..n..............4n....n.............a....n..............4n....n............4................. Source: Courtesy at Health Leads Co-Founder and CEO Rebecca Onie, July 5. 2013. 78 __" chapters _:' Time to Act: Investing in the Health of Our Children and Communities Recommendation Adopt new vital signs to assess nonmedical indicators for health. Health professionals use vital signs to gain a picture of a patient's physical health. Essential clinical vital signs include heart rate, blood pressure, temperature, weight, and height. But other, nonmedical vital signs such as employment, education, health literacy, safe housing, and exposure to discrimination or violence can also significantly impact health. For low-income patients in particular, nonmedical vital signs can both help clinicians make better-informed decisions regarding treatment and care, and clarify additional elements of care delivery necessary to health. These may include: Employment status Financial resources Access to healthy food Access to adult education classes Educational attainment ZIP code (which can be a strong predictor of health and longevity) Family structure Access to social supports Transportation Safe housing To gain a broader picture of a patient's health, health professionals and institutions should incorporate nonmedical vital signs into their health assessment process. New vital signs for health should be objective, readily comparable to populationlevel data, and actionable. New vital signs checklists can be broad, assessing a variety of factors, or can be more focused, such as a poverty assessment tool focused on income level, one factor that is known to greatly affect health. Another toolkit, developed by University of Toronto's Dr. Gary Bloch, provide primary care clinicians with guidance on how to assess whether poverty is affecting a patient's health, including the following questions: Time to Act: Investing in the Health of Our Children and Communities Do you have trouble making ends meet? Do you have trouble feeding your family? Do you have trouble paying for medications? Do you receive the child tax benefit? Do you have legal or immigration challenges? Do you have a safe and clean place to live? The goal of adding nonmedical vital signs is to expand the country's approach to health beyond providing health care to also prescribe ways to enhance overall health. Adding nonmedical vital signs to the health assessment process will yield betterinformed clinical decisions; trigger patient referrals to appropriate community resources and public benefits; improve health professionals' understanding of their patients; and forge greater connections between health care and public health and community supports. Collaboration between health professionals and other sectors in the community will be vital to forming a much-needed bridge between health care and health. Commissioners reviewed different models and initiatives aimed at connecting patients with nonmedical services that will help improve their health. Some hospitals train social workers or lay health workers to reach out to patients, conduct health screenings, and link them with needed services. As an example, Kaiser Permanente's Colorado region has implemented hunger screening as part of its wellchild visits. For positive screens, clinicians provide brief counseling and refer patients to a statewide hunger-free website and hotline that provides information on where to find food assistance and information on applying for federal nutrition programs. Creation of a national, online clearinghouse of evidence based models and best practices for linking patients with community resources to help maintain or improve health would help speed greater adoption of best practices. A clearinghouse could be modeled after the federal Center for Medicare & Medicaid Innovation, which supports the development and testing of innovative health care financing and service delivery models. Chapter 3 79 Health Leads Health care institutions and professionals have a critical role to play in connecting patients to resources and supports that can help maintain health. . . . . ........ Photo: Matthew Moyer 80 Chapter 3 : Time to Act: Investing in the Health of Our Children and CommunitiesPromising Approaches Health Leads, a national health care organization, enables Community colleges and other local education leaders physicians and other health professionals to systematically can also implement or expand training programs for lay screen patients for food, heat, and other basic resources health workers (e.g., community health workers, patient that patients need to be healthy and "prescribe" these navigators, and peer health coaches) who can connect resources for patients. Patients then take the prescriptions patients with health care and other services they need in to a Health Leads desk in the clinic, where a corps of well- their communities. Such programs improve the economic trained and well-supervised college student advocates security and stability of people in low-income communities, "fill" the prescriptions, working side by side with patients providing them with jobs while addressing a growing need o access existing community resources. Health Leads for new kinds of health care workers. For example, Jobs advocates also provide real-time updates to the clinical For The Future65 trained more than 800 frontline health team on whether a patient received a needed resource, and health care workers, the majority of whom increased resulting in better-informed clinical decisions. Health Leads their pay, earned college credits or professional credentials, currently operates in 23 clinics-pediatric and prenatal, or achieved other positive outcomes. Seed funding from newborn nurseries, adult primary care, and community local businesses should be considered a potential source health centers-across six geographic areas, all with of support for these types of programs. Also, community significant Medicaid patient populations organizations (e.g., YMCAs, faith-based organizations) could train their employees, members, and volunteers to help Inspired by Health Leads, Basics for Health in Vancouver match patients to social services and community resources. has developed a poverty screening tool for primary care clinicians, with questions such as, "Do you ever have Nearly one in five