Population Health and Social Determinants in Health and Healthcare

Welcome to our health professions education series on health systems science today we're going to focus on the ever important topic of population health and social determinants of health which should be meaningful to us all across the board to guide us through this important understanding and conversation today we have dr cynthia morrow who is our health system science and interprofessional practice domain co-leader for virginia tech curling school of medicine and also our health director for the roanoke city and allegheny health districts for the virginia department of health and mr aaron bush who is the director of community health and outreach for carillion clinic both of these individuals are well equipped to lead us through this conversation and to answer any questions you all might have on the topics if you do have questions please don't hesitate to type them in the chat which we'll be monitoring and our present presenters will answer them as they're able also deb will periodically post the link in the chat to obtain continued medical education and faculty development related to teaching credit any other questions just add them in the chat we'll address them as they come up and uh cynthia and aaron i'm turning things over to you okay great thanks so much um so first before we go on to our introductory slide uh we don't have any relationships with industry although i am using two definitions from a book that i co-authored um that i do get royalties on so i just want to be transparent about that um so for the overview if we can just go ahead next slide thank you um the the goal of this session is to improve your understanding uh about social determinants of health we're also going to talk about population health population health management um and i think one of the things that's going to be important for us as as we go forward with the specific objectives is for us to help um for us to help understand how you as educators can can convey this information to your to your learners so so please let us know anything that we can do to help you uh with with conveying this information um so we're going to define uh we'll go through a few definitions we're going to talk about major classes of determinants of health really focus on describing the role of health care systems and health care practitioners and and educators and we're going to end with examples of what perlian is doing hopefully to make it very practical so you can see what curling is doing to improve the health of the community that it serves as well as protecting the health of the individuals that it serves so we're going to start with some definitions um the the first thing i want to do is is launch a pulse to sarah if you could please launch that hole just to get a gauge on how comfortable everyone is with these terms and it looks like we might be having some trouble with the slides okay so if we can close that poll um so we have some people it looks like it's it's good mix so hopefully um by the end of this everyone will be comfortable are the slides all right if folks can okay perfect thanks so much um so the first thing we're going to do is look at at population health um and uh as i mentioned this is from a book that that we use there are lots of different definitions there isn't general agreement so for the purposes of this discussion population health refers to the health of a population now as a public health professional i might think of the entire community as health care professionals you might think of the population that you serve your patient panel so so there are different definitions if we go to the next slide with population health management this might feel a little bit comfortable more comfortable to some of you so popular population health management is a term that's sort of a subdivision of population health that really is what a health system is doing or a health insurer is doing to look at both the costs and the outcomes of the communities that it serves um so i make that distinction not everybody does but to help understand the the parameters um of of the organization's obligation or commitment um and so public health as a general rule if we're talking about the population health of a community has a much broader scope and less direct accountability than population health management an accountable care organization like acrillions doctors connected just as an example so if we go to the next slide um one of the things that is really critical as we think about what population health means is that we understand health equity um and we're going to go specifically into health equity health care disparities and disparities but one of the things that's important is that we look at the difference between equity equality and justices i'm sure that i would bet that most people here have seen some iteration of this slide for us in pop in public health we view social justice or justice in health outcomes um and social determinants and structural determinants of health to be a critical part in improving the health of the population that we serve um so we're going to talk about that and in greater detail as as we move forward um but this is just you know again i'm sure most of you have seen this to me this is a great slide that shows the different principles of equality equity and justice with the idea that at the end of the day if we can remove whatever barriers there are that require different accommodations we've really achieved our goal of justice so if we move to the next slide if we now look at equity more specifically with respect to health one of the things that i think gets lost in translation relatively frequently is that by definition equity refers to the avoidable unfair or remedial differences among groups of people and it's really however we stratify people whether it's socially economically religion language race ethnicity there are any way that we can stratify people were basically introducing the opportunity for health inequity and the responsibility to address that inequity so health equity really at the end of the day implies that everyone should have a fair opportunity to achieve their full health potential and that's that's going to look different for different people and that's one of the things that we really need to look at um so again the focus is is on avoidable unfair now i think with respect to disparities i hear confusion about this relatively frequently disparities are specific that the metric by which we um measure health equity so it's not necessarily differences although it is it