For the past few years, public health researchers from Washington University and Saint Louis University have been looking at what it would take to improve the health and well-being of African Americans in the St. Louis area.
The last of seven community action For the Sake of All forums took place at the Danforth Plant Science Center on June 27. Themed “Disease Prevention and Management: Better Models for Better Health,” panelists each made their case on what it would take to create such models. Rebecca Bennett, principal and founder of Emerging Wisdom LLC, moderated the session.
The For the Sake of All Report to the community previously pointed out that race zip code and individual behavior play a greater role than genetics in health disparities.
Their community discussions have looked at what can be done as a region to improve overall health, including removing social and economic barriers that directly affect it – such as housing, education, jobs with livable wages, transportation and access.
Panelist Deborah Kiel, PhD, associate professor, director of Graduate Nursing Programs and director of the Undergraduate Public Health Program at Lindenwood University – favors a modification of the current health model, which she said has been around a long time, although it is not funded consistently and often.
“And that model is really about community-based public health nurses and community-based community health worker teams that are based in the communities – and not program-based,” Kiel said. “They have a district and they become as much a part of the community as anybody else – they know the mailman and they know the policeman and they know the fireman and the person that runs the nail salon. They know who’s in trouble and who’s not in trouble. The model is proactive and holistic vs. case management.”
Panelist Jorge Riopedre, president of Casa de Salud, said the case management model has been successful in improving health at his clinic. Patients are referred into care, and the clinic advocates for patients to make sure they obtain, understand and own their health care. Additionally, it assists with financial aid and payment plans so that the patient knows how much they are going to spend, he explained.
Riopedre said for the past year, the clinic has conducted home visits for chronic conditions, like diabetes and hypertension, which have been quite effective.
“I firmly believe it’s just the idea that the patient understands that someone is there, in their home, caring for them and about them, that has a medicinal impact for that patient,” Riopedre said. “If we’re going to have positive outcomes, it’s not just payment structures that are going to have to be redone … but we have to put collaboration ahead of competition.”
Riopedre said non-obvious collaborations and partnerships are needed, such as its collaboration with a housing corporation.
“The more we do that, the more successful we are going to be moving forward,” Riopedre said.
BJC senior vice president, chief clinical officer, director of the BJC Center for Clinical Excellence and professor at Washington University School of Medicine, Dr. Clay Dunagan, said the St. Louis region is applying for a $4.5 million grant from the Centers for Medicaid and Medicare (CMS). The new CMS Accountable Health Community Model will connect patients with health care and social services needs to supports to make their lives healthier.
Dunagan said convener of the proposal is a consortium of organizations, including the Missouri Patient Care Association and the Behavioral Health Network. It would screen up to 75,000 adults per year and make at least 3,000 referrals to social services.
“The idea of the Accountable Community Health model is to establish a group organization that can broker those connections when someone appears for healthcare can figure out what their additional needs are and get them to those services as needed,” Dunagan said.
With Missouri being a non-expanded Medicaid state, Dunagan said, “there is some risk that we could clog up the system with people who do have Medicare and Medicaid, at the complete expense of those who don’t have insurance.”
Even if they don’t get the grant, Dunagant said the foundational work is important to continue.
“This is an opportunity to try to focus on community rather than individual providers or individuals themselves,” Dunagant said. “It addresses core areas of need… and it builds on the evidence … that health outcomes are affected by factors beyond healthcare.”
Panelist Sidney D. Watson, the Jane and Bruce Roberts professor of Law at Saint Louis University School of Law’s Center for Health Law Studies. Watson said without Medicaid expansion, Missouri’s safety net for the most in need is like an umbrella or safety net with a big hole in the middle of it.
“Because of the rules that govern Medicaid now, Missouri has some of the stingiest Medicaid eligibility rules in the country,” Watson said, and there are about 300,000 Missourians in that hole.
“Women who are pregnant get Medicaid, but at day 60, they are thrown off the program,” Watson said. “Otherwise, if you are an adult, a caretaker, an aunt, a grandmother and caring for a minor child – but you can’t make more than $318 a month for a family of three.”
That’s 17 percent of poverty, she said, adding, “If you work 10 hours a week at a minimum-wage job, you earn too much money to qualify for Medicaid here in Missouri.”
She reminded the audience that expanding Medicaid would save Missouri tax dollars, because of federal dollars that would go into the state program.
“How do we close the gap, Missouri can do as 31 other states have done now and pass a statute that allows all adults, 19 to 64, who have incomes of up to 138 percent of poverty – for a family of three, that’s almost $28,000, to qualify for Medicaid,” Watson said. “It would actually save Missouri tax dollars to cover the 300,000 more people in Medicaid each year.”
A live audience-participation poll, Bennett asked attendees about what they needed to improve health; gaps they see in implementing a healthier community model and actions needed to improve health equity in St. Louis.
In summary, a healthy community would involve medical workers asking different, culturally competent questions for a more complete picture of patient needs and partnering with them to reduce health disparities in chronic and infectious disease. It involves cultural empathy; supporting healthier behaviors within communities with fresh fruit and produce access; safe spaces for play and exercise; and eliminating smoking to lead a healthy lifestyle.
“People don’t think about that, but a job is a health intervention. An income is a health intervention. And having liquid assets is a health intervention,” said For the Sake of All project lead Jason Purnell, PhD. of Washington University. “People don’t think about that – but the earliest years of life … even before – the months prior to the earliest years of live are crucial for health outcomes. So it turns out – early childhood intervention is a health intervention.
“Children that can’t hear and can’t see and can’t breathe and have been hurt and are hurting – can’t learn, so it turns out that education is a health intervention,” Purnell said.
“The strongest, most consistent predictor of all public health is your level of education.”
Where you live – your neighborhood – is a predictor of health outcomes, he added.
“That zip code turns out to be a health intervention.”
Purnell summarized points of discussion from previous community meetings – behavioral health and toxic stress – to what it takes for a healthier community.
“Health is the whole thing – live, learn, work and play. Health happens everywhere, but it doesn’t happen equally for everyone. And that’s not a mistake.
“It’s not a mistake the way resources are distributed in our region, in our nation. And real equity means providing more to people who need more – not giving everybody the same thing.
“People are struggling and suffering and it’s not enough to talk about equality in giving everybody the same thing when somebody’s in a hole – somebody’s in a ditch.” Purnell said. “You try to get them out of the ditch, because we are only as strong as a region as our most vulnerable members.
“You should care because this is costing us a great deal of money, Purnell added. “If you don’t care for the moral reason; if you don’t care for the preventable causes that we can do something about – you ought to care because of the billions of dollars… that we are leaving on the table by not expanding Medicaid.”
He said seven working groups are already strategizing to address issues that hinder a healthier community and their ongoing work will be posted online.
For further information, visit www.forthesakeofall.org.
