Lessons From the Field on Improving Social Determinants of Health

For decades, Nationwide Children’s Hospital in Columbus, Ohio, kept itself separate from its surrounding urban areas. Gretchen West, who grew up in its shadow, said it was “not always viewed favorably by the neighborhood.”

Today, West heads the hospital’s Healthy Homes public-private partnership, which was created 10 years ago to start attacking housing problems—one social determinants of health (SDOH) factor in the lives of their patients—in the same way they would as if they walked in the door with a grave illness.

West spoke in New Jersey at the Building a Culture of Health conference to share national examples of best SDOH practices with local Newark leaders from healthcare, universities, foundations, and residents. In addition, the conference, held at the New Jersey Institute of Technology, focused on leadership skills and strategies that are needed by health and community staff, especially those working in challenging environments.

SDOH encompasses a number of factors that influence a person’s health outside of a medical office: income, social status, and education; physical environment, including access to safe water and clean air; safety and conditions of residences and workplaces; employment opportunities and social support networks; and access to health services. The Newark conference focused on housing, food, fitness, and adverse childhood and community experiences.

“Your zip code can tell you more about your health than your genetic code,” said West, the executive director of Healthy Homes.

When Nationwide built a massive campus expansion in 2008, it also embarked on a project to revitalize the immediate area to its south, the Southern Orchards neighborhood, where West grew up. It had a high infant mortality rate, and 34% of the children were already behind when they entered kindergarten, she said.

They began with housing, as medical staff came to realize how much their patients were affected by subpar housing conditions, such as moldy dwellings housing children with asthma. The hospital partnered with a local community development corporation, however, for housing expertise.

Healthy Homes has rehabilitated or built 340 homes near the hospital. That includes home improvement grants, new builds, and renovations.

“Improving housing and its cost can have multiple health benefits, just as a vaccination,” said West.

The desire to improve the local neighborhood was not 100% altruistic. In its quest to become one of the nation’s top 5 children’s hospitals, leadership knew they needed to do something to attract talent, West said. She said staff were afraid to walk to their cars at night, since muggings were not uncommon.

According to a recent CityLab article, leadership was initially prompted by a request from the city to invest in housing if it also wanted to receive tax incentives in order to get the 2008 hospital expansion rolling; after seeing early successes, however, hospital leadership bought fully into the idea).

The effort has made an impact, she said. Vacancy rates have dropped to below the community average of 7%, down from 25% before Healthy Homes existed. High school graduation rates have risen from 64% to 79%.

Read more about investing in social determinants of health.

In addition, while the homicide rate climbed in 2017 for the city as a whole, Southern Orchards did not have a single homicide, West said.Kimberly Brown, the chief program officer for DC Central Kitchen, also talked about the returns on investment in her social venture organization, which focuses on using food not only to fight hunger but also as a tool for workforce development and community building. DC Central Kitchen trains people for culinary careers and also hires them back.

Brown said the organization has a “triple bottom line” by expanding access to healthcare, creating opportunities for meaningful careers, and testing solutions to systemic problems.

Food access is not often thought about as a social justice issue, Brown said; one of the things DC Kitchen focuses on is to “change behaviors so that people demand the food that we’re providing.”

To that end, it also trains college students at 63 campuses across the country in food policy and hunger issues; the students work to bring unused food from dining halls and other places to community agencies. One dollar invested in their Campus Kitchen project translates into $6.71 into society, she said. “Investing in poor folks in an investment in everyone’s lives,” she said.

In addition, DC Kitchen was recently selected for a Food Insecurity Nutrition Incentive (FINI) grant from the US Department of Agriculture that incentivizes the purchase of fresh fruits and vegetables by essentially doubling the value of Supplemental Nutrition Assistance Program (SNAP) benefits.

It also recently partnered with Medstar Health to bring health and nutrition information to high-risk pregnant women in Washington, DC, where the rate of maternal mortality is the highest in the country.

Trauma-informed care is becoming a standard, said Ruben Cantu, program manager at the Prevention Institute, but more focus has to be put on community trauma and adverse community experiences. Community trauma is a risk factor for violence, which in turn increases exposure to adverse childhood experiences, he said.

He gave the example of working with public health departments to implement violence prevention programs, but found they were impossible to implement effectively because of the systemic health issues facing the community.

“Communities need to be engaged at all steps of putting in place these strategies to improve conditions,” he said.

These issues demand a new model of leadership, and not the hierarchal-based traditional one some people in the room might be the most familiar with, said Kaytura Fells, MD, managing director of leadership development at the Robert Wood Johnson Foundation (RWJF). Traditional hierarchies are not built for problem solving, she said.

“We don’t need leadership for the sun to rise,” said Fells. “It is what you need when you cannot create something on your own.”

The other critical ingredient is trust, speakers said—trust within organizations and trust building between organizations and the communities they serve. That trust is often lacking, and in addition, issues created by poverty may lead parents to feel powerless.

“Being poor in this country robs a parent of the understanding of how much they matter to their own children,” said Charles M. Payne, PhD, director of the Joseph Cornwall Center for Metropolitan Research at Rutgers University, who spoke about a program at a Newark school that trains parents to work as paraprofessionals in the classroom.

This was the second year of the conference run by Believe in a Healthy Newark project, which is a program of the NJ Health Initiatives, which is funded by the RWJF.