it is a type of difference but its difference is that we can attribute to differences in the the distribution of resources differences in the distribution of um of health outcomes that can be attributed to in something else that is inequitable um and really at the end of the day the crux here is that disparities by definition are unfair because it's the fair um opportunity right and they can be reduced by the right mix now this is world health organization so it's government policy i would strongly encourage all of us as we're teaching um is to also look at organizational policies um so local policies state policies but specifically within our health care system what policies can we put into place that can reduce health disparities or what policies do we have in place that may actually be contributing to health disparities so next slide please sorry next slide please yeah if we go to um that disparities healthcare disparities oh i'm sorry i'm i'm missing messing you up i'm totally messing you up my scream healthcare just i'm so sorry about that if we look at healthcare disparities specifically what we want to focus on differences in access to our availability of um medical facilities and services and we're going to be spending quite a bit more time on this in a few minutes but the idea here is that the health care system some experts focus on what the health care system itself is doing to contribute to health inequity or to prevent health inequity within the health care delivery system so now we're going to go to just to to make it more real um go to coven 19 in um virginia so if we look at coven 19 this is um some ratios that were were done in april they still hold true um and we can look at so these are ratios of the rate so it's a bit it's it's not necessarily intuitive but it's ratios of the rate using um our white population as the standard so in this situation we can see that um the the health care outcomes so age-adjusted death rate case case rates hospitalization rates in general are far poorer for our black and hispanic population so looking at race and ethnicity as as a way of stratifying um while our vaccination rates are lower in in those populations as well not not for us hispanic population as much and so we're looking at at disparities in health outcomes as well as disparities in accessing vaccine so those are some recent data from virginia department of health we can also look at disparities by geography so if we look at what our vaccination rates are across virginia we can see that there are significant differences across the state some of that may be artif artifactual as we look at some of our our most southern counties being bordering north carolina but in general we believe that these are relatively good statistics to show how different vaccination rates are across um localities within virginia and it's our obligation to look at how much of that is is due to disparities due to differences that we that are remediable um so if we go to the next slide here we can look at so that's virginia in general here are data that i pulled for the roanoke city allegheny health districts those are the jurisdictions that we serve and you can look at differences um by age and some of that is going to be disparity some of it's not so as an example we can't really compare the 10 to 18 year olds because many of those can't can't get vaccines so that that um that is a a difference not necessarily disparity yet um because it's not approved but we can look at it by race and ethnicity and also by bisex and so that just gives you a snapshot of where we are with one disease and one healthcare strategy that's vaccination but if we look overall at overarching health disparities within virginia um one of the common ways of looking at at how different localities are within a state are the county health rankings um and this is a benchmarkable within a state it's benchmarkable because the same indicators are used for for every locality but also um we wherever you live you can find the county health ranking so this is a really really common model um that is shown again across across different um communities across the country now one of the things that's um really important for us to understand is what the root causes are so i'm just going to ask you i my guess is that most of you will know this if we can launch poll 2 what are the most contri what are the most significant contributing factors to life expectancy okay i think we can probably close that um yeah and not not surprisingly um many of you the majority of you picked socioeconomic factors so if we look at socioeconomic factors um if we can pull up the next slide we can look at the distribution so again this is the county health rankings one thing i wanted to share is that there are i mentioned that there are a lot of different models out there and sarah if you can post a link to social determinants of health using the bari model that's just for for those of you who are interested this is a great model for learners um and it just shows visually a lot of different social and structural determinants of health and i found this to be a very useful tool when i'm i'm teaching students about um social determinants of health so but if we look at this we can see that um there that again there are different models but clinical care itself um contributes perhaps up to 20 now there is something missing from this model and it came up in the slot in the poll so what is missing from this model i'm just going to look at the chat it did come up in the pool see if you guys are let's see not seeing any genetics yeah so so genetics is missing and if you look at health equity the idea is that which is remedial remediable that which is preventable um avoidable and and we can't at this point uh effectively change our genetics so that has been removed from this particular model but of course we know that for some individuals genetics are the overwhelming determinant or influence on health so i just wanted to keep to to keep that in context um so so yes there's and there's been a lot of discussion about determinants of health um and and some people will even say that we shouldn't use the the term determinants of health but we should use influences and the reality is that they're so closely related so those of you who put health health behaviors as the key contributing factor the reality is that our behaviors are so strongly shaped by our environmental factors um what is the advertising in our community what is access to healthful food in our community those are environmental um determinants of health and and so much of our access