Crossing the Line
by Alex Vuocolo
Lankenau Medical Center, a 93-acre hospital complex, is located just across the border of West Philadelphia in the Main Line community of Wynnewood. For a patient crossing the city line, the transition is almost immediate: The auto shops and fast food joints that line Lancaster Avenue fade into green suburban neighborhoods. Corner delis and discount grocery stores give way to high-end supermarkets and boutiques. The sidewalks and bike lanes taper off into narrow road shoulders.
There is another, less visible difference between the two communities straddled by Lankenau in Montgomery and Philadelphia counties. The Robert Wood Johnson Foundation, which tracks public health metrics nationally, ranks Montgomery County the sixth healthiest county in the state out of 67. Philadelphia County ranks dead last.
Reckoning with that divide is part of Chinwe Onyekere’s job. As associate administrator at Lankenau, she heads up community programs focused on meeting the health needs of all patients. In her view, hospitals as institutions have a clear mandate to serve the communities around them.
“The role of the provider is not only to address health care, but to address social issues,” says Onyekere, 40.
One of her latest projects, the Delema G. Deaver Wellness Garden, is a community garden and learning center now under construction on the outskirts of the hospital’s main campus. The half-acre plot, situated next to a helipad, will feature 20 raised garden beds, a high tunnel greenhouse and an organic composting area. Once the garden opens in February of 2016, a professional farmer and educator will teach classes at the garden for community members to learn about fresh food and healthy eating. As for the produce, some of it will be used in the hospital cafeteria, while the rest will go to local food banks and into patients’ kitchens.
The idea behind the garden, Onyekere says, is to help improve the health of community members before they ever have to enter an emergency room or doctor’s office. She is focusing on nutrition because a number of the hospital’s low-income patients suffer from conditions such as obesity, diabetes and hypertension, which are related to poor eating habits.
A growing body of research, including a 2010 report from the Food Trust, a Philadelphia-based nonprofit with a national focus on food access, shows these health disparities may be the result of a lack of access to healthy foods. On the Montgomery County side of Lancaster Avenue, for example, residents can choose among Trader Joe’s, Whole Foods and GIANT, all located within a mile of one another. On the Philadelphia side of the avenue, options are limited to corner delis and small discount grocery stores.
“The thing that gets highlighted for us is that there are a diversity of needs,” Onyekere says, “and so we really need to think creatively and innovatively on how we can develop interventions that meet the needs of our patients.”
The garden is part of a broader effort by Lankenau to embrace preventative health measures in creative ways. Lankenau has also partnered with the Food Trust to offer patients $6 vouchers, called Philly Food Bucks, which they can use to buy fruits and vegetables at select farmers markets. The hospital is also sending nurses out to the farmers markets to offer free blood pressure testing.
“I think we’re changing the paradigm that health is just about sick care,” says Phil Robinson, 59, president of Lankenau Medical Center.
Individual treatment or community intervention? The historic divide between health care and public health
While it may seem like an obvious step for a hospital to promote nutrition, or any public health benefit for that matter, the connection between health care and social and environmental factors has not always been so clear.
“Historically, there’s been a disconnect between public health and the medical profession,” says Erin Johnson, 40, professor at Drexel University’s College of Nursing and Health Professions. “They are not well-integrated.”
Health care is built to respond to individual needs, Johnson explains. When a person shows up at the hospital with a broken bone, a clogged artery, or even just an ache or pain, health care is at its best. That’s when the whole apparatus of modern care—the nurses, the screening tests, the drugs—kicks into gear. But understanding the environmental, behavioral or social reasons why someone got those aches or pains in the first place is where public health comes in.
“You have the upstream perspective, which is public health, root causes, context,” Johnson says, “and then you have the downstream perspective, which is treatment at the individual level.”
The problem, she adds, is in how those two sides of the health world coordinate. On the ground, the difficulty is often in getting health care providers to look beyond treatment and into the communities that shape the health needs of their patients.
