When diabetes rates increased among minority groups in an urban neighborhood, department leaders at the local academic medical center each addressed the problem through their unique perspectives. Clinicians provided diabetes prevention education. Researchers examined the reasons for the rise in new cases. Medical school students learned about the disease and worked with diabetic patients in a free clinic. A critical problem with this approach? The department leaders didn’t work together or with community members to develop a common goal and determine the best ways to improve the health of patients and the community.
Although this scenario is hypothetical, programs like this one have become common as medical schools and teaching hospitals have placed a higher priority on addressing health disparities, in part because of Affordable Care Act provisions designed to improve community health and reduce inequities. Research has shown that these types of initiatives can help reduce inequities, such as higher rates of elevated blood pressure or diabetes in minority populations, but there isn’t always collaboration across education, research, and clinical care within the institution. In addition, academic medical centers don’t always involve community stakeholders. Could such important initiatives be more effective if institutions enhanced collaboration across mission areas and partnered with community-based organizations?
Many of the programs designed to reduce health inequities and promote community health are “cordoned off from other departments, other expertise, internal and external,” said Philip Alberti, PhD, AAMC senior director of health equity research and policy. “We need to do this work in a more coordinated, more systematic way that will maximize its impact.”
A new AAMC project, funded by the Agency for Healthcare Research and Quality (AHRQ), is seeking to jumpstart this coordination by encouraging institutions to bring mission areas together in partnership with community organizations and public health departments to address local health challenges. The Building a Systems Approach to Community Health and Health Equity for Academic Medical Centers initiative launched in February 2017 with a kickoff workshop at AAMC headquarters.
Creating sustainable systems
At the center of a successful academic-community partnership is the community health needs assessment (CHNA), the process of collecting data to identify local health needs, with the ultimate goal of using the results to engage community stakeholders, define priority health issues, and develop initiatives that address those issues. The key piece of the CHNA is the community, Alberti said. “The CHNA tells us what the community needs and wants and what its hopes are.”
“This is not just the researchers going into the community and doing the work, but really involving community stakeholders. What we don’t want to do [as researchers] is say what the community is. We’d like the community to tell us where they are, what they represent, and what they see as important.”
Courtney Aklin, PhD
National Institute on Minority Health and Health Disparities
Throughout the kickoff workshop, participants underscored the importance of including local stakeholders to ensure that health equity efforts reach patients and address their needs.
“This is not just the researchers going into the community and doing the work, but really involving community stakeholders,” said Courtney Aklin, PhD, chief of staff at the National Institute on Minority Health and Health Disparities. “What we don’t want to do [as researchers] is say what the community is. We’d like the community to tell us where they are, what they represent, and what they see as important.”
The AAMC project is designed to develop a systems-based approach to move toward health equity at medical schools and teaching hospitals. Over a three-year series of meetings, each of the eight teams participating will create a system unique to their institution that combines community health-focused programs already taking place and determines opportunities to enhance the synergy among clinical, educational, and research efforts and to expand existing community partnerships.
“We had a significant amount of community-relevant projects but few have identified specific goals, objectives, and metrics to evaluate outcomes,” said Rick Barr, MD, senior associate dean for graduate medical education and pediatrics chair at the University of Mississippi Medical Center.
The first step was for the eight teams to begin mapping all community health programs at their institutions—from diabetes programs targeting seniors to prenatal programs for expectant mothers. “We found there were silos of greatness in our health equity work, but there were missed opportunities with systematizing this,” said Terry Fairbanks MD, MS, associate director of the MedStar Institute for Innovation at MedStar Health in the Washington, D.C., area.
As part of the AHRQ grant, the AAMC developed a Health Equity Inventory tool that will help teams collect information about existing efforts into a searchable database that can show all institutional programs that are addressing diabetes or heart disease, for example. Do those efforts involve all mission areas and could they be more effective if they join forces? Are community organizations and public health partners involved to ensure that AMC efforts meet community needs?
“It is critically important that the community have a say-so in the process,” said Al Richmond, MSW, executive director of Community–Campus Partnerships for Health. “What that might look like is a series of open house events between the community and the academic institutions and medical centers. It also might include establishing community advisory boards or other groups that would provide leadership opportunities for communities to have a really important say-so in the design of the work and in the implementation of the work, as well as the evaluation of the work.”
The result is a “learning community health system” that brings the resources and assets from institutions and community partners together to tackle specific health issues, said Candice Chen, MD, MPH. “In a 30-foot view of an ideal learning [community] health system, I’d like to see a network of different learning health partners, including the [institution], other health providers, social service providers, local government, community-based organizations working together, utilizing everybody’s resources and expertise to address population health,” added Chen, director of the Division of Medicine and Dentistry at the federal Health Resources and Services Administration.
In the program’s second year, the teams will develop metrics to evaluate the systems. Like each component of the project, community and public health stakeholders will be involved in deciding what measures define success.
Institutions should develop “metrics from the community perspective [that] honor what is important to them and integrate that into the system,” Richmond said.
In the final year, the teams will evaluate system implementation using the metrics they developed and collect data to determine the system’s benefits not only for the community, but also for medical schools and teaching hospitals—from physicians and researchers to medical students and other stakeholders. “The ultimate goal is to improve health, whatever that may be,” said Chen, noting that regardless of the specific goal—reducing infant mortality or hospital readmissions, for example—success happens when “people in the community [begin] believing health is improved.”