to health so much of our clinical care is also influenced by all of these things but if you had to identify two or three of the most important influences on our health taking genetics aside um if we're focusing on on equity what are some of the most important of the influences that you see here of the social economic influences um what is what are some of the most important influences on health what are the things that really leap out to you when you think about social determinants or structural determinants of health income community safety education access to care access okay adequate food um so yeah all of the all of these are are really important um and if we think about access access to food access to care a lot of that is determined by two overarching determinants and that is income and education so if we go to the next slide what we know is that it would be really difficult for us to look at health equity without thinking about income equity or or lack thereof and educational equity if we if we had to boil down what is the most looking at all of our studies looking at systematic reviews what is the most significant predictor of health outcome if we isolate it education but we're going to we're going to get back to that in just a few minutes um so education and income are the overwhelming uh influences on our health and within those two key influences we have massive uh disparities in those in those two um categories so if we look at the next one and i'm not going to read these to you you guys can can see these so we have huge differences both by um by race ethnicity but also by many of the other ways that that we so if we look at income for example gender was was on there um so the reality is that we need to look at our influences on health if we want to try to improve our health so when we combine all of these these influences the reality is if we can go to the next slide that our zip code is the best predictor of our um health our health outcomes um and the this has been a saying in public health for i don't even know for how long but for a really really really long time um and what's really important is that even within zip codes um we need or even within geography which represents really the constellation of all of those social and structural determinants of health we also have to look at the larger policy larger larger issues what we know is that people living in poverty in new york have better outcomes a higher life expectancy than people living in oklahoma as an example and that has to do with some of that structural policy determinants of health um that that is far overreaching so again looking at the chat um any ideas of i'm sure most of you will know but give me one example of why even if you're living at the same income in new york your life expectancy is going to be significantly higher than that same income in oklahoma so ideas there from the audience better social services and resources right so if we think back to um equity being looking at distribution of resources what we know is that that states that have stronger social support systems the the individuals living in poverty are going to have access to more resources including some of the things that we've talked about access to care think medicaid expansion access to food think food programs um and and how those food programs are are implemented in different states so if we get go to if we think about um roanoke valley what do you think is the largest life expectancy difference in our most vulnerable community versus our most affluent community with most resources and we'll put up that poll now please poll number three looking at health healthy life expectancy difference in the roanoke valley okay okay so um i i wish i wish we were doing a better job with health equity um but the reality is and this is from a slide from i stole shamelessly from from aaron so if we go to the next slide and aaron's going to be talking a lot about what what we do in our community um so if we look at roanoke valley um we can see a more than 20-year life just over 20-year life expectancy difference between the red star and the green star there's some great maps robert wood johnson foundation there's some great maps that that look at this by zip code by um public transport um there's some really cool maps out there that show the extent of differences in life expectancy within 20 miles um some some of them are within five miles uh just profound differences in life expectancy and again that reflects the resources that are available um as well as the how we cluster in in our country how we how we cluster people by um income education and and other other stratifications now i did want to talk so so that's really a broad overview of social determinants of health there are so many resources for educators on social and structural determinants of health and anybody who's interested feel free to reach out to me or to aaron and we can be sure to set you up with some great resources um but but that's just an overview we could talk about any one of these for an entire hour um we're just going to quickly transition to clinical care determinants of health so if we think about social determinants of health and the underlying causes of income education neighborhood safety access to food you all identified many of them what are some of the clinical care determinants of health i'm just going to be silent here for a minute access to primary care access to programs insurance all right other thoughts about clinical determinants of health so access is clearly stigma absolutely um so how do we treat people or how do people perceive that we treat them right other ideas this is always hard on zoom it's much better in person but that's okay transportation absolutely um transportation so if we think about broadly just as we broke down some social determinants of health into income education just broad deter um environmental determinants there are so many broad categories in general we think about access and there are lots and lots of categories within the access and quality of care exactly sally beth just put quality of care so those are really important um aspects so if we look at the next slide we can break down access in lots of different ways access and this is not exhaustive there are many of you in the audience who who have more expertise in some of these specifics than i do but we can look at costs um so are you insured what does your insurance cover does does your health care provider is that co-pays is it deductibles so we can look at access to care by cost next slide we can look at access to care by health care