Lankenau, like most hospitals, spent most of its 150-year history sticking to what it did best: treating the sick and injured.
“We were very much just looking at what got [patients] into the hospital and fixing that and then sending them home,” says Robinson, a veteran in hospital administration. “That’s how we got paid. That’s how the whole health care system has been for the past 100 years.”
With a quarter of its population below the federal poverty level, the relationship between individual health and public health in Philadelphia is hard to ignore. The Philadelphia Department of Public Health found in a 2013 community health report that 15 percent of premature deaths are related to social circumstances, such as neighborhood safety, occupational health or access to healthy food, and five percent are related to environmental exposures, such as air, housing or water quality.
These negative effects often fall along racial lines. About one-third of black and Hispanic Philadelphians self-report that they are in poor or fair health, nearly double what the city’s white population reports, according to a 2012 survey from the Philadelphia Health Management Corporation.
“In terms of the social determinants of health, the single biggest driver is poverty,” says Dr. James Buehler, 64, former health commissioner under the Nutter administration, now a professor at Drexel University. “For just about any disease or public health concern, when there is more poverty, the problems tend to be more severe.”
Meanwhile, public health has gotten short shrift at the state level as well. A 2013 report by Trust for America’s Health, a nonpartisan, nonprofit research group, ranked Pennsylvania in the bottom 10 states in terms of how much it invests in public health.
And yet, Lankenau is one of a number of local hospitals that are taking the problem into their own hands with programs aimed at addressing the needs of the region’s most vulnerable populations. As a result, the divide between public health and health care is steadily closing.
Getting to this point, however, required a culture shift that is still very much in progress, including getting regional health care providers to work together.
One impact of the Affordable Care Act: prescriptions for vegetables
One policy change that has edged hospitals toward focusing more on public health is the Affordable Care Act (ACA), the much-debated health care reform bill drawn up by the Obama Administration and passed by Congress in 2010. Much of the focus on the ACA has centered on its expansion of Medicaid and creation of health insurance exchanges. But the law also made a series of regulatory tweaks that have made hospitals devote resources to public health.
Among those tweaks is the requirement that nonprofit hospitals carry out a community health needs assessment every three years, or else be subject to a $50,000 excise tax. Hospitals are also required to produce an implementation plan to address the needs they have identified.
Lankenau implemented its first community health needs assessment under the ACA in 2013, pulling together basic income and population data from the surrounding areas and combining it with key health statistics. As Lankenau quickly found out, there was a lot to learn in the numbers. “It provided this whole new realm of data,” Robinson says.
The assessment broke down Lankenau’s service area into four main geographic sections, including Delaware and Montgomery counties and Northwest and West Philadelphia. By a number of measures, from hypertension to diabetes to obesity, West Philadelphia ranked the worst. A measure looking at nutrition found that West Philadelphians consumed the least amount of vegetables, the majority eating just one to two servings per day.
“If we have a huge patient population that has diabetes and who are overweight, and they’re only getting one to two servings of vegetables, then maybe we prescribe healthy eating,” Onyekere says.
The concept of prescribing healthy eating has been shown to improve consumption habits. A 2013 report by the U.S. Department of Agriculture looked at the effectiveness of nutrition education programs on youth and seniors that received Supplemental Nutrition Assistance Program (SNAP) benefits and found that “well-designed” programs did encourage people to eat healthier.
Another major aspect of the ACA is its requirement that all hospitals use an Electronic Medical Record (EMR) system to track patients’ medical histories.
“The EMR, to me, was probably the most transformational thing, because without that, you’re still relying on paper charts,” Robinson says, and “if the patient doesn’t tell you they’ve seen three other doctors, been in to two other hospitals—and they often don’t—you only have a little sliver of information instead of everything.”
This silo effect made preventative care more difficult because a doctor had to piece together a patient’s medical past, not to mention any social or environmental factors that may have shaped it. The EMR program has made doctors more accountable to their patients, according to Buehler, because they can now set health benchmarks based on that history.
