Dr. Nir Menachemi, chair of the health policy and
management department at Indiana University’s
Richard M. Fairbanks School of Public Health.
There is one clue that speaks volumes about your health prospects but has nothing to do with your medical records.
“We know now that one of the greatest predictors of health outcomes for almost any patient, undergoing any procedure, or with almost any disease, is one value on a patient’s chart,” says Dr. Nir Menachemi, chair of the health policy and management department at Indiana University’s Richard M. Fairbanks School of Public Health. “And that value isn’t medical. It’s their ZIP code. You can tell with extreme accuracy how someone is going to fare, after a procedure, by their ZIP code.”
Where a person lives is critical because health is shaped by factors outside the scope of traditional medical interventions and advice.
“In this country, we tend to medicalize health-care issues,” Menachemi says. “If someone is having a health issue, we automatically assume the medical system can fix it. A lot of organizations are now beginning to realize that many health issues are not necessarily problems that can be addressed through medical care alone. They’re bigger issues in the communities where people live.”
Menachemi is participating in a study, funded by the Robert Wood Johnson Foundation, that aims to help medical professionals and institutions make better use of that data. The project, which draws on the resources of The Polis Center, the Regenestrief Institute, and the Richard M.
Fairbanks School of Health, is testing a tool that predicts what kind of care might best serve a patient. To do so, it uses an algorithm that incorporates medical records as well as neighborhood-level data from the SAVI Community Information System supplied by Polis.
“We’re taking data about the neighborhood where patients live and seeing if we can predict who’s at risk for needing some of these social services,” Menachemi says. Services include nutritionists, financial and legal advisers, and mental health professionals. “The medical way of thinking about a problem is, if the patient isn’t doing well after a couple of visits, figure out the next medical intervention. Whereas, if you deploy a nutritionist to take them grocery shopping, and better educate the family on how to stretch the buck to incorporate healthy eating into the family’s lifestyle, maybe you’ll actually put a dent in the ability of the family to manage diabetes, for example.”The tool has been in the pilot stages and will soon be implemented in the 10 health clinics maintained by Eskenazi Health.
“This is absolutely at the cutting edge,” Menachemi says of the collaboration. “It’s almost like this perfect marriage of forces— all of us on the same team, trying to figure out how to lead the nation in improving quality and reducing costs in health care.”
A team whose players complement each other well is sometimes described as “more than the sum of its parts.” Patrick T.S. Lai was drawn to Central Indiana because such synergies are emerging in the realm of health care.
Lai, a doctoral candidate in the School of Informatics and Computing at IUPUI, says that the region has two resources that
are valuable in themselves: a network of comprehensive electronic health records, called the Indiana Network for Patient Care,
and The Polis Center’s SAVI database, which offers comprehensive community data.
By combining data from these resources for his dissertation work, Lai is trying to understand which neighborhoods have the
highest rates of two sexually transmitted diseases (STDs), chlamydia and gonorrhea. But, he’s also aiming to understand why
those neighborhoods have higher rates.
Getting at the “why” requires the kind of rich neighborhood profiles that SAVI offers, which when used with health record data
“is a great opportunity to understand the underlying factors of disease.”
Certain social factors influence and predict the rate of STDs in a given neighborhood. These “social determinants” include median income, education level,
population density, and the unemployment rate, among others.
It’s well know that such factors play a role in disease transmission, but the exact relationship isn’t clear. Lai aims “to identify which social determinants contribute most” to STD rates in a neighborhood.
His work is important, he says, because “knowing some of the biggest contributors could guide us in thinking about how we can effectively combat and reduce the
spread of disease.”
Another example of how SAVI is fostering healthcare synergies is the community public health course offered by Barbara Blackford, an assistant professor in
the School of Nursing at Marian College.
Blackford assigns groups of nursing students to conduct a “windshield survey” of certain census tracts. Each group drives around its assigned area, making notes of the community’s assets and liabilities. Then, they use SAVI to flesh out their observations with hard data about the prevailing socioeconomic and physical conditions, and each group gives a presentation about what they’ve learned.
Before Blackford’s students began using SAVI five years ago, they drew on a variety of scattered sources to supplement their windshield surveys.
“SAVI makes it so much easier,” she says. “It’s been a fantastic tool to help my students consider social and environmental determinants of health.”
