Innovation and disruption
Creating Health Neighborhoods: A Place to Live, Work, and Play
As health care continues to evolve, what if some of the current or future brick and mortar locations of our health care delivery system could serve as a mixed-use environment that addresses not only individual health, but expands to consider population and economic health in a community? Would this new model create communities where people want to live, work, and play?
If we look at shifts in the industry today, we can see doors opening for these health neighborhoods, including:
- Health care delivery is changing. Care is continuing to move from the inpatient setting to outpatient settings, virtual, or home-based care, and consumers are demanding convenient and customer-focused options. These shifts alone have many implications for incumbent hospitals, health systems, and providers, including the need to revisit their built environments.
- Social determinants of health (SDoH). Health care providers do not have the ability to address everything that impacts an individual’s health, yet they are increasingly being held accountable for the downstream ramifications of these factors. If health care leaders are willing to consider new models, like a health neighborhood, it could afford them increased opportunities to directly and indirectly impact more SDoH.
- Market dynamics and fiscal policies. There are growing pressures on revenues and margins. New competitors are moving into the health care delivery system. Payers, particularly government programs, are driving reimbursements lower and demanding better value and outcomes. This means health care providers may be saddled with high debt loads, decreasing reimbursements, and physical structures that no longer meet the needs of a shifting delivery system. Reimagining those buildings and the surrounding environment could better connect individuals with their local neighborhoods, while also providing new revenue streams.
- Changing demographics. There are major shifts in how different generations think about health care and where they want to live, work, and play. Younger generations want to live in walkable cities where health care is convenient and amenities are located nearby. Older generations want to age in place and tend to desire in-person health care delivered close to home.
As all of these changes come together, there are ramifications on health care’s long-term physical infrastructure. The fundamental shift underway in health care is pushing out from within the walls of a hospital or clinic and into the community.
If we are simultaneously working to keep people (and populations) well and out of hospitals and clinics altogether, and if we agree that economic health contributes to both individual and population health, then revisiting the physical footprint of health care is important. The health neighborhood model creates new ways of imagining health care’s built environment — both current and future facilities — and the areas that surround them to create a new micro community.
Understanding what impacts individual health
Looking at the County Healthy Rankings, a collaboration between the University of Wisconsin’s Population Health Institute and the Robert Wood Johnson Foundation, health care itself (hospital care, physician care, etc.) accounts for only 20 percent of what impacts an individual’s health. This percentage comprises access to and quality of care, which hospitals and providers across the continuum are able to directly affect, and historically, are what they have focused on.
However, hospitals, providers, and health systems should also take into account SDoH they cannot control, and yet are increasingly held accountable for, that also impact health outcomes. These remaining 80 percent of factors impacting health are:
- 40 percent — Social and economic factors (e.g., education, employment, social supports, safety)
- 30 percent — An individual’s health behaviors (e.g., tobacco use, diet, exercise, drug and alcohol use, sexual activity)
- 10 percent — Physical environment (e.g., walkable cities, transit, air, water)
Patient case study (current state)
A patient has had a recent heart event, combined with ongoing obesity, hypertension, and diabetes. He has a difficult time accessing healthy food, is nowhere near a fitness center, and does not have a car. The hospital has successfully treated him for the heart event, and has indicated he should take cardiac rehabilitation classes, including education on diabetes and the importance of exercise, diet, and nutrition.
To date, he has sporadically attended class due to a lack of transportation. He lives in a food desert and frequently gets fast food or frozen meals. His weight, blood pressure, and diabetes is unchanged.
Unless these other SDoH are addressed, he could find himself back in the hospital with a worsening condition. Even though these aspects are outside of the provider’s control, under varying payment models or requirements (such as readmissions and value-based payments, among others), providers could be financially penalized for this patient’s higher utilization of services and poor health outcomes.
While it is completely understandable that providers have focused on the 20 percent of factors they can directly impact, they will need to determine how to better influence and impact more of the remaining 80 percent. This is where a health neighborhood model could begin to fill in some gaps.
Moving beyond individual health into population health
Health care providers increasingly need to understand how to better impact population health, and they are well positioned to do so. From relationships with social service agencies and local government to local chambers of commerce and businesses, providers already are active members of their local communities. But could there be another way for providers to leverage these relationships and resources more effectively and efficiently to address the health of local communities?
The AHCM is based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs.
Learn more about AHCM and the 31 communities participating in this CMMI model.
The Centers for Medicare and Medicaid Services (CMS) and its Center for Medicare and Medicaid Innovations (CMMI) Accountable Health Communities Model (AHCM) revolve around this very concept. The model is designed to leverage resources, encourage alignment, and address unmet needs like food insecurity or inadequate housing. In other words, the model seeks to focus on the other 80 percent of SDoH impacting health outcomes.
The head of the Department of Health and Human Services, Alex Azar, has also indicated CMMI is looking at other health care models that allow hospitals and health care providers to address SDoH. This would be in addition to what the agency has already undertaken to allow Medicare Advantage plans more flexibility to address SDoH in the future.
If a health care provider, say a hospital, could help coordinate resources or locate them directly on its campus or in the surrounding area, it could result in better access and an even stronger and tighter clinical-community linkage. In doing so, it would allow for new ways of leveraging and deploying limited resources in ways that are specifically aimed at the community’s needs. In this sense, re-imagining or reconfiguring health care’s built environment to allow for these types of enhanced linkages presents a targeted, unique opportunity to improve population health.