“The ACA, in many ways, is a formal declaration of alignment between health care and public health objectives,” Buehler says.
Walking the talk
Even as the ACA drew more attention to public health, hospitals were undergoing their own evolution in how they define their role in the community. In part, that evolution was spurred by a desire to become healthier, more sustainable institutions.
For Lankenau, its focus on environmental issues such as food access grew, in part, out of a process that began nearly 10 years ago with the construction of a new building on its main campus.
“Some of this awareness began on the facilities side, when we looked at what it would take to become LEED certified,” says Robinson, referring to the voluntary, international green building design standard of the U.S. Green Building Council. “It sort of got us into that mode of thinking.” The initial idea for the garden, he adds, came from conversations about potentially putting a farm on a green roof.
For other local hospitals, the push to become better institutions, while also improving public health, has taken different forms. The University of Pennsylvania Hospital System, for example, banned smokers from its work force in 2013 in an effort to encourage healthier behaviors among its employees—who ultimately make up the surrounding community—and to set an example for the public.
The issue with arguably the most interest from local hospitals would be local food sourcing. In 2014, four regional hospitals—Einstein Medical Center, Pennsylvania Hospital, Temple University Hospital and Jeanes Hospital—made a pledge to adhere to voluntary nutrition standards for their own food systems.
The initiative, called Good Food, Healthy Hospitals, is spearheaded by the Philadelphia Department of Public Health and supported by Common Market, a food distributor that draws most of its product from within the region. Last fall, the Department of Public Health held a symposium around the initiative that attracted 20 hospitals and a number of food advocates and public health organizations.
From the health department’s perspective, hospitals are a natural place to try and push for better nutrition and food sourcing.
“Hospitals serve a lot of food,” Buehler says. “They serve food to their patients. They serve food to their visitors, and they serve food to their employees.” Many of their employees, he adds, have the same health problems that the rest of the public faces. As some of the region’s largest employers, hospitals have an added responsibility to change their own practices.
While a number of programs have begun in the last few years, there has been at least some interest in public health issues—particularly food access—for longer than that.
“Hospitals have been doing environmental things for a long time, looking at their practices, looking at efficiencies in heating, landfill practices, recycling,” says Rickie Brawer, 63, associate director at Thomas Jefferson University Hospital’s Center for Urban Health and longtime public health expert.
In the early 2000s, for example, there was a big push by hospitals to encourage community members to bring in their mercury thermometers, which had long been considered an environmental and health hazard, in exchange for digital thermometers.
What’s changed, according to Brawer, is the scale and focus of hospitals’ engagement with public health. “The food piece of it is newer,” she says, adding that it grew in concert with a national awareness of the health implications of obesity.
Brawer adds that Thomas Jefferson University Hospitals have implemented a number of public health programs, including free blood pressure testing at corner stores in partnership with the Food Trust and the Department of Public Health’s Healthy Corner Stores initiative. First piloted in 2004, the initiative has evolved into a citywide effort to deliver healthy foods and preventive health care through the corner stores ubiquitous in urban neighborhoods.
Many hospital-led initiatives are still in their beginning phases, however, and some public health professionals argue in favor of more focus and collaboration among hospitals.
“There are a lot of efforts going on, but they’re a little bit scattered,” says Johnson, who recently joined the Philadelphia chapter of the advocacy group Physicians for Social Responsibility. “We still don’t have an overall, coordinated plan that takes into account the huge diversity of needs for health services.”
In Johnson’s view, it’s not lack of data or support, but the challenge of getting the health care community to work together more effectively.
Hospitals as advocates for clean air, indoors and out
In order to facilitate collaboration among Philadelphia-area hospitals, the Hospital & Healthsystem Association of Pennsylvania (HAP) launched a project last September to unite partners around tackling a single set of public health issues. So far, the Philadelphia and Montgomery County health departments, the Health Care Improvement Foundation, and eight hospitals and health systems are onboard, including Aria Health System, Children’s Hospital of Philadelphia, Einstein Healthcare Network, Holy Redeemer Health System, Jefferson Health, Mercy Health System, Temple Health, and the University of Pennsylvania Health System.
