By Judy Cole
Picture this: You’re a single mom struggling to make ends meet. Your baby needs his check-up, but the nearest doctor’s office is more than an hour away by bus. Taking time off work isn’t a viable option, so you cross your fingers and hope for the best.
Or you’re a working parent who just moved into the only housing you can afford. You’re trying your best to feed your kids healthy, nutritious meals, but with no supermarkets in the neighborhood, the options are limited. Frustrated, you think, “Fast food is better than no food at all.”
Over time, fast food becomes your way of life.
The circumstances that allow these unhealthy scenarios to develop and take root in a community have a huge impact on the health and healthcare of the people who live there. And nowhere is that impact more keenly felt than in traditionally underserved, low-income communities, including those in Charlotte-Mecklenburg.
Now, thanks to a collaboration by Carolinas HealthCare Systems and Novant Health, usually rival institutions, these “social determinants” are under sharper scrutiny.
For years, public health experts have tracked the forces that push people into unhealthy behaviors, but medicine has been slower to see those connections.
“In the last 10 to 15 years, healthcare has really started to recognize these issues,” said Alisahah Cole, a physician who is vice president and system medical director at Carolinas Healthcare. She is spearheading the initiative.
Social determinants in laymen’s terms
The process of mapping social determinants begins with gathering information about specific factors that inform the medical landscape of people in a community. Income, where homes are, access to transportation, language, genetics, diet, cultural beliefs and education, among other things, all contribute to the people’s overall health.
“We pool information from multiple resources,” Cole explained.
The first stop is the U.S. Census.
“There’s an American Community Survey taken every one to three years; the USDA does an update every three to five years looking at things like food deserts (defined as a low-income census tract where a many residents have limited access to a supermarket or decent-sized grocery store); [state and federal data on minority health] is another.”
Analyzing the data reveals patterns that allow healthcare professionals to pinpoint areas of need, and track behaviors that may result in disease. They can also red-flag logistical barriers preventing patients from accessing care.
“In Mecklenburg County, there are six zip codes that are considered public health priority areas that have a high social determinant factors,” said Cole.
Cole found neither CHS nor Novant had a significant presence in the neediest areas. Without primary or urgent care nearby, people from those communities were forced to travel for treatment.
“If they’re relying on public transportation, it sometimes requires transfers on two or three busses just to get to the nearest primary care facility,” she noted.
In laying the groundwork for the current CHS/Novant initiative, Cole, along with a CHS steering committee, partnered with the NCIPH (North Carolina Institute of Public Health, housed in the UNC Gillings School of Global Public Health) to put together an online interactive map (see below) that assessed 12 social determinants of health indicators at the neighborhood-level within a 10-county service region.
They were then able to create an index that summarized which neighborhoods had the highest disparities.
Cole used the NCIPH ’s index, along with information taken from the Quality of Life Explorer which was created by partners, the City of Charlotte, Mecklenburg County, and the UNC Charlotte Urban Institute. She was able to overlay findings with pertinent CHS clinical data to see where they lined up.
“For example, with the prevalence of diabetes in certain communities, we found a lot of the clinical data actually overlapped with the high-need [areas] of the social determinants data,” she explained.
Cole also pointed out that communities with high incidence of poverty, low educational attainment and food deserts also had an increased prevalence of diabetes, and more preventable emergency room visits.
An Evolving Paradigm
Armed with the social determinant index, CHS and Novant began creating a roadmap to put preventive measures in place, and get resources where they are most needed.
For example, Gaston County did this a few years ago: After mapping where teen mothers lived, county health officials placed teen-focused clinics in neighborhoods where larger number of girls were getting pregnant.
“We can start to have targeted intervention at a community level,” said Cole. “Actually getting outside of our walls, and getting into the community, instead of expecting community members to come to us.”
That sentiment, too, is something of a departure.
While this willingness of Charlotte’s major medical players to “step down from the ivory tower and go out among the people” may not be the direct result of a better understanding of social determinants, it does signal a shift in policy.
Traditionally, hospitals have been geared toward treating people once they’re already sick, while exploring underlying factors that lead to disease or inadequate care access was left to researchers.
But the role of medical institutions—CHS and Novant included—is undergoing something of a sea change. Historically competitive, CHS and Novant have cast aside their adversarial roles to work in unison for the greater good of their patients.
With the possible demise of the Affordable Care Act, this investment in the community takes on an even greater significance.
“By being the two largest healthcare systems in this community and working together, we have made a commitment to provide sustainable access to care in those communities, regardless of what happens with the law on a federal level,” Cole explained.
She believes grassroots community organizing from both the public and the private sector will likely be the key to ensuring success.
“What’s been extremely exciting is the number of people who want to help, the number of people who’ve been doing work in this space for a very long time, [and] the number of people who want to work in a collaborative nature,” Cole said.
“Everyone is just really ready for this, particularly in Mecklenburg County. The community engagement has been amazing.”
Mapping the future
As the population of Charlotte continues to expand, healthcare must keep up. According to Cole, the demographics are changing: people are moving to the area for retirement or to start second careers.
“So you’re looking at baby boomers, and what services are needed [in terms of] healthcare.”
“Even if we’re healthy, what we need from a preventive standpoint is different from what someone in their 20s and 30s needs,” she added, “so we have to make sure there’s access to care that meets those requirements.”
Charlotte also has a burgeoning Latino population. Geo-mapping data has shown that community settling in the east and northeast of Mecklenburg County. Latinos have also started to move in along South Boulevard.
That area is sorely lacking primary care facilities.
The result, Cole notes, is that the Latino community is using the emergency department for things that could be treated in a primary care office.
“So, now, we’re looking at what resources from a clinical care standpoint we can provide in that area of town,” she said.
Primary care is only one piece of the puzzle. Making sure the community is linked to appropriate resources that are culturally competent is also a paramount concern.
“[They need] providers that they can understand. We have to be handing out materials in their language of origin,” Cole explained.
With improving dialogue between Charlotte’s hospitals and the patients they treat comes real hope that detrimental social determinants can be headed off before they become hazardous to public health.
“It’s changed the way we’re looking at healthcare from how things were being done in the past,” said Cole. “We are on target, but there’s so much work to do.
“[Still,] it’s exciting to have so many people who are engaged and energized to help out our communities in need.”
Correction: In the original version of this story, credit for creation of the Quality of Life Explorer was given to the NC Institute of Public Health.
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Education and Birth Control can increase everyone’s quality of life. maternal education specifically is a “Major Predictor of Health Outcomes”:
“Of the various social determinants of health that explain health disparities by geography or demographic characteristics (e.g., age, gender, race-ethnicity), the literature has always pointed prominently to education. Research based on decades of experience in the developing world has identified educational status (especially of the mother) as a major predictor of health outcomes, and economic trends in the industrialized world have intensified the relationship between education and health. In the United States, the gradient in health outcomes by educational attainment has steepened over the last four decades.”
https://www.ahrq.gov/professionals/education/curriculum-tools/population-health/zimmerman.html