CONNECTING THE DOTS - Harvesters · Connecting the dots to promote health equity at the community...

CONNECTING THE DOTS: HOW WE ACHIEVE HUNGER FREE HEALTH CARE FOR ALL

3rd Annual Hunger-Free Healthcare Summit

September 24, 2019

Richard Sheward, MPP

Director of Innovative Partnerships

I have no relevant financial relationships to disclose or conflicts of interest to resolve.

Disclosures

Roadmap

•Setting the stage• What are we trying to fix?

•How we achieve hunger free health care• National perspectives, trends, and examples of success

•Shifting from isolated impact to collective impact• Connecting the dots to promote health equity at the community level

What drives your health?

• “The conditions in which people are born, grow, work, live, and age” and “the fundamental drivers of these conditions”

• Hospitals and health care systems have begun to address the social determinants of health

• Initiatives that connect patients to food, housing, transportation and other social interventions

Source: Castrucci B, & Auerbach, J. Meeting Individual Social Needs Falls Short Of Addressing Social Determinants Of Health. 2019. Health Affairs. Available at: https://bit.ly/2HhwcxT.

An important distinction

• There’s a difference between individual-level “health related social needs” and community or societal level “social determinants of health”

• Health care and social service agency partnerships are necessary, but not enough

• Systemic social policy changes are needed in addition to addressing individual needs

The Social – Ecological Model

1. Anti-hunger groups partnering with health care community to address food insecurity2. Influx of research, resources, and innovation in practice & policy3. Window of opportunity for addressing food insecurity in clinical/community settings

Current State:Identifying and addressing food insecurity

Clarity (your why)Why am I screening for food insecurity?

Begets confidence (your what)Am I using the right screening tool?

Is this the right intervention?

Followed by action (your how)The work I do everyday!

Outcomes: food security, health equity, ROI

• Take a broad perspective of ROI – beyond financial• Improved quality measures• Patient/provider satisfaction

• There are limits to economic self interest• Ultimately we must address the root causes of SDOH

• Unintended consequences• Undervalue non-medical, health-related social needs

Return On Investment (ROI)

• Where is the transformation taking place?• Organizations connecting people with the right care

and services• Ensuring that all service providers have complete

information available when and where they need it

• The lifeblood of success: a sense of urgency • data sharing, collaborative systems not a technical

challenge, but coordinated and strategic actions promoting health equity at the community level

How we achieve hunger free health careNational perspectives, trends, and examples of success

• Strategic coordination of resources• Information flow across

organizations • Based on relationships, shared goals,

trust• Driven by and for the community

How we achieve hunger free health care

• cross-sector approaches do not mean that all services need to be medicalized

• The sectors need to focus on and share the same end goal

• identify synergies and mutual interests • share the responsibility – and the resources

How we achieve hunger free health care

• State and/or regional efforts• Vermont Child Health Improvement Program• Hunger to Health Collaboratory (H2HC)• Massachusetts Food Is Medicine State Plan• Vermont Accountable Community for Health (ACH)

• Learning networks and communities• Moving Health Care Upstream• BUILD Health Challenge• Hunger Vital Sign National Community of Practice• Community Information Exchange (CIE) powered by 2-1-1 San Diego• Data Across Sectors for Health (DASH)• All In: Data for Community Health


• State and/or regional efforts• Vermont Child Health Improvement Program

• Goal to increase the efficiency, economy, and quality of care provided to Medicaid-eligible children and families

• Building on the momentum of Bright Futures and Vermont's health care reform activities

• Network of practices that engage in collaborative improvement activities to meet the evolving needs of health care professionals, children and families


• State and/or regional efforts• Hunger to Health Collaboratory (H2HC)

• A group of cross-sector stakeholders committed to reducing the health consequences of hunger

• H2HC aims to build alliances with others who believe that health begins with reliable access to inexpensive, nutritious food

• H2HC seeks to accelerate the impact of sustainable initiatives


• State and/or regional efforts• Massachusetts Food Is Medicine State Plan

• Builds on the momentum of recent health and food systems change in the Commonwealth by providing the data and strategies necessary to systematically expand access to Food is Medicine interventions


• State and/or regional efforts• Vermont Accountable Community for Health (ACH)

• Structured, cross-sectoral alliance of healthcare, public health, and other organizations that plans and implements strategies to improve population health and health equity for all

• The Vermont Health Care Innovation Project’s Population Health Work Group created a statewide network of Accountable Health Communities in 2015.


• Learning networks and communities• Moving Health Care Upstream (MHCU)

• Health systems address persistent and costly health inequities by moving “upstream”-working in collaboration with community-based organizations to address the root causes of disease

• MHCU seeks to accelerate the adoption of upstream strategies that produce large-scale, sustainable population health improvements, with an emphasis on improvements among children and families


• Learning networks and communities• BUILD Health Challenge

• National program to support partnerships between community-based organizations, health departments, and hospitals/health systems that are working to address important health issues in their community

• Each community collaborative addresses root causes of chronic disease in their local area by leveraging multisector partnerships

• To date, BUILD has supported 37 projects in 21 states and Washington, DC


• Learning networks and communities• Hunger Vital Sign National Community of Practice

• Co-convened by Children’s HealthWatch and the Food Research & Action Center (FRAC), the National Community of Practice (NCoP) works to facilitate conversations and collective action among a wide-range of stakeholders interested in addressing food insecurity through a health care lens.


• Learning networks and communities• Community Information Exchange (CIE)

powered by 2-1-1 San Diego• Designed to assist communities interested

in learning how to harness the value of cross-sector collaboration and data sharing

• Enables a network of health, human, and social service providers to deliver coordinated, person-centered care to address social determinants of health to improve population health.


• Learning networks and communities• Data Across Sectors for Health (DASH)

• Identifies barriers, opportunities, promising practices and indicators of progress for multi-sector collaborations to connect information systems and share data for community health improvement

• All In: Data for Community Health• The All In online community is a virtual group of

individuals dedicated to improving community health through multi-sector data sharing and collaboration




• The collective impact model is being widely used as a cross-sector organizing and implementation framework for community based groups and multi-sector organizations alike.

• Shifting from isolated impact to collective impact is not merely a matter of encouraging more collaboration or public-private partnerships.

• It requires a systemic approach to social impact that focuses on the relationships between organizations and the progress toward shared objectives.

Shifting from isolated impact to collective impactConnecting the dots to promote health equity at the community level

Shifting from isolated impact to collective impactConnecting the dots to promote health equity at the community level

Connecting the dots to promote health equity at the community level

Thank You!The mission of Children’s HealthWatch is

to improve the health and development of young children by informing policies that address and alleviate economic hardships.

[email protected]

www.ChildrensHealthWatch.org@ChildrensHW

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