There is a certain amount of humility and audacity required to admit that the care you provide only accounts for about 10 percent of what ultimately determines a patient’s health. Such a thought runs completely counter to the “doctor knows best” belief upon which our current health system is based. It’s quite unusual for your health system’s CEO to acknowledge the truth of this statement and to choose to address some of the other 90 percent of factors that determine people’s health. But that is just what the leadership of First Choice Community Healthcare has done by expanding the scope of its primary care system.
Doctors tend not to dig for the underlying social causes of poor health when they have nothing to offer a patient but words of encouragement. In fact, they have come to dread the “doorknob confession” that patients sometimes divulge about how the patient lost a job or is having trouble at home. A recent Robert Wood Johnson Foundation study found that four out of five of physicians wish they could prescribe food or housin but feel unequipped to address social determinants that impact patient health. That is why First Choice has taken steps to build its and the community’s capacity to address more of the 90 percent while maintaining the highest quality of care for its 10 percent share of health impact.
First Choice is asking itself the question, “How can we as healthcare teams build on the assets we, in partnership with our communities, possess to amplify the impact we have on the health and well-being of our communities?” The two main strategies it is using involve deploying community health workers and developing an expanded Health Commons to address the upstream drivers of poor health in the South Valley, where health outcomes are among the worst. In many ways, these two strategies represent a return to the roots of the community health center movement of the late 1960s started by Dr. Jack Geiger in the Mississippi Delta. The founders of First Choice emerged from the War on Poverty, who organized with medical allies to establish the first clinics in the South Valley. The leaders knew then what we know now –health comes from more than just high-quality healthcare. It comes from high-quality childcare, education, jobs, access to healthy food and safe neighborhoods.
Once we got the health center going, we started stocking food in the center pharmacy and distributing food—like drugs—to the people. A variety of officials got very nervous and said, ‘You can’t do that.’ We said, ‘Why not?’ They said, ‘It’s a health center pharmacy, and it’s supposed to carry drugs for the treatment of disease.’ And we said, ‘The last time we looked in the book, the specific therapy for malnutrition was food.’ – Jack Geiger. The Unsteady March. Perspectives in Biology and Medicine, 48, 1-9
The current healthcare system that is predicated on generating office visits leaves little time and resources to address the social determinants of health and their policy antecedents. But the Affordable Care Act’s slight pivot toward prevention has given doctors like Art Kaufman and his son Will Kaufman the opportunity to test their audacious theories about how taking action on the social needs of patients will net results in patient health, satisfaction and, ultimately, cost. Both Drs. Kaufman have pilot-tested a simple screening tool for poverty, created by Dr. Janet Page-Reeves from the University of New Mexico (UNM), called WellRx. This allows doctors to systematically screen for social needs like they screen for tobacco use. They and the doctors they train in residency write “prescriptions” for assistance from community health workers, whom the doctors have embraced as equal partners on the healthcare team. While there is no magic pill that cures a patient’s difficulty with finding a job or paying for utilities, a WellRx connects patients with a source of food so that they may be able to afford their medicine, or with transportation to their follow-up appointment. A more traditional approach would regard patients who can’t afford medicine or transportation as “non-compliant.” One goal of the pilot project is to prove to health insurers that addressing social needs can prevent costly disease treatment.
There is an oft-cited parable of three friends who see children drowning in a river: Two rush into the water to save the children. The third friend swims upstream, acting to “stop whoever or whatever is throwing these children in the water.” As “upstreamists,” Dr. Art Kaufman, a pioneer in spreading the social mission of medical education and Dr. Will Kaufman, a family doctor who heads the Community Health and Wellness programs at First Choice, are addressing needs at the source to prevent problems downstream. The First Choice Wellness program has brought a subsidized CSA program to patients; a Mobile Farmers’ Market; a monthly healthy cooking class; a USDA children’s meal program; Spanish-language yoga; meditation; massage therapy; legal assistance and other resources. But they are still working at the individual level.
First Choice plans to be even more effective by developing communities that promote and engage people in healthy lifestyles. We know that people’s individual choices are shaped by the many contexts in which people live. That’s where the First Choice expansion plans for the South Valley Community Commons come into play. The Commons becomes the context in which patients can fill their wellness prescriptions with vendors whose missions are aligned with ours.
The board of directors of First Choice, more than half of whom are patients, have acquired more than 10 acres, doubling the size of its South Valley campus, to provide a platform from which to launch five health promoting enterprises: an early-childhood development center; a health professions charter high school; an ‘aging well’ wellness center; a community farm/local food hub; and a farm-to-table-style restaurant that also serves as the Commons commissary. These projects were selected with the goal of investing in those enterprises that have the best hope of mitigating socio-economic indicators, as well as becoming financially sustainable through co-location and cooperation, thereby generating a sustainable wellness ecosystem.
The ambitious $25 million development project is getting underway in 2016, with funds from the state Legislature and the National Fish and Wildlife Foundation to start the community farm. The AgriCultura Network has given input into the farm design and expressed its interest in locating its food hub operations at the site. Agricultura and First Choice have collaborated on the CSA, cooking classes and Mobile Market, which have been supported with grants and subsidies from Presbyterian Healthcare Services, the CDC (REACH) and the BUILD Health Challenge (Robert Wood Johnson, Kresge, deBeaumont, and Colorado Health foundations and The Advisory Board Company).
The next major phase of the expansion project will focus on building a permanent campus for Health Leadership High School, with whom we have been partners since inception in 2012-13. First Choice and HLHS boards have entered into a long-term lease and Memorandum of Understanding (MOU) that spells out how together, along with other healthcare partners, we will prepare the next generation of health leaders, grounded in the ethos of community health and upstream thinking.
The full build-out of the project could take 5-7 years, but the return on the investment will pay dividends in terms of better health, educational attainment and jobs for years to come. An independent economic analysis shows that the project will create a minimum of 100 new jobs, with total salaries of $4,820,000, generating an estimated additional $ 24,100,000 annually into the New Mexico economy.
Michelle Melendez is development director at First Choice Community Healthcare and serves on the Con Alma Health Foundation Community Advisory Committee and the Bernalillo County Community Health Council.
First Choice Community Healthcare is a nonprofit primary-care health system that provides medical, dental, behavioral health care, and specialty care, as well as WIC. First Choice serves more than 50,000 individuals in three counties in Central New Mexico regardless of income or insurance status. 505.241.5182, fcch.com