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Creating a Roadmap to Achieving Community-integrated Health

Published on 9/27/2017

One of the questions I am frequently asked in my role at the YMCA is, "What is community-integrated health?" It's not a new phrase, and organizations like the Robert Wood Johnson Foundation and the National Council on Aging have been developing toolkits to support community integrated health strategies for several years. As health care systems, public health agencies and community organizations have begun to align to improve the health of the communities they serve, awareness of community-integrated health has increased in the past several years.

One of the reasons why we're seeing the awareness of community-integrated health rise is the industry is beginning to understand that what we provide, at the clinic and the hospital level, is a small fraction of the "care" that contributes to a person's health and wellness.

The majority of a person's barriers to being healthy and staying healthy are impacted by what's happening in the community. These nonclinical factors - including a lack of safe places to be physically active, a lack of access to nutritious food or a lack of adequate transportation to a clinic, hospital or pharmacy - all impact a person's health. Community-integrated health is an attempt to coordinate and align resources across all parts of the community to impact and to improve the nonclinical factors that impact a person's health and wellness.

Achieving community-integrated health

To me, community-integrated health means finding intentional strategies to connect traditional health care structures with community-based organizations and programs. It's an effort to extend the scope of what we think of as the care team to include those community-based providers. There are a few ways to accomplish this integration:

1. Partnerships among clinical, community and public health organizations

Any health care system, private practice or employer can look at integrating with community-based programs in a way that serves their population to fill gaps in needed wellness, prevention and care delivery services.

Many of these strategies can be driven off the community health improvement plan, which most organizations will complete to get some sense of what the community's needs are. Based on what those needs are, the next step is to identify who in the community they can partner with to help meet those goals.

2. Cross-community referral strategy

Having a cross-community referral strategy can help leverage resources across the health and care continuum. For example, if food insecurity is an issue for a population, hospital or organizational leadership might reach out to the local food pantry. If safe spaces to live and work and play are an issue, it might be appropriate to partner with the local community parks organization to create safe, pleasant walking spaces so that people can safely get outside and become physically active.

3. Focusing on health promotion and disease prevention

All community partners should invest in the delivery of evidence-based programs that are focused on health promotion, disease prevention and the treatment of chronic disease. At the Y of Greater Kansas City, we offer several evidence-based programs focusing on primary, secondary and tertiary disease prevention. Examples include:

  • Primary prevention - an eight-week weight loss class, options for a wellness consultation and one-on-one coaching sessions
  • Secondary prevention - our YMCA Diabetes Prevention Program, a 12-month program designed to help at-risk adults reduce their risk of developing Type 2 diabetes; this program is open to all members of the community, and a Y membership is not required
  • Tertiary prevention - a wellness program called LIVESTRONG at the YMCA for adult cancer survivors and a therapeutic arthritis exercise class called Enhance Fitness

Programs like these can be duplicated and scaled to other communities, helping individual members of the population maximize their health potential.

Creating a connected community health record

When we're in the school or education setting, we're talking about the health and wellness of our children. When we're in an independent living facility, we're talking about the health and wellness of our seniors. Instead of seeing these as disparate aspects of a community, we must think of them as parts of a greater whole. The health care system, the public health system, academic institutions and community-based organizations are all part of the community. How do we all start to work together?

That's what I drive toward - that idea of a connected community. If I go to the hospital one day and my local food pantry the next, why don't those two organizations know who I am with the same information? If I'm diabetic, the hospital might know, but the food pantry might not, and the food pantry could help me make wise decisions and food choices if they had that information.

Ultimately, we should be working toward the goal of a community health record. This gives health care organizations, community organizations and public health systems alike the ability to understand and truly know the individuals in its community.

How HIT can advance community-integrated health

How do we start to pull all these different sources of information together? How can we continue to sow the seeds of community-integrated health?

A big piece of the strategy lays in evidence-based health interventions at the primary and secondary levels - there should be a focus on health prevention wherever possible. Not every prevention program will meet everyone's needs, and there should be an emphasis on meeting people where they are.

This is where health IT (HIT) comes in. Mobile health could be a huge aid in prevention programs. We've already seen Centers for Disease Control-approved curriculum for diabetes prevention that can be delivered on a mobile platform. At the Y, we're working with a partner to do mobile Diabetes Prevention Program and mobile blood pressure self-monitoring. We know that if we want to meet people where they are, we need to offer them both in-person and virtual health coaching options.

There's also an opportunity to leverage data aggregation to help engage the person in their wellness and their disease prevention. Part of what community-integrated health addresses are social factors that HIT won't necessarily solve, but what we're able to identify - especially with a more robust set of data - is where in the community we need to focus resources or programs. Being able to look at the data and translate it into actionable programs or services is where all of this will come together.

The path to successful community-integrated health

There's no silver bullet that will fast-track the industry toward scalable and sustainable community-integrated health initiatives. We need strong leadership that believes in a focus on wellness and not sick care, we need interoperability, we need intentional health care-community partnerships, we need intelligence and we need a true community record at the person level.

To me, this mission is personal: I watched my father struggle with his health, and after his death, I went back through his health record to see where there were opportunities to make interventions. It begs the question: If the care team had been more connected and looked at my dad holistically, would he still be here with me today? I believe that no one should lose a loved one because of things that we have the capability to solve, and having a more comprehensive view of a person and being connected to the parts of a community where the person might travel along their health journey will only empower us to do much better for the individual and the community.

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