A view on health and poverty from the 74126

Health Care in the U.S. in the 21^st Century:

Inspiring Innovations that Disrupt The Status Quo---

A Response and View From the 74126

Ron Robinson

(Photo above, taken in our community gardenpark and orchard we are creating here; for the purposes of this post, it is a photo of a physician delivering innovative health care here in the 74126)

Some bottom lines about health and the U.S.: What contributes to making a real difference in the health of people in our nation?
 51 percent of health comes from lifestyle choices,
 20 percent from genetics, 
19 percent from the environment,
and only 10 percent from the health care delivery system (data from the presentation mentioned below)

And yet, of course, what is spent to effect change in health care in those areas is not anywhere near proportionate to what in fact makes the difference. We are stuck in an institutional, attractional model, that is maintanence rather than mission based. But, there are seeds of new endeavors underway to try to re-orient us (connected issue but also separate from this are the issues of the health care insurance and coverage of uninsured in our country; won’t get into that here; but if Governor Fallin is serious about looking beyond the box and trying innovative local plans to improve health outcomes that do not involve insurance coverage, then she should pay attention to what is said here and what is going on in these new seedbeds of innovation). Of course, good things are happening and health is being improved through the current institutions, but it is out of whack when it comes to comparing outcomes and costs.

This conversation stems from being privileged to attend a presentation at OU Tulsa yesterday that looked at some key aspects of our health care situation in the United States, particularly regarding the inability to see changes to our life expectancy especially when connected with the costs of care, and that mapped out some of the steps being taken to try to step away from the current system. This is especially important here as we live and have our community renewal efforts in the 74126 zip code, one of the ones with the lowest life expectancy in the Tulsa region, some 14 years lower than in midtown Tulsa just a few miles south of the 74126. Plus, we at the A Third Place Community Foundation have been working on these issues since our founding in 2009, with our mission of growing healthy lives and neighborhoods in our area (note the connection we make between the health of the two, people’s lives and their neighborhoods; can’t separate them).

This took on critical function when we hosted an OU Community Health Clinic, which was closed in winter 2011, and as we sought ways to replace clinic-based health care with ways that were “disruptively innovative” to the status quo and the system that perpetuates it, partnering in research and focus groups in our community toward a lay community health worker proposal, where the community worker lives in the neighborhood targeted for better health outcomes.  And my interest in these issues has been personal since I used to work with the OU Health Sciences Center years ago, and my wife is a graduate of OU Medical School and one of the few physicians (maybe the only one, we don’t know) who lives in the 74126. Health concerns underlie our major projects in our community foundation through the creation of the community garden and orchard and the community center. It is also why we are working with the Tulsa Health Department and its new Wellness Center in our area that opened its doors after our clinic closed, as well as with McLain High School and the healty living grant and the Taste of North Tulsa event; our food pantry with our weekly nutrition class and other programs is better named The Health Hub, and just about every program and partner we work with is directly connected to community health in the 74126 and other zips in our service area north of 46^th St. Our latest project to get a senior citizens program and center going in our area is also at heart health related. People in community live longer and more abundantly, and in doing so, give back to the community itself. 

Before I get into my take-aways from today’s presentation, and what my response and questions would have been to the inspiring presenters, here is what I have written about these issues, often, during the past eight years we have lived in the 74126. Here is a link to a few of the earlier works about some of our projects and the lay community health worker proposal in particular; you might want to check them out for further reflection after reading this one:

The powerpoint presentation on community health workers, which I had not posted before: http://www.scribd.com/doc/124103581/Community-Health-Workers

Blogposts on health care in our area and projects we have been involved with:

http://turleyok.blogspot.com/2011/05/radical-health-care-change-for-poor.html

and the related http://progressivechurchplanting.blogspot.com/2010/08/disruptive-innovation-for-real.html.

Also the lecture I gave at OU in Norman that looked at our area in a comprehensive way and what we were doing at the time collaboratively to make a difference: http://turleyok.blogspot.com/2010/10/ou-lecture-pragmatics-of-collaboration.html

Now on to the most recent conversation at OU yesterday…

1.      They didn’t use the precise term but I liked that in essence they, physicians and health care and economics leaders who had gone through a Masters program at Dartmouth, were talking about the need to expand the bandwidth of how health care is delivered. That is in itself a good way to look at how to make the changes necessary, which often seem clear but too major to be undertaken. The community health care worker plan they later mentioned, as one of the small steps needed, is just one of the places for this expanded way of delivering health care. I am going to talk below about an even more radical, and basic, but simpler way as well.