Combining population health with economic health
Current models do not typically aim to improve the economic health of communities, yet this factor influences both individual and population health outcomes.
Oftentimes, health care providers are economic lynchpins in their communities; not only do they provide access to health care close to home, but they provide direct and indirect jobs, and economic impact. By considering the built environment in and around the hospital or clinic, health care leaders can extend that impact even further via a reimagined, mixed-use neighborhood of health care, retail, and even residential options.
For example, a hospital campus could serve as an anchor business in an area, bringing with it a built-in customer base of patients and visitors. The hospital could work with the city, businesses, and local community to understand retail and housing needs. As it builds the hospital campus, it could consider more mixed-used space (retail and housing) to help address local community needs, as well as create more economic activity. In turn, this creates an even more attractive business climate.
When we consider combining this with the potential of different housing options in and around the area, it adds in another dimension and customer base. When more individuals live, work, and play in closer proximity, the area lends itself to a broader tax base. Population centers also provide the potential for collaborations with local government on better public transit options, public investment in improved walking or biking routes, and more.
The new health neighborhood model
In this re-imagined built environment, a health neighborhood model holistically combines the individual health, population health, and economic health of a community. Symbiotically, these three pillars will ideally work together to benefit all.
Let’s see how overlaying our SDoH factors onto this model addresses needs:
- Health care, 20 percent — Access to and quality of care could actually increase by facilitating new care delivery models, like hospital-at-home or regular in-person home visits for complex patients. A health neighborhood (large or small) could serve as a competitive advantage, even drawing people in because of the accessibility of both health care and retail needs in one trip. It could also serve in attracting or retaining health care providers, including the younger generations who may want to live within walking distance of where they work and play.
- Social and economic factors (e.g., education, employment, social supports, safety), 40 percent — A health neighborhood will not be able to address every factor, but it could certainly provide new opportunities for employment (via new retail locations, for example), better collaboration, integration, and use of social supports, and even new educational partnerships with tech colleges or training and mentoring programs within the neighborhood itself. The health neighborhood may even qualify as an opportunity zone with additional tax advantages.
- An individual’s health behaviors (e.g., tobacco use, diet, exercise, drug and alcohol use, sexual activity), 30 percent — Health neighborhoods could begin to impact individual’s behaviors by initiating collaborations that spark programs or classes, and provide better access and availability to support groups, a fitness center, healthier food options, and a grocery store, all located within walking distance.
- Physical environment (e.g., walkable cities, transit, air, water), 10 percent — Health care providers can work to make their built environments greener, and encourage other businesses in the health neighborhood to do the same. This may include working with city planners to create or facilitate better walking trails in the area, and advocating for better transit options to or within the health neighborhood.
Imagine a health system building a new micro hospital to address the needs of a local community with these factors in mind. They host brainstorming sessions with the city, businesses, and community leaders, during which they identify key retail needs and collaborate on shared goals. The health system develops plans and space that will be filled by a local social service organization, a fitness club, small grocery store, locally-sourced restaurant, and co-working office space that will also serve as an incubator for start-ups. The whole neighborhood will have access to community Wi-Fi.
During these brainstorming sessions, housing needs in the area also arise. They discuss condos, senior living, and even an intergenerational living community. Additional residential options in the area would provide for the housing needs of health care workers and others who want to live in the area. Senior living, or intergenerational living, allows for better aging in place and addresses different generational needs. The health system works to develop or support opportunities to meet these residential housing needs. The area sees growing economic vibrancy. There is less social isolation as more individuals live in community.
Health care providers and social services begin to cluster in this area, creating a cohesive deployment of resources to meet specific, local needs. New health care delivery models emerge that allow for better chronic care management, prenatal care, wellness, and more. Individual and population health needs begin to improve, which result in providers seeing better quality outcomes, reduced readmission rates, reduced utilization of resources, improved patient satisfaction, and increased patient-centered care.
Patient case study (future state: health neighborhood model)
When the cardiac patient from earlier is placed in this model, he is able to take public transportation (a bus stop was added due to the health district) to his new job at a business in the health neighborhood. He is also able to walk to his cardiac rehab classes at the hospital nearby. His physiological data is being monitored remotely, and he is checking in regularly via telehealth with his exercise physiologist, nutritionist, and doctors. As a team, they are working together on behavior modifications, healthier food choices, an exercise program, and any physical or mental health needs that arise.
Taking what he’s learned, he shops at the local market for groceries before heading home. Due to a partnership between the hospital and local social service agency, when his cardiac rehab classes end, he can continue his exercise regime at a local fitness club that has opened up nearby. As a result of these changes, he has lost 15 pounds, his blood pressure is moving in the right direction, and his diabetes is better managed. He is hopeful about his future, and his care team is pleased with his progress and that he has not needed any additional care.
Does this all sound a bit too utopian? Perhaps. But if we are in a time period when health care is being re-considered, then re-imagining health care’s physical footprint and leveraging the role it can play — small or large — is important, as well. Doing so offers the opportunity for forward-thinking health care leaders to dream differently, envision health care delivery in new ways, and push further into the very fabric of their communities. The goal: to create better spaces to live, work, play, and be well.
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