provider and so i think one of the things that was not yet mentioned but i'm sure some of you were thinking about this is how responsive is the health care provider to to to seeing the patients when the patients need to be seeing seen is there trust if a patient doesn't trust you they're not going to come to see you that becomes an access issue is there language barrier is there is there a barrier for the healthcare provider themselves okay next one next slide please access to services and and transportation is one of them availability primary care was one of the the things that came up in chat um so access to the actual services transportation acceptability of the insurance um those are all service related okay next one and then we get into quality of care and these are some cms indicators these are derived from the county health rankings and so they're gonna again it's not exhaustive there are a lot of other indicators of quality of care but these are ones that are are typically benchmarkable so um preventive services what are your rates of preventive services um really important point access to primary care than in the delay of getting into primary care but back to quality access of quality of care access to preventive services and utilization of preventive services next slide please appropriate treatment and again there are benchmarks there are standards so a health system may be graded on um whether it's providing appropriate treatment now one thing that's missing from community health rankings and again i just chose one model is patient safety so i just want to point out that that is a big hole that's missing in these slides and i know there are many people at the corellian system that really prioritize and do an amazing job with quality of care with respect to patient safety but these are these are things that are benchmarkable across across the states next one adherence to recommended treatment um so once once someone has a diagnosis are they getting all of their management that they that they need to optimize their health outcomes um next slide the reality is i mentioned that we would get back to this that we need to look at the healthcare delivery system itself as a potential source of inequity and um there there was the sentinel report um unequal treatment confronting racial and ethnic disparities and health um that was written in 2003 the reality is that we know we've got good evidence that even when we control for social and structural determinants of health there are there appear to be pretty significant problems within the healthcare delivery system that contribute to health and equity and it's really important that we take a hard look at our own health systems our own organizational policies that can contribute to these health outcomes next slide please the this sentinel report triggered an annual report of from a hrq of health care quality and disparities reports so i if you if you aren't familiar with this i would strongly recommend that you take a look at this if you go to the next slide um just to show you where we are if we look at the most recent report so this is the 2019 report that that looks reflects on the data from the three-year cycle before disparities persist and the focus here is that disparities persist most significantly for our poor and underinsured populations and so if we look at the the various ways that we stratify people um what's what's really clear is that we have made great strides in many areas but we continue to treat our people who are poor and underinsured or or uninsured uh differently than those who are not and this is again disparities within the healthcare delivery system so i strongly encourage you to look at that if if that is an area of interest and certainly if that's something that you are looking at teaching your your uh learners all right next slide please there the ama has guiding principles to how we address disparities and that's again a whole another um many part series of trying to address specifically what we can do aaron's gonna the second half of this is aaron's gonna be sharing how carilion puts these principles into practice um but it's critically important that we look at our healthcare delivery systems we look at the the systems in which our learners are going to be going into and what principles they can follow to try to address healthcare disparities all right next slide please so if we look at virginia i just wanted to kind of take this full full circle before we transition to um to errands in a few slides if we look at where virginia is doing with respect to overall health system performance right in the in the middle so while this isn't about carilion specifically it it gets back to zip code and geography and where you live matters um and so we have a lot of room for a lot of opportunity for improvement here in virginia and i believe that carilion is really well on its way to trying to advance virginia's standing in in how we can improve the overall health system performance in in virginia all right next slide please so this gets back to you before we get into some of the pragmatic things that the system is doing why should you care why is it important clearly physicians the learners that were responsible for the healthcare delivery system and this is really for all healthcare practitioners are increasingly being held accountable to address determinants of health and addressing determinants of health is so integral in our shift from value-based care to from volume-based care to value-based care and and i know that there are people in this audience who are far more expert at value-based care than i but i think it is really important for us to understand why it's so important as as our health care delivery system and our payment system continue to shift towards value-based care it's critical that we think about how we address social determinants of health next slide and one of the key things that we're trying to do at the school of medicine and and dean lehrman is just such a strong proponent of this is how do we ensure that we're creating system citizens um how are we creating a learning environment in which our our healthcare professional students recognize that not only do they have an obligation to deliver high quality high value care to all of the patients that we serve but an obligation to improve the processes and the outcomes of care within the systems that we live and within the communities in which we live all right um so i'm going to give show one shift one one example from cms as as we shift to carillion itself one of the things that i was really intrigued by during