How Community-Clinic Integration is Boosting Population Health

Communities play a critical role in shaping Total Health. Too often, the ability to lead a healthy life is stymied by a person’s environment. A lack of access to healthy food, community violence, and pollution can lead to conditions like obesity, depression, or asthma.

Loel Solomon, Vice President of Community Health for Kaiser Permanente
Loel Solomon, Vice President of Community Health for Kaiser Permanente

Community-clinic integration is the next frontier in strengthening the health of populations. Holly Potter, vice president of Brand Communication for Kaiser Permanente, sat down with Loel Solomon, vice president of Community Health for Kaiser Permanente, and Jandel Allen-Davis, MD, vice president of Government and External Relations for Kaiser Permanente Colorado, to talk about what community-clinic integration is, and how it’s driving improvements in health. Today’s post is the first in a two-part series.

HP: Thank you both for making the time to talk with me. Let’s start with the basics. What is community health and how does it affect individual health outcomes?

Loel: There are two elements here. One is that community health is the health of a population, not just an individual. That means that you’re looking at those whose health is most challenged and lifting them up in order to increase the health of the whole community.

On another level, community health points a spotlight on community factors that influence behaviors – things like parks and walking trails, which can increase physical activity, or access to grocery stores and farmers’ markets, which can increase consumption of healthy food. There are other factors in neighborhoods that influence people’s health directly like pollution and environmental toxins. So community health invites us to think about both influencing the health of overall populations, as well as focusing on these things in the community environments that influence health.

Jandel Allen-Davis, MD, Vice President of Government and External Relations for Kaiser Permanente Colorado
Jandel Allen-Davis, MD, Vice President of Government and External Relations for Kaiser Permanente Colorado

Jandel: There are other contributors to health beyond our physical status. Community health also includes components of well-being such as our relationships, our community connectedness, our emotional state and our financial well-being.

HP: To address community health, you both speak of community-clinic integration. What is community-clinic integration and why does it matter?

Jandel: As a physician, I experienced 25 years of observing the impacts of social factors on health and how they play out in the exam room. I can speak to the frustration that I felt in knowing that social needs are not being met, and you don’t have the tools to deal with them. I’ve often thought over the years, “What this person needs cannot be found in a pill bottle or addressed with a scalpel.” I think that community-clinic integration has the potential for us to be thinking about, “How do we bring those resources not just to our patients, but to the providers who are doing their best every day to provide that level of care for people?” I think there’s real value for us to be able to help solve for that dilemma, which is hopefully going to improve cost, quality, and the care experience for patients.

Loel: It’s also what we do as an organization to systematically connect our members to the very rich set of assets and organizations that exist in their communities. Doing this at scale is a real challenge given how varied our members’ needs are, and how diverse the local resource landscape is. But it’s a real imperative for us to figure out how to do that, and there’s a lot of great work under way in our organization that will help us move forward.

HP: What does that really look like in practice?

Jandel: One example is our work with Hunger Free Colorado. When the recession hit, hunger became more evident among populations we typically didn’t think about. In 2011, we did a pilot program and screened our own members for food insecurity by asking the question, “When was the last time you worried whether your food would run out before you had the money to buy more?”

Of the population we screened, about 14 percent of those screened tested positive for food insecurity. These were people who had commercial health insurance, meaning they had jobs that provided health benefits. Given that, there were all sorts of assumptions about who they were and what resources they had. What we found is that if you don’t ask the right questions, this foundational need related to food access would go unnoticed. Today, under the leadership of Dr. Sandy Stenmark, we are screening all of our new obstetrical patients for food insecurity and are rolling the screening out in pediatrics.

Loel: Due to this assessment in the exam room, we were able to connect these members to community-based resources through Hunger Free Colorado. This organization helped them get food stamps (SNAP), it helped connect them to local food pantries, and with a whole variety of other resources.

Then there’s the policy change piece. Out of the 50 states, Colorado ranks at the bottom in terms of the percentage of the population eligible for food stamps who actually receives them. Through Hunger Free Colorado, we have been able to make changes in state and local policy to lessen the burden and lower the barrier for people to take advantage of food stamps.

Check in tomorrow for Part 2 of this interview.

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