In Spring 2013, we are on the precipice of dramatic, disruptive change in the health field that offers an unprecedented opportunity and challenge to transform health care and population health. We know that traditional public health approaches along with more and better health care are not enough to improve health outcomes, equity, and cost. We must also: - implement sustainable, fundamental "upstream" changes that address the root causes of disease and disability; and - transform the way we deliver health care to ensure access to quality, affordable health care for all. Enjoy this Bright Spot presentation with David Law of Joy-Southfield Community Development Corporation, which was presented at the 2013 Annual Leadership Conference, co-sponsored by the Center for Health Leadership (CHL) and the California Pacific Public Health Training Center (CALPACT) at UC Berkeley's School of Public Health. To learn more about this event, please visit: http://calpact.org/index.php/en/events/leadership-conference Learn more about CALPACT: http://calpact.org/ Learn more about the CHL: http://chl.berkeley.edu/

1. Dave Law, PhD, Executive Director
Joy-Southfield Community Development Corporation
Population Health in Detroit:
Clinical- and Community-Based Prevention
UC Berkeley School of Public Health,
Center for Health Leadership
5th Annual Leadership Conference
Health 3.0: Transforming Community Health and Care Delivery
Upstream Innovations in an Era of Health Reform

2. Why Go Upstream?
Even though “Going
Upstream” is hard
work, there is a
compelling reason to
do so…
… “Goin’ with the
Flow” is harmful and
lethal!

3. Overview of the U.S. Health Care System
Disease
• Common chronic diseases such as type-2 diabetes,
hypertension & CVD account for 70% of deaths *
• Chronic diseases account for 75% of annual $2.5 trillion in
healthcare costs *
• Communities of color and low SES individuals experience
increased morbidity & mortality (preventable)
• Obesity epidemic is creating a tsunami of CD
• Access to care is important, but SDOH are also key
• Place and Race Matter (See Policy Link/CA Endowment)
* A Healthier America 2013: Strategies To Move From Sick Care To Health Care In The Next
Four Years. Trust for America’s Health, January 2013. www.healthyamericans.org
http://www.policylink.org/site/c.lkIXLbMNJrE/b.6728307/k.58F8/Why_Place___Race_Matter.htm

4. Closing the racial/ethnic disparities gap would save more than
83,000 African American lives every year
(http://www.americanprogress.org/issues/2011/01/war_minorities.html/print.html)
Satcher D, Fryer Jr. GE, McCann J, Troutman A, Woolf SH, Rust G. 2005. What If
We Were Equal? A Comparison of the Black-White Mortality Gap in 1960 and 2000.
Health Affairs 24:459-464.
36.449.936.6Uninsured
(Millions)
9.5306.1279.5Population
(Millions)
% Inc.20102000
Income, Poverty, and Health Insurance Coverage in the United States: 2010
U.S. Census Bureau. Sep 2011.
Racial Health Inequality is Lethal

5. Racial Health Inequality is Lethal
Michigan Department of Community Health 2009 Health Disparities Report, February 2010
http://www.michigan.gov/mdch/0,1607,7-132-2940_2955_2985---,00.html
Examples of Black-White Health Disparities (MI):
• Overall mortality - 136%
• Infant mortality - 284%
• CVD mortality - 149%
• Stroke mortality - 136%
• HIV-AIDS prevalence - 858%
• Diabetes incidence - 201%
• Diabetes mortality - 156%
• Cancer incidence - 112%
• Cancer mortality - 127%
How can the U.S. legitimately criticize other nations for human rights violations?

6. County Health Rankings in MI
www.countyhealthrankings.org/michigan

7. 2013 County Health Rankings
County
www.countyhealthrankings.org/michigan
Overall ranking = 82 (dead last)
Bad news > mobilize action > create good news

8. Ecological Approach to Promoting Health Equity

9. PPACA: Increased Access to Healthcare a Necessary But
Insufficient First Step Toward Health Equity
Source: CBO Briefing to House Speaker Pelosi, Mar 2010
Health Disparities Persist Even in Countries with Universal Access
Alter DA, et al. "Lesson from Canada's Universal Care: Socially disadvantaged patients
use more health services, still have poorer health" Health Affairs 2011; 30(2): 274-283.
Number of
uninsured could be
higher depending on
the extent of
Medicaid expansion.

10. PPACA: Framework for Improved Health & Reduced Costs
Prevention = ê Healthcare Costs é Health Outcomes
http://www.healthcare.gov/prevention/nphpphc
NATIONAL
PREVENTION
STRATEGY

11. Healthy & Safe
Community
Environments
Clinical & Community
Preventive Services
Empowered
People
Elimination of
Health
Disparities
NPS Model Revisited
Revised NPS Model: D. Law, Dec 2012

12. Promoting Health Equity at the
Grassroots Level
Joy-Southfield Health and Education Center
6 Treatment Rooms (1 dental)
Triage
Reception Dispensary
Clinic
Admin
Modular Classrooms
Health Educ/CDM
CDC
Admin
CDC
Admin
Kitchen
Lunchroom
Cooking
Demos
Mech.
Stor.
Stor. WC
WC
WC Copier
FAX

13. Ecological Approach: Clinical Care
• Free primary & preventive care for uninsured adults
• Pediatric care for uninsured & insured
• HFHS HANK
• Preventive health education
• Chronic disease management
• Telehealth support
• Pharmacy, labs/diagnostics (including POC)
• Selected specialty care (diabetes, hypertension); referral for others
• Oral health, behavioral health added to scope in 2012
• Health IT to measure outcomes
• Diverse pool of volunteer providers