Medicare patients discharged from a difficulty making ends meet at the end of the month?" The hospital is re-admitted within 30 days, at a cost of over goal is to encourage health providers to consider poverty as $26 billion every year. In an effort to improve care and a major health risk, noting: "The evidence shows poverty to be keep high-risk patients from being re-admitted to the a risk to health equivalent to hypertension, high cholesterol, hospital, the Centers for Medicare & Medicaid Services' and smoking. We devote significant energy and resources Community-Based Care Transitions Program (CCTP) is to treating these health issues. Should we treat poverty connecting patients to local organizations such as social like any equivalent health condition? Of course." Funded service providers, nursing homes, home health agencies, by ImpactBC, Basics for Health trains recent graduates pharmacies, primary care practices, and other types of to be volunteers who connect low-income patients with health and social service providers in the community. community resources (food, shelter, and job training, for There are currently 102 organizations participating in the example) to improve their health. CCTP and working to prevent hospital re-admissions. The Medical-Legal Partnership program removes legal The University of Michigan Health System's CCTP barriers that impede health for low-income populations. program assigns specialized case managers to patients who Legal professionals-legal aides, law school students, frequently visit the ER to assist them with finding resources and private-sector attorneys- are integrated into the care once they leave the hospital. Geisinger Health System's team, where they partner with health professionals, case Proven Health Navigator program calls patients after they managers, and others to provide direct legal assistance leave the hospital and provides heart failure patients with to patients. Currently working in 38 states and 235 care digital scales that transmit data back to their nurses. The settings, Medical-Legal Partnership volunteers intervene Washington, D.C.-based Medical Mall Health Services with landlords, social service agencies, and others to provides home visits and makes sure that prescriptions are address health-harming conditions ranging from lack picked up and that patients have transportation to their next of utilities to bedbugs to mold in rental properties to doctor visit. accessing school support services for children with severe medical needs. Research shows that patients who receive Launched in April 2011, CCTP has made up to $500 million in Medical-Legal Partnership services have fewer emergency total funding available through 2015 for acute care hospitals room visits, shortened hospital stays, decreased stress, partnering with community-based organizations in an effort and better coping mechanisms to reduce readmissions. 66 Time to Act: Investing in the Health of Our Children and Communities Chapter 3 81Recommendation Create incentives tied to reimbursement for health professionals and health care institutions to address nonmedical factors that affect health. The ACA and other initiatives undertaken by employers, health insurers, and states are accelerating the use of new physician payment mechanisms and incentives, including paying more to health professionals who deliver better outcomes at a lower cost. Some public and private insurers already are moving in this direction. Government and private insurers should further expand payment reforms to include incentives and measures that relate to identifying and addressing social factors that affect patients, in keeping with the goal of using health care resources to have the greatest impact on the health of patients. Such incentives and measures should also address rewards for health professionals, hospitals, or other provider organizations that screen patients for social needs and work with community partners to link patients with appropriate sen/ices and resources in the community. New financial incentives are needed to re-align health care delivery so that it is more effective in achieving and maintaining health. New kinds of payment mechanisms and incentives are already taking shape, moving away from traditional \"feeforservice" models that reward the quantity of medical services to those that reward better quality care and better health outcomes at a lower cost. For example, patient-centered medical home payment reforms give primary care providers a \"permam ber\" rather than fee-forservice payment to help physicians coordinate and provide services that each patient may need to get better outcomes. Some accountable care organizations (ACOs) pay health care professionals at least partly based on performance. Bundled or episodebased payment models provide a lump payment to one or more health care providers that reimburses the cost of all sen/ices a patient may need over a period of time and across a continuum. Under these 32 :3 Chapter3 types of health care financing reforms, health professionals have more flexibility in how they spend resources on behalf of their patients. But they must also demonstrate greater accountability for their results. In many cases, performance measures in accountable care payment reforms already address important health outcomes, such as reducing hospitalizations for preventable complications and achieving better control of common chronic diseases like diabetes and coronary artery disease. Health care organizations with accountability for better health outcomes recognize that these outcomes may be achieved by removing obstacles to healthy behaviors that include housing insecurity, food insecurity, lack of cooking facilities, or lack of safe places for exercise. Health care payment reforms must go beyond incorporating measures that address individual patient health. Such measures might include the results of health risk assessments for adult patients, incorporating such elements as body mass index, smoking status, and cholesterol levels, but also factors such as employment, financial resources, and ZIP code. Traditionally, adoption of such measures has been limited because they are difficult to influence through traditional approaches to health care. Health care institutions and payers are recognizing the need to change. In addition, it is