The current goal is to figure out which public health issues will be prioritized and how exactly the collaborative will work together.
“As one of the public health people in the room, I can tell you these are really productive discussions,” says Cheryl Bettigole, 50, director of the Department of Public Health’s Division of Chronic Disease Prevention and head of the city’s own public health initiative, Get Healthy Philly. “We have people thinking very seriously and thoughtfully about how we can improve the health of the city.”
For Bettigole, the collaborative is exciting for the mere fact that hospitals are in the same room together.
“As someone who has been a part of the health care scene in Philadelphia since my training in the late ’90s, I don’t recall ever seeing the hospitals work together,” she says.
What has been decided among the partners, according to Bettigole, is that hospitals can no longer operate in silos, as they have in the past, which has led to overlapping, yet uncoordinated efforts.
What kinds of issues are they likely to address?
Michael Consuelos, senior vice president of HAP and head of the collaborative, says the choice of environmental issues will be focused on related illnesses “that hospitals have a great amount of competency in treating.” As an example, he explains, “Because hospitals treat a lot of respiratory diseases, you’ll see activity around clean air, improving air quality around the hospital, and trying to work with stakeholders and public officials at improving air quality.”
Public health issues that would be more difficult to address, according to Consuelos, include crime, transportation and education problems, which are largely in the hands of government agencies. The effect of housing quality on health, on the other hand, is an area in which he thinks hospitals can be impactful.
“Hospitals are starting work now to improve housing options,” says Consuelos, in part because the IRS has opened up housing improvement as a form of community benefit under the ACA.
In fact, the Healthy Rowhouse Project, a nonprofit aimed at increasing housing quality throughout Philadelphia, has drawn a number of hospitals to the table. Though still in its beginning phases, the initiative is looking directly at the health effects of bad housing, such as asthma and lead poisoning.
Bettigole says the city has made a lot of progress in terms of providing healthier food options and arguably even more progress in altering the built environment of the city so that it encourages more physical activity. She cites the increase in cycling and a number of the recent trail projects as examples of this. Her goal is to get similar support for other issues.
“I’m hoping that the collaborative has a really significant effect on whatever public health issue they decide to tackle, but I’m also hoping it’s the start of them working together for the foreseeable future,” Bettigole says. “Because this is a group that together could have a lot of leverage and a real impact on health across the city.”
Bringing it home
Annie Stewart, 71, was diagnosed with borderline diabetes and morbid obesity in 2014. Today she is a healthy weight—down to a size eight from a size 12—and she is no longer diabetic.
“I don’t have to stick myself no more,” she says. “I watch what I eat, and I exercise.”
Stewart attributes her turnaround to the Adult Senior Nutrition Education Program, which is funded by the state and run by the Agatston Urban Nutrition Initiative, a program of the University of Pennsylvania’s Netter Center for Community Partnerships.
For the last five years, the program has sent registered dieticians into West and Southwest Philadelphia communities to teach residents about nutrition. The classes range from cooking demonstrations to discussions about how to read labels and diversify your grocery list.
The strength of the program is in how it brings the classes into the communities where the information is needed most, according to Michelle Faulkner, director of the program.
As much as hospitals or health care centers are crucial to public health, they are still seen as places to get treated for acute illnesses, not as community centers. “When people go into a health center, they want to get treated and leave,” she says.
Jerome Shabazz, executive director of the Overbrook Environmental Education Center, which runs its own community garden and nutrition programs and is just down the road from Lankenau Medical Center, says that hospitals should be “exporting” public health initiatives into communities instead of trying to bring the community to them.
“I think the most effective model is to export talent” into the community, Shabazz says. He adds that while hospitals have the health care expertise, community organizations ultimately know how to best engage with a community.
For Stewart, the fact that the program was available within her home at the Greenway Presbyterian Apartments was crucial.
“Bringing this class in here was the best thing they could have done,” she says.