Parkview Regional Medical Center
This year, Parkview Regional Medical Center in Fort Wayne will open a 2,000 square-foot greenhouse that the community can use for growing fruits and vegetables. The greenhouse facility will house a “learning kitchen” and meeting space near a home for seniors and an early childhood education center.
The Parkview Regional Medical Center is part of Parkview Health, a not-for-profit health system in northeast Indiana that consists of nine hospitals serving about 800,000 people across seven counties. Its new greenhouse will address the problem of obesity by encouraging a culture of healthy eating. A wide range of community
groups in Fort Wayne have expressed interest in partnering on it.
Parkview Health is targeting obesity based on a community health needs assessment (CHNA) that it released this
past December. As part of the assessment process, input was gathered from the community about their top community health concerns. Public health data was collected to understand the size and seriousness of identified health problems. Obesity ranked highest among several community health challenges.
The Affordable Care Act of 2010 mandated that hospitals produce a CHNA every three years, but Parkview has been producing them for more than a decade. The assessments “help us identify the community’s priorities,” says Sue Ehinger, the Chief Experience Officer with Parkview Health. “And then, we can partner with
people in the community in order to close the gaps on those issues.”
Creating an assessment
To create its 2016 CHNA, Parkview Health collaborated with The Polis Center and Indiana University’s Richard M. Fairbanks School of Public Health, acting
collaboratively as the Indiana Partnership for Healthy Communities (IN-PHC). The mission of IN-PHC is to make the knowledge generated by communities and
academic institutions more accessible to the public, and to translate that knowledge into practices that improve public health. It was founded in 2012 with the support of the Indiana Clinical and Translational Science Institute.
According to Karen Frederickson Comer, director of collaborative research and health geoinformatics at The Polis Center, the IN-PHC team used a variety of state and national sources to create a preliminary list of health needs in the counties that Parkview Health serves and used SAVI’s inventory of community assets to identify relevant community programs. Then, it gathered more detailed data about them by conducting phone surveys and organizing focus groups with people who live in the communities.
By analyzing hard data and incorporating community input, the team identified 13 major health issues in the region, including cancer, diabetes, the cost of healthcare, mental health, and sexually transmitted diseases. Next, it applied a method for ranking them that took into account the size of the problem, the seriousness of the problem, and the effectiveness of potential interventions.
Last summer, the IN-PHC team presented its findings to executives from each of the Parkview Health hospitals, who then voted on which health issues to prioritize. Obesity was easily their first choice, followed by mental health, maternal and child health, drug abuse, and diabetes. Each hospital in the Parkview Health system also selected its own top priorities.
The challenges identified by the CHNA are well known to health experts, but the process of creating a formal assessment is useful, according to Ehinger, because
it “helps us to focus and funnel all our activities into what the community believes is most needed.”
The process is also valuable because it helps keep the issues in the public eye.
“It’s very easy for us, as humans, to keep our heads in the sand,” says Sarah Wiehe, director of the Community Health Engagement Program at the Indiana
Clinical and Translational Sciences Institute. “These are very challenging problems to address. A lot of them are interrelated, and they don’t have a silver bullet answer. Having a place to start is extremely valuable. It starts the conversation within the health system, and between the health system and the community. And together, they identify ways in which they can intervene.”
The collaboration between Parkview and IN-PHC has now moved into a new phase, and The Polis Center is helping Parkview with implementing solutions. “We’ve asked them to walk through the solutions, and help us figure out: Are these indeed best practices?” Ehinger says. “Or, do we need to stop going in this direction and go a different route? They’ll help us solidify the direction that we’re going with all our solutions, and understand which measures we should
be focused on.”
“We’ll help them assess their chosen interventions,” says Comer, “to determine which are best practices and whether there’s a better way to measure their
effectiveness. So, we’ll be doing literature reviews, looking at which programs are evidence based and which are not. For the ones that are not, we’ll look at how
others have measured whether they have the desired impact.” Effectiveness is the most obvious metric to measure programs by, “but there are other dimensions to take into account,” Comer says. “For example, a program might be effective, but if it’s also extremely costly, it might become a lower priority than a program that’s very effective but less costly.”
Parkview’s commitment to cultivating partners both inside and outside the community—partners who can help them both identify and solve problems—is critical to the organization’s long-term success, according to Wiehe.
“By going through this process, they’re getting more than just a report at the end,” Wiehe says. “Now, they have partners who are invested in it. And, that spirit of partnership is notable.”