Care Redesign
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Embedding Health Care in the Community (11:43)

“What if health systems were built around the needs and preferences of the people receiving care, not the providers?” asks Consuelo Wilkins, Executive Director of the Meharry-Vanderbilt Alliance. What if Nathan, a 34-year-old father and husband who works two jobs, could receive his health care in a place where he felt comfortable, not vulnerable, such as at the community center where he plays basketball on weekends?

A key piece of achieving this change to the health care system is partnering with community organizations. We must think about how we can earn their trust and be more trustworthy, says Wilkins. “That’s the only way we’re really going to get the system to evolve and get to a place where we can think beyond what our needs are as providers and health systems, and get on to changing the lives of our patients.” Trust, especially among the most vulnerable populations, is closely linked to whether people perceive that they are being treated fairly and that they will be safe — it’s not about how many degrees we have, rewards we receive, or the prestige of our institution.

We’ve seen progress in making health care more available in terms of mobile clinics, retail clinics, and extended hours. But hours and location are not enough. “We have to embrace the fact that people live in communities that are important to them, and we have to begin to embed ourselves in these communities,” says Wilkins. “As long as we remain siloed, we’ll continue to have poor outcomes, especially among the most vulnerable.”

Health care is structured around supporting clinicians who are providing services — not paying them to keep people healthy, but to provide health care. Saying the words “social determinants of health” is not going to change care management, but recognizing that health providers and health systems have a role in solving them is a start.

So how can we evolve the health care system to keep people healthy? By working with community organizations, and by thinking of that work not as community benefit, but as a strategy. “What if we valued their assets and resources and the knowledge that they bring to the table? Perhaps then we could begin to address the 60 or 70% of the drivers that are impacting health,” says Wilkins.

Wilkins shares insights she’s gained while working with community organizations through the Meharry-Vanderbilt Alliance’s interprofessional education program, an initiative across multiple universities that partners with community organizations to solve problems that they identify, not problems the Alliance identifies. In this program, students travel to community organization settings, where the organization brings a problem forward, students present ideas to resolve that problem, and the organizations then rank those ideas and decide who to work with.

These organizations focus on affordable housing, supporting former offenders, and providing skills to runaway teenagers, meals to seniors, after-school programs, and other services. This may seem either like an overwhelming list or not connected enough to health care, but, says, Wilkins, “we’re taking on housing, we’re taking on food insecurity, we’re taking on the alienation that has become so much a part of our daily lives.”

Meharry-Vanderbilt’s community partnerships are just that: partners. They explain what they want and what to do, design programs, and even co-author academic papers. “We pay them, we respect them, we invite them to the table,” says Wilkins. As for the students, they become more prepared to take care of the most vulnerable of patients.

Community organizations are not only important, but they are crucial to transforming health care. “We have to begin to embrace their knowledge, their assets, and incorporate them into the plans that we make at the beginning, not at the end.”

The All of Us Research Program, part of the Precision Medicine Initiative, for example, aims for the involvement of a million people in a longitudinal study. To help achieve this, Wilkins’ team has sought input from many different populations on their preferences, needs, and views on the emerging space of precision medicine. They started 18 months ago, and in less than 6 months held 77 face-to-face roundtable sessions all over the United States. Local organizations hosted the roundtables, or what they called community engagement studios, and recruited members of the community to join them. They provided input on flyers, the best ways to communicate with community members, when to host sessions, and where to order food.

“We respected their advice,” explains Wilkins. “If they told us to have a session in the morning, we held it in the morning. If they told us that we should order food from the neighborhood store and not Panera, that’s what we did.”

And that’s another lesson: cultural humility. “We must recognize that if we are going to work with the community, we have to be humble enough to realize that we don’t know everything we need to know about the people they serve, and we need to be ready to and willing to gain that knowledge,” says Wilkins. Different from cultural competence, cultural humility requires willingness to change the way one thinks and the way one values the unique characteristics of individuals.

Once we establish authentic community partnerships, it’s time to expand beyond this boundary and truly integrate with these communities. One solution is to co-locate services within community organizations, as Wilkins mentioned in her example about Nathan. “It shouldn’t just be a referral to them; we must be embedded in the community in order to see some change.”

So, asks Wilkins, “What if we pick up our laptops and our stethoscopes and go to the community?”

From the NEJM Catalyst event Expanding the Bounds of Care Delivery: Integrating Mental, Social, and Physical Health, held at Vanderbilt University Medical Center, January 25, 2018.

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