the second part of the obama administration was the idea of accountable health communities and looking at how do we create and deploy evidence-based interva interventions to address social determinants of health knowing that clinical care is approximately 20 of health outcome if we can measure and it's pretty gray but how do we influence all of those other social and structural determinants of health um and so as as payments have shifted one of the things that cms did is it started pilot programs in accountable health communities next slide oh yes i'm sorry um and the accountable health communities and the the studies are still out the the data are still being looked at look at how health systems address social needs so how do how does a health system link its patients once it addre once it identifies a social need how does it link its patients to services within the community that can help them address that need and that's really where it's important for us to see yes this is a cms model the pilot studies are still being done we should hopefully build our evidence based around this but we can now look internally we can shift internally to say what is happening within carillion and with that i'm going to turn it over to my wonderful partner aaron thanks so much dr morrow um before we leave this slide um i i love this uh cms model but we are actually working um with the state of virginia on unite virginia which is a platform um that helps us connect our hospital delivery systems doctor offices with social service providers um so many of you have probably heard of unite virginia and it actually launched last week with our community organizations and we'll be launching within corroying clinic later this summer into the fall but we're really excited to see how this system can help us coordinate our community-based services but then we on the back end will be able to see the referral patterns and also which community resources are able to accept referrals and which ones do not have capacity which will help with our community development work so next slide please um so a little bit about collecting data so um really in order to understand where we are as a community we need to have good indicators um so really we're looking at data and then stratifying that data across things like race ethnicity language and then being able to analyze it and look for data in terms of access service utilization quality safety and outcomes next side please um so one of the things that's most important when when we have data to base our decisions is really being able to look and designing systems that really meet the needs of our marginalized populations so one of the things that i like to say here is when we're planning interventions we really look at uh data and indicators to drive our decision making but then as we're implementing different models we really work with the populations that we're trying to deserve and really transition some of that power back to to the community to because an intervention that you have in one community might not be implemented the same way in a different community next slide please so a little bit about community health needs assessment so this was a requirement of the affordable care act and was implemented as part of the affordable care act and is a requirement actually of the irs so we are required to conduct community health needs assessments every three years and adopt what's called an implementation strategy that says specifically what the hospital system will do to address community health need what the expected outcomes are and what resources we plan to address um carillion we have conducted community health needs assessments historically about every three years but with the affordable care act being implemented in 2008 the requirement started in 2012 and now we conduct needs assessments every three years we do these using some of the guiding principles that dr morrow suggested but one of the most important principles that we use with our needs assessment work is relationship building so with these assessments we do use community health assessment teams and since 2011 we have fostered community coalitions that help address our community health need in the community and then help implement programs to overcome community health need um so next slide please um here in roanoke we specifically work with the united way of the roanoke valley as our backbone organization um and healthy roanoke valley has been around for about 10 years now and they serve as our community health assessment team during assessment cycles and then we work with them throughout the year for some of our community health improvement work and then have our own internal programs as well so next slide please um so within our community health needs assessment we'll be talking today about our 2018 community health assessment our 2021 community health assessment will be available in early july and we have updated the process so we do use a cqi process and we do look at the assessment reports and update them every three years but in the 2018 report we included a community health survey which system-wide we had over six thousand responses we do over uh sample our target population of underserved folks we do stakeholder surveys and focus groups and key informant interviews and focus groups with underserved populations and we're looking at community level health concerns individual health concerns and then barriers to health care health and social services in the 2018 report we did look at over 40 data sources but this year we did invest in a data service that combined even more data sources and provided geospatial analysis of those sources and more indicators down at the census tract level which we're really excited about but we look at things like demographics social and economic factors health behaviors clinical care physical environment and health outcomes and health status and in our 2021 report we will have a specific section on health care disparities and equity as well so next slide please um so these needs assessments uh the requirement is specific for each hospital service area so we will be publishing six community health assessments and then we combine all of the needs and look at the service area as a whole and in our community health assessment reports we have an emphasis on underserved vulnerable populations that are disproportionately impacted by social determinants of health including poverty rate race ethnicity education and lack of insurance so in 2018 our top findings for roanoke included the list below but kind of in general for our entire service area we