important to recognize that having the right measures is not sufficient. We must invest in the technology and infrastructure needed to systematically screen and refer patients to needed services. In other words, our measures must be actionable. Time to Act: Investing in the Health of Our Children and Communities Promising Approaches The Oregon Medicaid program has implemented community care organizations, which are similar to A005 and which facilitate collaboration between health care and social services providers, with the goal of improving community health. In Minnesota, the Hennepin Health Accountable Care Organization, created as part of an early Medicaid expansion, is linking Medicaid health We Must Act Now Greater flexibility in using Medicaid or other health care funds for community-based approaches to improving health should also be tied to accountability for both improving health results and reducing overall health care costs. Strategies to spur greater integration could include: - Patientcentered medical home payments tied to improvements in nutrition and health outcomes related to nutrition that support referrals to community-based services such as vouchers for healthy food. - Patient-centered medical home payments for pediatricians that track and aim for improvements on attendance at school and preschool. - Bundled payments that address social needs as part of prevention of complications in treating common health problems. - Pathways for reimbursement for community health workers and other nonmedical community supports through Medicaid managed care organizations and other Medicaid providers that are reimbursed on the basis of improving outcomes without increasing costs. services and county-provided social services such as housing and employment counseling.67 The Center for Medicare & Medicaid Innovation recently issued a request for proposals for innovative payment systems at the regional or community level that may spur new, more cost-effective ways of paying for and improving population health. - Differential payments for providing augmented services to patients requiring help with nonmedical factors that affect their health, in conjunction with more integrated funding between health programs and social services programs affecting such patients. Providers including screening for social factors known to impact health as a routine part of electronic medical records to get meaningful use credits. Financial disincentives, such as penalties for readmissions. that can be wielded to support connecting patients to nonmedical services that support health. Philanthropywith its ability to take risks and invest in innovationshould support evaluations of new \"vital signs\" initiatives that deploy lay health workers to connect patients with community resources and services. Evaluations should determine the effectiveness of these initiatives, including whether they achieve cost savings and improve health outcomes. The federal government, through the Center for Medicare & Medicaid Innovation, and states should support further development and piloting of payment reforms that recognize linkages to community-based services. Recommendation Incorporate nonmedical health measures into community health needs assessments. In order for a nonprofit hospital to maintain its taxexempt status, it must provide community benefit services that support the health and well-being of the community it serves. Historically, a majority of community benefit funds were used to help pay for clinical care for the uninsured or underinsured. Under the ACA, every nonprofit hospital is now required to conduct a community health needs assessment every three years, with input from public health and community members, and adopt an implementation strategy to address community needs identified through the assessment. This requirement, along with reforms in health care financing, and greater evidence on how a broader approach to health care can improve health, presents an opportunity for nonprofit hospitals and health systems to have a greater impact on health improvement efforts in their communities. To date, the percentage of investment that hospitals have put toward this requirement has averaged 7.5 percent, but it varies widely by state. An assessment of 2009 data shows that hospitals applied 45 percent of community benefit spending to offset Medicaid losses; dedicated 1.9 percent to true charity care; and put 20 percent of all community benefit expenditures toward community health improvement. This translated into approximately 2.2 percent of total hospital spending.\" Hospital and health system leaders should engage and collaborate with the community, governmental partners, social services professionals, foundations, and others to determine the most effective ways to direct resources to improve community health, and link community support to measurable impacts on community health. In addition, the community health needs assessment process should require that residents and stakeholders be engaged in the assessment and prioritysetting process. B4 Chapter3 This may require establishing measures that look at access to early childhood programs, wellness centers, job creation strategies, mental health services, or environmental factors. Assessment alone will not be sufficient to produce health improvements at the community level. Hospitals must prioritize investment in improvements identified through the health needs assessment. The assessments must include collection of information on social determinants of health. Special attention should be paid to quality early childhood and family support programs and initiatives to foster healthy community development, building a bridge between personal health and community health. Ideally, community health assessments would identify the most pressing priorities for community benefits dollars, facilitating efforts at the health system level to improve population health improvement. Hospitals or health systems would screen patients for unmet resource needs and connect patients to community resources, including those that have come to light through the community health assessment. At the same time, community benefit dollars would be deployed to address priorities flagged in the needs assessment, improving population and community health. Time to Act: Investing in the Health