On the stump for better health
Grass-roots appeal aims to boost S.C. town’s health
Can the community organizing tactics that empowered migrant farm workers in the 1970s and helped elect President Barack Obama in 2008 empty out America’s overloaded emergency departments?
Six physicians-turned-organizers are working in Columbia, S.C., to find out.
They are using organizing tactics—cold calls, house meetings, community assemblies and rallies—to jump-start a campaign in ZIP code 29203, one of the unhealthiest areas in the country. The campaign goal: to empower residents to take responsibility for the health of their community.
The Healthy Columbia campaign had its official kickoff in March, but it has been building steam for more than a year. During that time, many ideas have bubbled forth—from expanding hours at primary-care clinics and building walking trails to training church members how to do blood pressure checks and recruiting drivers to take people to medical appointments.
The campaign has enlisted the help of the area’s major healthcare providers, Palmetto Health and Providence Hospitals, along with the city of Columbia, the South Carolina Hospital Association, the South Carolina Department of Health and Environmental Control, Blue Cross and Blue Shield of South Carolina and Eau Claire Cooperative Health Centers, which operate federally qualified health centers in the 29803 area.
The core component of the campaign is a community covenant, in which people who live and work in 29203 sign a pledge to take care of their own health and the health of their neighbors. That may mean monitoring their blood sugar level or starting an exercise program, but it also may mean volunteering to be on a health watch team that checks on frail elderly neighbors or advising a hospital CEO about what time the primary-care clinic should open.
If the campaign works as envisioned, one measure of its success will be that residents stop using emergency departments for primary care or emergency care that could have been avoided. But that indicator would have more impact on residents than it would on the hospital, said Dr. Michael “Shawn” Stinson, one of the campaign’s physician organizers and vice president of clinical quality and patient safety at Palmetto Health, a three-hospital system based in Columbia.
“That will unclog our emergency rooms so that we’re not providing emergent care to a diabetic that could have been dealt easily in the ambulatory setting three weeks earlier,” he said. “Or could have been dealt with three years before with better diet and exercise. Or could have been dealt with 30 years before with education about a healthier lifestyle.”
Because this approach has never been tried in healthcare before, the potential outcomes are hard to predict. Dr. Laura Long, vice president for clinical quality and health management, Blue Cross and Blue Shield of South Carolina, said the campaign must keep going until residents’ health status—and healthcare costs—are brought under control.
“We must succeed,” she said. “It’s not a choice any more. We must succeed.”
Agitating for change
Long and Stinson are two of six physician-executives recruited to serve on the “vision team” of Organizing for Health’s first-ever community campaign. The six were recruited in part because of their leadership positions in area organizations, and working on the Healthy Columbia campaign is now a part of their jobs.
Organizing for Health is a project of Rethink Health, an initiative of the Fannie E. Rippel Foundation that brings together top thinkers in healthcare and other fields to consider how a sustainable healthcare system might be created. Dr. Donald Berwick, former administrator of the CMS, and Dr. Elliott Fisher, director for Population Health and Policy at the Dartmouth Institute for Health Care Policy and Clinical Practice, are founding members of Rethink Health, along with Peter Senge, director of the Center for Organizational Learning at the MIT Sloan School of Management, and others.
Since July 2011, the Rippel Foundation has given $250,000 to support the Organizing for Health organizers and consultants in the Healthy Columbia campaign. The grant pays for one full-time worker and four part-timers.
While Healthy Columbia is the first campaign, its proponents think the concept will spread as the organizing model proves itself.
“Any community that said we’re going to just go out and totally change the health of an
entire city or metro area would find that is overwhelming,” said Dr. Richard Foster, senior vice president of quality and patient safety at the South Carolina Hospital Association. “So we are starting small, but the work we are doing should be able to be replicated in the larger community or across an entire state.”
Terri Jowers, Organizing for Health’s lead organizer in Columbia, said the task is to change the balance of power between healthcare providers and the people they seek to serve. She sees the current balance as physicians and other providers having “power over” patients. “It’s the medical profession up here and the people down there,” she said. “We hope to build a system so it is ‘power with’—individuals taking personal responsibility for their own health, making a commitment to support each other’s health, and asking key stakeholders like providers and payers to support them in their efforts.”
According to organizational theory, that model will increase the likelihood that residents know about and use healthcare resources that can improve their health status.
“In the past, we would put a lot of money into a project and then be frustrated when the community didn’t embrace it, didn’t show up, or didn’t make a change,” Stinson said. “Now I’m really starting to understand why.”
Kate Hilton, the director of Organizing for Health, is a principal in practice for the Leading Change Project at Harvard University. During the site-selection phase of the project, Hilton honed in on Columbia’s largest ZIP code—29203, known as Eau Claire/north Main area—in part because it has more than 40 neighborhood associations.
“So there is this power structure, and lots of people who are actively involved in neighborhoods and safety issues and a number of things,” Jowers said.
The entire state of South Carolina has health challenges—more than 60% of the population is overweight, one-third has high blood pressure and 11% suffer from diabetes—but the picture in ZIP code 29203 is even worse. Stinson said 29203 has one of the highest rates of amputation in the country due to diabetes.