saw poverty across the board and it came up in each assessment as well as access to mental health services and substance use services so those were the top names that came up in all six of our community health assessments and it's been really interesting to see dr mora mentioned the clinical care determinants of health and back in 2011 and 2012 our top community health needs really were access to care so access to primary care behavioral care dental care care coordination and then healthy behaviors but we've seen in the 2015 2018 and 2021 community health assessments a real shift and the community's understanding of social determinants of health and now in our 2021 assessment we are seeing social and economic factors coming up as top needs across the board and then we're still seeing mental health access still being a very important need as well so for the next slide this shows our community health improvement process which includes conducting the needs assessment and then we go into strategic planning so strategic planning is done kind of in different buckets so we do strategic planning with each hospital board and hospital administrator and stakeholders within the hospital but then we also work on strategic planning with our community coalitions that consist mainly of community stakeholders and so we update our implementation strategy that says specifically what the hospital will be doing to address need and then also our community stakeholders concurrently are updating um their process and their interventions to align with the updated needs assessment and then one of the things that we're really focusing on in our 2021 assessment and strategic planning is how do we partner with our neighborhoods and the areas that we're focusing that we know have um community health need and have health disparities and how do we partner with those communities and have them be part of the decision making process um then we implement various programs and do program implementation and evaluation ongoing and then the cycle repeats every three years so um community health and outreach our department we not only support the community health assessments but also what's called community health benefits so another requirement of not-for-profit health care organizations specifically hospitals are reporting back to the irs specifically how we're improving health in terms of dollars and cents which is called community benefit so our department we work closely with the tax department and collect all of that community benefit we report it back to the irs and then to the virginia healthcare and hospital association we also are involved with our community investments through our community grant and sponsorship process community partnerships so here in roanoke we work with the united way and healthy roanoke valley but have similar coalitions throughout southwest virginia and then partner with specific non-profits that can also address community health need and we gather outcomes through our community grant process and we fund programs that specifically are addressing identified health needs in our assessments we also have a variety of community health programs and we'll go over a few but if anybody is interested in learning more about our programs we do have a lot of educational programs that focus on behavior change and then today i'll cover some more of our um social determinant interventions and then we do specific place-based interventions so our neighborhood health initiatives and today i'll talk a little bit about our southeast roanoke city initiative so next slide um so one of my favorite programs and i i love our healthy food and our local food programs they're kind of what i'm most passionate about but fresh foods rx is a program that's in partnership with healthy renault valley and we've done this program at various clinics throughout our area so crohn's family medicine roanoke salem southeast internal medicine at riverside three and this program has also been piloted at new horizons healthcare and it's actually a fruit and vegetable prescription program that is based off of wholesome waves model where we actually prescribe quote-unquote weekly produce our community partners leap for local foods come with the mobile farmers market we have a health educator that does health education on healthy behaviors and then they receive weekly produce at the clinic along with that health education and then we actually have folks that are outside helping with uh cooking demos and and it's just a great program and the results are really promising um 60 of participants saw a decrease in their bmi and a1c and half of participants saw a decrease in blood pressure so this is a program that is quite resource intensive it does require um subsidizing the food as well as staff time but you can see the results are really promising and if we could really quantify this this program a little better i think that we could really scale this program up next slide please um some of the other interventions that we've really been exploring um specific to social determinants and this one specifically with substance use and mental health are peer level interventions so over the last couple of years we've added two quasi clinical service lines to community health and outreach our community health worker program and then our peer recovery support program so peers are individuals that are actually lay individuals they require a high school diploma or ged they go through a training through the department of um behavioral health and we actually offer that training through our office and then you're eligible to sit for an exam to become a certified peer recovery specialist and peers are individuals that can help coach patients through their own personal recovery and they have that shared experience so they all are in recovery themselves from either a mental health or substance use disorder currently we have peers that are embedded in five west in inpatient psychiatry we also have them working with our edie bridge clinic and we also have them leading community groups that are available for free in our community and we've seen really great results with this program and really see a success when individuals connect with the peer i'm being able to transition from more emergent uh care more intensive utilization in the ed or inpatient to more outpatient care and then helping people stay accountable and on track with their own recovery i'm similar with community health workers community health workers are lay level individuals we try to hire individuals that work in neighborhoods that they're serving and then they