“Castes—we might think they are from another century, another country—but they are ours, today.”
Isabel Wilkerson, Pulitzer Prize winning author of Caste: The Origins of Our Discontents, shared this message in kicking off this year’s Association for Community Health Improvement’s (ACHI) conference on May 16, 2023.
The American Hospital Association (AHA) runs the conference to share best practices in community health improvement. The AHA Community Health Improvement Network, an affiliate of the AHA, is the premier national association for community health, community benefit, and population health professionals.
The urgent messages that Wilkerson raised—that racism and disempowerment of people of color persist in our health care system, that our inaction leads to increased and unequal sickness and death, and that we need shared accountability for these outcomes across our hospitals and community leaders—carried through the three days of this health equity-focused conference.
But what struck me most was that the solutions presented in conference sessions—while innovative, impactful, and often community-led—often did not match the scale of these challenges. Our workforce diversification programs, community engagement approaches, hospital diversity equity initiatives, and other solutions—while valuable—are often small, underfunded, short-term, and focused on only the publicly insured patient population.
But what also strikes me is that the nation’s growing number of health conversion foundations—now topping 300 nationwide with assets approaching $40 billion—are uniquely suited to advancing the health of their local communities with large, place-based, scalable impact.
Here are five questions I would offer to guide our collective thinking:
1. Are our community partnerships to scale?
Health care providers have been creating community partnerships to extend health outside of the clinic’s walls for decades. This conference offered many examples of these partnerships, small and large. For example, M Health Fairview is investing in partnerships with community health care providers and organizations ranging from dental care to food organizations like the Hmong American Farms Association to address some of the most significant inequities impacting BIPOC communities in the area. The program seeks to reduce childhood dental disease, increase healthy food access, and diversify the health care workforce. And so far, the community is satisfied—with 98% of the program’s participants saying they would recommend the program to their friends and family. Several hundred adult and child patients have benefited in 2022.
But these programs are tiny compared to our health systems (M Health Fairview alone employs over 30,000 people). I urge health care foundation leaders to consider: What would it take to scale up hospital-community partnerships to address the multiple, complex barriers to health that marginalized populations face?
2. Are we transforming our clinical workforce pipeline? Or just tweaking it?
Conference presenters also demonstrated how hospitals are leveraging their positions as huge economic engines to diversify and build the clinical workforce pipeline. When the Ann & Robert H. Lurie Children’s Hospital of Chicago saw its patient demographic rapidly ranging and diversifying, they started a workforce pipeline program to diversify their future clinician workforce. Last year, 100% of their 17 alumni hires identified as minority residents and came from 28 different Chicago zip codes.
But are these small workforce diversification programs truly transformative? What would it take to change the face of our nation’s clinical workforce to match the racial and ethnic diversity of our patient populations?
3. What is the promise of health data sharing?
Many conference sessions revealed how health care data innovation (data sharing, artificial intelligence, etc.) have the potential to advance health equity. But since health happens in community settings—in homes, schools, grocery stores, parks, and workplaces—it is important that the systems that support people’s health, social, and economic needs are connected. And that is not always the case.
Many hospitals are connecting patients with the services they need to stay healthy even when they’re not in the hospital. For example, Intermountain Healthcare is implementing the PRAPARE Screening Tool to screen for social needs—and they are engaging community health workers, the local homeless shelter, and others to ensure the collected data are meaningful even outside of the health system. They started screening only Medicaid-enrolled patients, and now they screen for patients enrolled in any health insurance. Soon, all inpatient wards will have access to screenings.
Other health systems shared how their health information exchange (HIE) efforts, like CRISP DC, Washington, D.C.’s designated HIE, are connecting health care providers with community-based organizations and payors to address the social determinants of health. They are implementing closed-loop referrals to ensure patients’ social needs, like food insecurity, are addressed even outside of the hospital.
But often, these programs are limited in scale and scope, data systems are not interoperable, and community-based service providers—like food banks, workforce development programs, transportation providers, and others—are not fully funded.
What would it take to build this data infrastructure with health equity at the center? What role might health care conversion foundations play?
4. What would it take to address the social determinants of MENTAL health?
An underlying conference theme suggested that promoting mental health—of communities, workers, patients, and clinicians—is a problem all of us must solve. And many hospital and philanthropic leaders are doing this work using big data and innovative partnerships. For example, Deryk Van Brunt, DrPH, Co-Founder/CEO of CredibleMind, has led the development of this tool to help employers equip their staff and the people they serve with wellness supports before behavioral health needs become acute. The tool focuses on helping people flourish mentally—while also connecting them with clinical care if needed.
But the social determinants of mental health are in action before many employers can intervene—in our families, schools, public programs, neighborhoods, and in our communities. A question our health care leaders must answer: what are the key drivers of mental wellbeing in our community, and what would it take to shift them?
5. How do we go beyond an antiracist system and decolonize health?
In his closing keynote address, Dr. Brian Smedley, author of the 2003 Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, posed a challenge. He argued that while some progress has been made in the 20 years since the publication of Unequal Treatment, much work remains to advance equity in health and health care.
He asked attendees to go beyond making our health care system an antiracist system. Instead, he asked us to decolonize health: “Today’s medical education and research system emerged from Western science that believed in a white supremacist society. That system believes that clinical trials are the only way to ‘prove’ we can trust clinical approaches. But we must embrace our whole humanness—and that means integrating new kinds of evidence, Indigenous ways of knowing, and non-white ways of understanding our outcomes.”
With this new vision in mind, what stewardship might our health care conversion foundation leaders offer—leveraging their assets, place-based expertise, and legal mandate to promote health in their communities?
Attending this year’s conference reminded me that when it comes to promoting community health outside of our health care system, we do not yet have all the answers. But I am inspired to continue this work at FSG—especially with our health conversion foundation leaders that are positioned so well to promote health in community settings. As we get clearer on the health care challenges we face—from racist practices to the continued marginalization of people of color even with decades of data demonstrating resulting poor health outcomes—our community-based solutions must keep up, at scale.