From Theory to Practice: Cultivating Health at Scale
Why is it so hard to make a difference in a community’s health? There’s an abundance of programs that are known to work, and vendors willing to run them. We’re talking about services such as diabetes prevention programs, early childhood education programs, cognitive behavior therapy… There are so many interventions and programs, and yet community health is still a big problem.
The problem is not so much with whether they work but with whether they are actually implemented, and implemented effectively. That requires not just a purchase order to a vendor, but buy-in from the individuals involved – not just the patients/end-users, but the chain of people from payers and physicians to community services and other institutions that talk to and educate community members and deliver the programs.
How is that achieved? There are many ways, and all of them work together to lead to success.
First of all, the health-care system needs to be involved, both as screener and referrer. But that doesn’t happen easily. Clinicians are busy and time-short; they have multiple priority tasks to handle in each 15-minute (max) patient interview. So there may be a role for other provider staff, both in screening and referring. (Consider the Other 45 program used in Spartanburg, SC, where medical residents spend 45 minutes (of the hour) with patients after a doctor’s appointment and take the time necessary to make sure the patient understands what the doctor said, what the doctor recommends, and so on. The resident also asks whether the doctor’s recommendations make sense given the patient’s situation: Can she afford the prescription co-pays? Does she have the necessary equipment to follow the doctor’s orders? Does she have the time to exercise daily? And so on. That same resident (in the Other 45) or medical aide could also do a blood test, ask about adverse childhood experiences or substance abuse, and refer the patient to to the relevant program. Because these referrals are issued during this more intimate 45-minute discussion, they’re more likely to be appropriate, and understood and acted on by the patient.
But in general, doctors are too burdened to be the primary «marketing» arm for most publib health programs. Instead, with the Wellville 4, we believe at-scale adoption of health programs requires some entity responsible for making things happen, whether directly or by coordinating the efforts of multiple local service providers. That entity could be a joint effort between between County Public Health and the Rotary Club, as in Muskegon, MI; it could be a joint venture between health systems (with a budget) as in Lake County, CA, or, in the case of a promising initiative we’re following (but not directly involved in, yet) an insurance company focused on population health, such as Humana’s Bold Goal teams in San Antonio, Louisville and Tampa. Whatever the precise vehicle, it’s not realistic to expect doctors to suddenly take on the job of recommending all those who need these services; there needs to be a new mechanism for that to happen.
The advantage of programs like Way to Wellville is that they can reinforce what the health systems are doing by working with employers, churches, schools, retailers and the service providers themselves to induce people to sign up. They can provide reminders or referrals – or offer incentives and discounts of various kinds to program members. But more importantly they can provide social support – meeting rooms, discussion group leaders and the like. Almost any of these programs will benefit both from peer support and group therapy. A whole range of programs depends on some curriculum/playbook/app accompanied by some form of coaching, whether totally automated or with a human, delivered online or by phone. That helps them to be effective, but support from local service providers and coaches, leading groups of peers, can make a huge difference both in recruiting people and in keeping them engaged.
All this means a delicate balance between launching the programs and building capacity, and lining up the members to make use of the services. Supply needs to match demand. And to make that happen, community leaders need to make commitments – both to provide the services and to reach the people who can benefit from them.