2.      In looking at the differences in different communities about how care is delivered and where, such as what percent die in hospitals, in hospices, in nursing homes, in their own homes, or elsewhere, one of the things not addressed directly yesterday and that leaped out to me that I would have loved to go more in depth about was about how hard it is to track the outcomes of health in a community that, like ours, is poor and underserved and with low life expectancy, hard to track and hard to design plans for because of the high mobility and turnover of the people in the community, and the diversity even within us. We have some who have lived in this zip code all their lives, and some who only will for a month, and the percentages of those is growing more equal, meaning the community is becoming less stable.

 Related to this is that very important truth that there are big differences in values and approaches and “class” perspectives among the very residents here, and these are big determinants on how residents trust, or not, the health care system now in place, and what they think of regarding their own health options and their willingness or reluctance to go to a doctor for what is generally considered preventive care or primary care, even if they, for example, lived next door to a 24/7 facility; there are differences if it is a walk-in anytime clinic as opposed to one where you have to make an appointment first, an act itself that is viewed as a barrier and difficulty for some. We have here differences of those who grew up middle class with its values and even though they are now poor, and perhaps new to the area, still have middle class attitudes toward themselves and their options; we have those who are multi-generationally in poverty who have different stances and responses; and we have those who are or were working class and who have assets that are above poverty line. So, any health care approach that considers people to be representative, even among their own neighborhood, will end up misconnecting; treatment for someone will vary due to culture and geography and economic condition, and will vary in a zipcode like ours as well. So, the bottom line here is that health care professionals, and planners, need to really, really know an area they want to make a difference in. more on what that entails below.

3.      One of the best questions that the presenters raised, in light of the points made immediately before this, is how do different people answer the question of “what does it mean to be healthy?” That is going to vary widely. It is something we need to ask more often here on the ground in the community as well. What I have noticed is that it will be a different response than what will be given by someone not in poverty: for me, for example, when I answer that question I think about how being healthy allows me to live in advance, to make long range plans, to carry out goals for me and others around me, to keep a career; in essence, to be healthy is not to have to be thinking about whether I am healthy or not. For many of my neighbors when we talk about things like this, I can tell that it means, like so many things, being able to live subsistently day to day with the ability to enjoy a respite now and then and a small pleasure now and then or be around others for a good time; in essence, for the day to just be a little easier because so many things are naturally hard in it to accomplish, such as keeping a child in school, being able to go hunt for work, etc. Health care professionals need to know these differences and account for them.

4.      Where can health care happen? One of the needed shifts underway that was mentioned in the presentation is the need to move from “rescue care to health care.” (others were moving from fee-based service to risk-based contracting; and the development of the primary care patient-centered medical home and care coordination, and reducing variability). I thought of this move from rescue care, which we in the U.S. do well, to health care and thought of those percentages above about what really affects health care life expectancy outcomes, and I thought of how we need to de-institutionalize and de-centralize health care and move that ten percent into the 51 percent lifestyle change category. What I really thought about is how my wife, a physician, delivers health care to our neighbors when she meets them and talks with them at the community center, and especially while in the garden or orchard, at the community events; just building relationships with them, listening to them, and out of that relationship when suffering arises she is able to respond, be it with information, resources, advice, looking at a cut or rash or hurt leg, the same way a knowledgeable family member would in some places, or in some times; and just in helping to create healthier environments and lifestyle choices of healthier food and community she is involved in delivering real health care outcomes in this unhealthy area the same as when she sees someone from this area in her own practice located across town (at the VA). I will say that her patients in the clinic who do live in the 74126 seem to be better patients and taking care of themselves and trust her advice more and are more compliant, as they say, with followup actions once they find out where she lives, when they see her in the grocery store or at a community event. This is one of the ways that the future of health care is reclaiming a culture of health care from the past. The catchword now for it is cultural competency, knowing something about them in a wholistic way.
And it is important to note that health care is being delivered, in such a way, by many people here, and in our wider community, by people who do not have medical careers; it is very true that a lot of the health problems in our area are also caused by the spread of misinformation on health matters. The key is to unlock the strengths of community connections and trust, and build on them with a little training, and using right information to spread in the community (where word of mouth, and personal relationships are the currency). All of which is testament to why the community health workers, health coaches, lay advocates, whatever you want to call those who will be partners in health with those most in need and without anyone serving that function from their family or their community connections already, why they must be people who live in the area where those seeking care come from. 
It is also why, if I had been asked yesterday what I thought would make the most difference in health care from the medical school, I would answer with the simple but radical response: tell your graduates to move and live in areas of high poverty, add to the diversity of those neighborhoods, learn from them, make a difference in that 51 percent category even if you make your living still in that 10 percent category; you can do it and you can make it happen; we are proof of it. Also, give your employees in health care institutions bonuses, merit pay, for choosing to live in the areas where the patients with the least resources live, and where they can be a part of that informal, community grassroots health delivery. If health care, especially, is more of a calling, a vocation, and not just a profession, and certainly not just a job, then be open to the nature of a call. Talk about “disruptive innovation” and helping to shift the focus and locus of health care…or we can continue to tinker and plan and rearrange the chairs on the Titanic.
This is also why there is a connection between the health of the community and the health of the neighborhood schools, why we need to be ble to graduate students from McLain high school now who can and will go on to become nurses and doctors and other health professionals, the same as happened when my wife was a McLain graduate. To grow health in the 74126, make our schools in the area healthier and give them the resources and the curriculum offerings to produce graduates who will not be scared to remain or return to the area to live and work and be a part of that important community informal day to day life.