of Our Children and Communities \fPromising Approaches To engage local residents in its planning process. Bon Secours Health System in Richmond, Va., initiated a series of \"public Visioning sessions" to ensure that community needs were being met during city planning. As a result, Bon Secours has created partnerships between the community and multiple private, philanthropic, civic and governmental organizations and established relationships for future city planning. From hiring a \"healthy neighborhood liaison\" to engaging multiple partners and local philanthropies, the public forums that Bon Secours convened have already led to new housing. new sidewalks and a wellness center in one of Richmond's housing projects. The next proiect: a new supermarket that will provide fresh, healthy foods for local residents. Boston Children's Hospital approached its community benefit compliance by working to identify and understand which local and healthrelated issues were most important to its community. By analyzing health data, reviewing best- practice literature, conducting focus groups with residents, and interviewing key stakeholders, Boston Children's Hospital aimed to understand what was most pressing. Over time, Boston Children's Hospital determined that it could produce the most measurable results if it focused its efforts on a select few health issues that were identified by the community and were an existing specialization for the hospital and could be addressed by leveraging community parmers. Ultimately, four were selected for this new portfolio: asthma, child development, mental health, and obesity. The hospital's asthma initiative, for example, has provided home environment assessments and asthma management education to families with a child who visited the emergency department or was hospitalized because of an asthma exacerbation. Such children are most likely to have poorfy controlled asthma. Program results have shown that participants have experienced fewer asth marelated hospitalizations, emergency department visits, and missed school days. The initiative has reached more than 900 families and has also shown some economic benetsfor every $1 spent on the program, $1.46 is returned to insurers and $1.73 to society.69 Nationwide Children's Hospital in Columbus, Ohio, launched Healthy Neighborhoods, Healthy Families in response to community benet requirements to improve neighborhood conditions that affect health. The publicprivate partnership between the hospital and local communitybased organizations has targeted affordable housing, education, safe and accessible neighborhoods, and workforce and economic development. To date, HNHF has: Renovated neighborhood homes and provided grants to homeowners to increase the availability of quality affordable housing. - Created farmers\" markets to improve access to fresh foods. - Facilitated the mentoring of local elementary school students by hospital volunteers. The Community Health Initiative (CHI), a program of the Children's Hospital Medical Center in Cincinnati, partnered with community groups to address asthma. accidental injuries, and poor nutrition in the community. For example, the hospital used geocoding technology to identify clusters of re-admitted asthma patients who lived in substandard housing units owned by the same landlord. The hospital then partnered with the Legal Aid Society of Greater Cincinnati to encourage the property owner to make repairs and improve living conditions. CHI also made referrals to Legal Aid for patients who needed help with Medicaid benefits or required other legal assistance. To improve air quality, reduce greenhouse gas emissions, and shrink Seattle's pollution levels, Seattle Children's partnered with hundreds of community residents and over a dozen community organizations and advocacy groups to develop the Livable Streets Initiative. The citywide program included a walking audit, resident surveys, and a town hall event to help the hospital create bike boulevards and institute road safety improvements to encourage community residents to bike and walk to work. To overcome challenges in public transportation connections, Seattle Children's developed its own transit program using 22 minivans (all with bike racks) to take passengers between transit hubs and workplaces. It reports that alternative commuting efforts have taken 630,000 cars off the roads and freeways; reduced vehicle miles travelled by 6.5 million (the equivalent of 13 round trips to the moon); and saved 235.000 gallons of gas. This has resulted in the elimination of approximately 2,100 metric tons of CO2 emissions.70 Promoting healthy eating and active living are two core components of Kaiser Permanente's \"Total Health" approach. Working in 40 lowincome communities across the country, Kaiser Permanente works with community collaboratives to identify and address barriers to health and combat the socioeconomic factors that contribute to obesity and related chronic diseases. Through partnerships with schools, Kaiser Permanente is working to make the school environment healthier for students, staff, and teachers. Programs include efforts to create safer routes to school and ensuring that healthy food options are provided. We Must Act Now According to the Hilltop Institute at the University of - Technical assistance should be provided to communities Maryland, financial benefits to nonprofit hospitals from that lack the fundamental resources or infrastructure to federal, state, and local tax preferences totaled an estimated support broadbased community engagement for community $12.6 billion annually in 2002.71 This represents a significant health needs assessment and follow-up improvements. opportunity that must be leveraged now. - The elements on the IRS Schedule H Form 990 regarding . Philanthropy, health care organizations, and the federal nonprot hospitals and community health benefit improvement government should support development and testing activities should be carefully monitored and assessed as of protocols (e.g., standard community health needs the field continues to evolve. Health care organizations assessment templates and procedures) and collaborative should look to initiatives that have changed the culture models for community health needs assessment. of health care for \"lessons learned." Photo: Nathaniel Wilder