help create patient-centered goals with the client to really focus on what their own well-being goals are but then also help navigate services um so anywhere from um access to housing to transportation to finding a medical home next slide please so i mentioned that i love the local food programming so carolinian clinic actually started our own urban farm in southeast roanoke city we have over 65 educational events um this season we have two a week during the growing season and pre-covet we had quarterly block parties that would attract 100 neighbors um at least at our different clinic or at our different um block parties but what's really cool about this intervention um you know i i didn't come up with an intervention we did uh community conversations after our 2015 community health assessment to really understand some of the barriers to getting access to healthy food we went into the neighborhoods knowing that access was an issue we had heard that during the community health assessment but we went over to morningside manor the southeast action forum and various places in southeastern ask participants you know tell us more about the food access issues in your neighborhood and we learned that not only was there lack of food access but the southeast neighborhood had really grew up grown up with local produce and and their their parents and grandparents growing their own food they still very much had the interest in learning how to grow their own food but didn't necessarily have enough space to grow their food so right next to this urban farm which is inside the fence is a space that's twice the size that is a community garden so the idea here is to get people interested in growing their food and healthy lifestyles using the farm when you go to a farm event you leave with fresh fresh produce that's available and about 25 of the produce that is grown in the farm goes to incentivize programming but the other 75 percent goes to area non-profits like the rescue mission the presbyterian community center boys and girls club that actually get given to those clients and fed to those clients to help with the food access area but then people can connect here they can learn how to grow and then go right next door to the community garden and grow their own food if they wish we offer four classes per year that a lot of the community garden uh participants attend and then our farmer is on site uh he's a contract farmer that works with us 20 hours a week and he's able to act answer any questions that you might have about growing your food but when we were talking with the neighborhood we not we learned not only that there was the interest in learning how to grow your own food but southeast didn't really have a space for neighbors to get together and socialize so that was part of the intent of the farm programming was to have programs that not only address nutrition but your mind body and soul so we do meditation classes out there we do mindful art classes and we really try to foster that sense of community in that neighborhood and then the farm is led by a steering committee of community stakeholders and neighbors that live in the southeast neighborhood and my staff actually just coordinate the farm it is led strictly by our steering committee and most of the instructors are actually from the southeast neighborhood and we're really excited that we're able to start offering classes again we have weekly yoga classes and then every thursday we have an educational class and then later this summer in partnership with healing arts we will be offering some poetry sessions for our employees on burnout and grief and other issues that we deal with so please have your patients or your staff members or yourself come to our programs at the farm they're a lot of fun and they just have a really great community feel and you'll get to know the southeast neighborhood a little more so next slide please so in addition to our urban farm um our place based strategy uh since 2015 has really been southeast um the reason why we focused on southeast one it came up as one of the top areas of need in the community health assessment but if you see at the the corner of the map vernon memorial hospital is located in southeast it is our neighborhood so we felt like we should start in our own backyard first and utilize resources in a very intentional way so you can see on the graphic to the left the different investments that we have had in southeast including fresh foods rx morningside our community health workers and peer recovery specialists we also have a team of nurses and health educators that go throughout the community and offer free immunizations and health screenings and then what i'm most excited about is fallon park elementary school this program is known as lyft and it is a partnership with korean clinic freedom first federal credit credit union and delta dental but it will actually be our first community and school model where we are building a clinic within the fallon park elementary school area we plan on having ped services there during school hours but then holistic health programming after hours and we'll be providing wrap-around services such as community health workers some of that financial counseling and we're really excited about this this intervention um this program we started with a asthma program that pids has been conducting for a couple of years i think we're in our third year of that program and we're really excited we currently have a school-based strategy position posted now so if you know anybody that is interested in that position it should be posted throughout the week so next slide please um so so all in all with community health improvement we truly believe that it takes an entire community working together public health system the health care system but also all of our stakeholders and our community really working together and being guided and intentional on how we improve the health of our communities so dr morrow i'll turn it over back to you if you have any final words no you know i i just every time aaron and i work together i just always think of such wonderful things that that are happening in this community so really want to open it up to um any questions uh i think that the key here as aaron just ended with is that it takes a community to improve the health of the community and we just want to make sure that you that all of you in the audience know about us know about what we can offer and if there's anything that we can do to help you help teach this stuff to your learners um we'd be happy to but also just just know that we are here because we're truly