One-third of the 45,000 residents are uninsured, and the average resident makes two emergency department visits each year. That translates into 90,000 ED visits a year, including 30,000 from residents with no ability to pay.
The ZIP code is home to two hospitals, including Palmetto Health Richland, a 647bed teaching hospital associated with the University of South Carolina.
“A few years ago, we were recognized as having the greatest improvement in mortality of any health system in America,” Stinson said. “And we sit in one of the least healthy communities in the nation. So we know the disconnect there.”
Recruiting the leaders
After conducting about 40 one-to-one meetings in Columbia to learn about leaders, relationships and history of the community, Hilton recruited the vision team. In addition to Foster, Stinson and Long, it included Dr. Lisa Waddell, South Carolina’s state deputy commissioner for health services; Dr. Casey Fitts, a surgeon and medical director of Tri-county Project Care; and Dr. Stuart Hamilton, CEO of Eau Claire Cooperative Health Centers.
Although their positions in the healthcare community were a factor in their selection, Hilton sought out team members with specific qualities, including tenacity and a willingness to try different approaches when something does not work as planned.
“We were looking for who felt really passionate about change and have a sincere urgency for change,” she said. “People who are learners. People who have a history of collaborating with one another. People who had been in the system at different places.”
Picking the ‘bad guy’
Team members went to Boston to be trained in organizing principles by Marshall Ganz, a key figure in organizing for the United Farm Workers and the man credited with mapping out the grass-roots campaign that elected Obama. He told them to figure out what they were organizing against. “We learned that we needed a bad guy,” Stinson said.
Brainstorming yielded the standard responses. Payers were proposed as the bad guy, then providers and then politicians.
“Whenever we came up with a ‘bad guy’ that was one of these entities, the fear was that we would end up on opposite sides,” he said. “We finally came up with chronic disease as the bad guy, and wellness as the good guy, and we actually could all work together to support it.”
Ganz and Hilton also taught the physicians something no one learns in medical school: how to recruit people to be active participants in a major change.
“We watched the Obama speech back in 2004 at the Democratic National Convention to learn the power of narrative,” Stinson said. “We spent a long time learning how to tell stories, how to evoke emotions to get people involved, and then how to follow that up with the ‘ask.’ It’s not just telling a story for the story’s sake, but you’re trying to accomplish something with it.”
Returning to Columbia, members of the vision team started practicing their newfound skills. They called people they had never met to ask for one-to-one meetings. They solicited specific things the campaign needed. And they started seeing their own roles differently.
“Although there is definitely a transition taking place in healthcare to empower the patient to be on equal footing with the doctor, that is not the way we were trained, and it’s certainly not the model that most of us have practiced,” he said.
The planning stage of the campaign began in July 2011, with eight months of work that included 130 one-to-one meetings, a town hall meeting that attracted more than 90 neighborhood residents, 45 house meetings attended by 750 community members and training for nearly 300 residents on how to be community organizers.
Organizers analyzed state health data to identify which blocks within 29203 have the highest rates of inappropriate ED visits, hospital readmissions, diabetes, heart disease and other indicators of poor health status. They used that information to map three “turfs”— geographic areas home to about 3,000 residents each—to start the real work of the campaign.
“While 1 in 3 are uninsured in the entire ZIP code, the three areas that we have targeted have about 50% of residents uninsured,” Jowers said.
The official kickoff in March drew more than 500 residents to hear a gospel choir, a speech by the mayor and a commitment ceremony in which residents, healthcare providers, church members and others pub- licly stated their commitment to improving healthcare in 29203.
Jowers said the campaign has no end date. As residents assume a greater role in improving the health of their community, Organizing for Health personnel will gradually reduce their involvement.
“It’s a paradigm shift with the community becoming equal partners in their health and healthcare,” she said. “The citizens of this community and of this state have to own the campaign. It is theirs. When there are needs for community organizers, then the folks who are involved will find a way to make that happen.”
The physician angle
Specific goals such as a certain percentage of reduction in ER visits have not yet been established, but the big-picture goals are set: to increase access to primary care, reduce the cost of healthcare for citizens and providers, and reinvest money saved into community initiatives, such as building satellite care centers and training health coaches.
Several strategies for improvement have already emerged. One is to recruit volunteers who will work under supervision of a nurse practitioner or nurse to provide care in people’s homes. “These are people who have a little bit of training that can actually go out and check people’s blood pressures, check their blood sugar, make sure they are taking their medication,” Jowers said. “If it looks like there is a problem, they can let somebody know, so that the patient is getting support immediately.”
Also, health coaches will be assigned to keep an eye on people who have just been released from the hospital and are at high risk for readmission or help pregnant women take good care of themselves.
As the community organizes itself, health systems and insurers have pledged to support their efforts. As part of their commitment to Healthy Columbia, Palmetto Health is adopting the patient-centered medical home model, and Blue Cross and Blue Shield of South Carolina will pay physicians for improved management of chronic diseases.
“Blue Cross would want to pay physicians differently and perhaps pay health coaches to do door-to-door services,” Long said. “We will be looking at all kinds of things that get created in that community if they are shown to reduce ER utilization and hospitalizations.”