5.      I like that the folks at OU are looking at all this, and others are across the country; that they are committed to exploring small projects to try to seed change; that they are open to such questions as how many physicians should we be paying to educate if we don’t see major changes in health outcomes especially among our poorest, and I would say, if physicians and institutions continue to take the safe and convenient route with least change to “the way we have done it.” I think more physicians actually might be the key, especially as population grows, and as it becomes more diverse, and especially given the vast physician deserts like here in the 74126. The question has arisen for us, for example: why given the current health care system is it virtually impossible for my wife to open up a practice here in the 74126 where she so would like, or have liked, to do so, as she did on her own in Tahlequah, OK years ago when completing her residency in internal medicine and going to be the only M.D. internist there? Why, given the health problems here and low life expectancy here, is it the hardest to have an OU clinic, or a private medical clinic, here? Answering that unveils the realities of the situation. Making it easier to do so would seem to be part of the solution. The other part of the solution is to not be physician-focused, clinic-focused either (I love that we now in our zipcode have the new OSU physicians clinic in the new Health Dept. building opening up, but it is going to face the same set of cultural barriers, attitudes toward one’s self and one’s view of what health means). I like how OU, and I suppose OSU, and Morton with its new plan for health coaches, and the Health Dept with its commitment to our area are all beginning it seems to take some small steps in trying to figure this all out, and due to the necessity that just knowing what to do is but a small part of the problem, since funds are being cut, Medicaid coverage is being kept from expanding, and those lifestyle choices and environmental realities that mean so much to health are also not being funded. When you live on the same block, or go by everyday, rows of abandoned houses, burned out houses and buildings, and have no sidewalks, few street lights, no ability to exercise where you can get to easily and are not hassled by stray dogs, etc , and when you add to that the deep issues of substance abuse, addictions, mental health issues, learning disabilities, lack of resources for the high percentage of incarcerated people getting out and coming into our area, and we remember that axiom we began with, from our mission statement, that healthy lives require healthy neighborhoods, and healthy neighborhood schools, and civic and church groups, and those require healthy lives. As I have talked recently about school transformations, (and in my other hats, have talked about church transformations), what goes on outside of a health care office, in the home and neighborhood of the person seeking care, is more important to creating health than what even goes on inside the office in the 15 to 30 minute to at most hour together, or in the hospitals.

6.      My final takeaway was just a notion, a small detail, that arose when the conversation focused on the role of the internet and technology, and sharing information, etc. in the new world emerging for health care delivery. While they were talking in those big terms, all good and needed and helpful, I was thinking how we could really use a text message database that sent out news, reminders, tips, free from us and from health caregivers to all those who are poor and out of usual means of communication and contact and who will only attend health classes or lifestyle classes, etc. if mandated to be there. Most of our neighbors have now phones (as vital as horses once were here, and for many of the same reasons, to keep in touch and connected with others) and I would love to be able to build on that basic technological tool; there are so many ways that health-driven text messages, info, resources, all could affect their lives, a small but significant way. We need to try to build that into our system here from the ground up, but would be an interesting project to explore with others its application possibilities and ramifications.

It has been great having OU as one of our community health partners. Some of our board members are going out to OU today to meet with a class of graduate social work students doing service learning projects with us later this month too back in the 74126. Love to do the same with other groups.