passionate about working together to improve the health of the roanoke valley absolutely a few questions in the chat um so thank you for just the describing a wonderful southeast farm program have you published about it and are there any findings thus far you know we have not published any findings on the farm if there are any researchers that would like to partner with our department i think that we would be open to it oh i know we've got them out there absolutely we've got to collaborate that's a great thought so this sounds like a wonderful program have you formed any partnerships with roanoke city schools to increase education regarding the fresh foods work on the rcps farm farm to school program yeah so um we actually uh roanoke city public schools and leap for local foods have received a farm to school grant and actually i i've been was part of that initial grant application and we'll be going to my first meeting which is a planning retreat on wednesday but we do have a really strong partnership with roanoke city public schools we're really excited with our new clinic to really be able to focus on that one school and see how we can bring more programming and even some produce to that that model and then we've also been working with roanoke city public schools on well-being during the pandemic and we just launched a mental health navigation line with roanoke city public schools as well as some area non-profits and our psychiatry department to really help provide those mental health resources and ultimately we hope to increase provider capacity for behavioral health going forward wonderful wonderful yes another comment the child and adolescent psychiatry will be helping with phelan um starting this year which is fabulous any other questions anybody you can feel free to unmute yourselves or type it in chat or um however you're most comfortable sherry this is mark watts uh i have one for cynthia has there been any more talk about an fqhc in southeast vernick not that i'm aware of but i can try to find out and i'll let you know mark okay thank you sure um one question that came up privately with with me is um aaron do you can you share any information that we have on return on investment because for for a lot of people bottom line is is is there a return on investment you know that that's something that's um just a fantastic question so a lot of the programs that we describe today are done as community benefit meaning that they have to benefit the community greater than carillion or we cannot write them off as community benefit for our hospitals but with that said we have looked into our community health worker and peer support programming and we can't show a direct return on investment but we can show some cost avoidance and some trends so we have shown that with our community health worker program um our 18-month pilot was done in partnership with the virginia healthcare foundation and uh we did show some trends that after engaging with the community health worker we saw re-emissions reduce we saw a shift from hospital care to outpatient care and we saw a potential of five hundred thousand dollars in cost avoidance in terms of charity care to the hospital system so in my mind as a community benefit professional that's shifting from one bucket of community benefit the free and uncompensated care or or our charity care policy over to you know our program bucket for community benefit programs and operations but if we can keep them out of the hospital that is fantastic and i i saw dr music's comment cost avoidance is indeed a return on investment i agree the other thing that we have been trying to work with is the virginia healthcare and hospital association to really clear up some of that gray area with these community benefit programs that do show an indirect benefit to the hospital through cost avoidance but still this is a very new requirement and there isn't a lot of guidance from the irs yet got it also dean lehrman commented there's a lot of interest in vtcsom and supporting karelian's community engagement strategy through research and other partnerships so you've heard it directly from the dean there's there's interest there so make some connections absolutely this was a wonderful overview of population and determinants of health as well as a discussion it's really the super impressive and really cool things that we're doing to address these issues locally um just for you all all of these health system science topics through this series are becoming increasingly familiar to our learners so as clinicians and other health professions educators it's really critical for us to continue to learn more about these topics so that we're able to effectively teach model and reinforce these concepts in whatever your space is particularly in the clinical environment so hopefully this discussion has inspired you to become more involved in having an impact in these areas not only through teaching and reinforcement but hopefully through modeling and becoming uh directly involved on your own and or through collaborations may that be research collaborations or a variety of ways so um cynthia and aaron are are both very approachable and um welcome you contacting them and initiating some collaboration or contact our office and we'll we'll be the little brokers there but um other than that i think it's we're one minute pass and i'm sorry about that but i hope you all have a wonderful day um if anybody wants to stay an extra few minutes for questions we're able to do that also otherwise have a great day anybody else who's staying behind have any questions they want to quit questions they want to ask uh dr morrow or aaron lots of great comments yeah um can you hear me i can dr banky from endocrinology i've been listening and i do want to speak with erin if you can reach out to me i would like to work with you in terms of getting some nutritional information on these pre-diabetics and there's some a survey we can do to really look at this more uh scientifically objectively and see how we can increase especially fiber content and decrease diabetes risk so yeah fantastic and we have a dietitian on staff with us angela charlton and we have dietetic students that that work with us so we would love to partner yeah i think maybe we could even get a nice thrive grant if you it's kind of timely but yeah i'll definitely uh reach out yeah what's your email aaron uh a-m-h-bush b-o-u-s-h crowingclinic.org a-m-h-b-o-u-s-h okay i'll send you an email thank you very much i enjoyed the presentation making things happen anybody else all right everybody have a great rest of the day.