14. Ecological Approach: Clinical Care
• 3,266 Adult Free Clinic Visits in 2012
• 8,047 Prescriptions (worth $550,230)
• Volunteer in-kind value $81,314
Where would you have gone if this
clinic were not available?
n = 1547
No Care
51.1% ER/ED 41.9%
Private Dr.
3.2%
Other Free Clinic
3.8%

15. Patient Satisfaction 2012
Treated with respect
Very Good 89.6%
Good
9.7%
Fair
0.7%
n = 1704
Clarity of instructions
Good
11.0%
Fair
0.6%
Very Good 88.4%
n = 1691
Wait time
Good
16.8%
Fair
5.6%
Poor
1.0%
Very
Poor
0.5%
Very Good 76.1%
n = 1488
Good
11.1%
Fair
0.7%
Very Good 88.2%
Overall satisfaction
n = 1688

16. Ecological Approach: Clinical Care
Laura W. - “I don’t know what I would have done without you.”
Robert M. - “They saved my life. I had no medicine for my pressure and they
gave me the pills and took care of me.”
Anonymous - “When I come to this place, I never want to go home. I can
sit and be happy.”
Anonymous client survey - Q: “ Where would you have gone if the clinic were
not available?” A: “Grave.”
Johnny C. - “This clinic help me to get medicine for my health. They have been
good helping me and others to stay well and get help that we need. Please let
this place stay open so it can help with low or no income like me.”
Linda C. - “God Bless you all. Thanks a million!”
Mario A. - “I need this clinic like I need oxygen. The clinic has been a blessing
beyond what I can think of.”

17. Ecological Approach: Clinical Care
• Patient feedback is compelling & valuable,
however it is limited by its subjectivity
• Utilizing a health IT intervention to improve health
outcomes and efficiency
• Chronic disease management, quality assurance
(HEDIS*), prompting & reminding, rapid outcomes
measurements
• Web-based, secure and HIPAA-compliant
• Pharmacy management software to enhance
adherence
* Healthcare Effectiveness Data and Information Set
(nationally recognized set of key health indicators)

18. Ecological Approach: Clinical Care
Successful Health Interventions
Ultimately Boil Down to Respect
Losing her job
was “a blessing
in disguise.”
Message to
health care
reformers:
Spend more
time with
patients!

19. Ecological Approach: Physical Environment
Downtowns of Promise Economic Redevelopment Strategy
• Grant from the Michigan State Housing Development Authority
(MSHDA)
• Provided detailed assessments, asset mapping and community
engagement to provide framework strategy for redeveloping the local
commercial corridor (Joy Rd from Evergreen to Southfield)
• Currently identifying partners for implementation over the next 3 to
5 years, including: City of Detroit, Wayne County, MSHDA, federal
government, TCAUD, Ross Business School, & many others
• 11 new businesses to date
• Façade improvement grants totaling $250,000 (matching funds)

20. Downtowns of Promise Economic Redevelopment Strategy

21. Downtowns of Promise Economic Redevelopment Strategy
Commercial Façade Improvements

22. Safe & Functional Places to Exercise:
Renovating Local 25-Acre Park

23. Knowledge is Power:
Especially When it Comes to Health
Health IT Tools for Quality Improvement:
• BP cuffs with memory
• Glucometers with memory
• Pharmacy management software to
improve prescription drug adherence
We use the carrot
99% of the time.
Sticks don’t work,
especially for the
“under-served”.

24. Kidney Rock
Knowledge is Power:
Especially When it Comes to Health
Trip to Berkeley

25. Empowerment: Health Education
• Showing is better
than telling
• Extended family =
extended lifespan

26. Treatment, Education, Management & Prevention
• Mission: To reduce ethnic health
disparities in ESRD (kidney failure)
• Detroit among 6 U.S. cities with
exceptionally high ESRD rates
• NIH-funded study (Howard University) to
test efficacy
• Developing a similar intervention for
type-2 diabetes (Howard University)

27. Empowerment: Bringing Healthy Options to the Table
• Addressing the food desert issue
• Community gardening with youth involvement
• Sowing Seeds, Growing Futures Farmers Market
• Healthy Corner Stores Project (WSU SEED)
“We just wanted to bring a sense of
unity back into the neighborhood.”
- Kaleb, 7th grade visionary for
community gardens & farmers market

28. What About the Last Piece of the Pie?
Saving the Best for Last
http://www.healthcare.gov/prevention/nphpphc

29. Public Policy Advocacy
“It has long been understood that many factors beyond health care actually
influence health. Social and economic determinants of health include income,
education, physical environment, social isolation, and concentration of poverty.
Given this reality, there is a growing realization of the potential for synergies
between work to revitalize low-income communities and the need to promote and
improve health.”

30. Conclusions
• The resources exist to provide universal access to
quality health care
• Runaway health care costs can be mitigated by
increasing prevention
• Effective patient engagement reduces costs &
improves health outcomes
• Health IT improves quality & efficiency
• Reducing/Eliminating health disparities requires an
ecological approach, i.e. addressing all determinants
• RESPECT is key to engaging previously under-served
populations
• Health SYSTEM reform will require multi-disciplinary
intervention, but will pay for itself over time

31. Conclusions (cont.)
• ACA implementation is necessary, but not sufficient to
reduce health disparities
• Need more integration of medicine & public health
(PCMH meets population health)
• The persistence of disparities adversely affects health
outcomes for all people (particularly uninsured &
underserved)
• Partnerships between health systems and CBOs will
enhance development of place-based health strategies
• CBOs & safety net organizations will remain an
integral part of a reformed health care system

32. Contact Info:
Dave Law, Executive Director
djlaw@joysouthfield.org
(313) 581-7773, ext. 105
joysouthfield.org