This is the fourth and final part in Death’s Disparities, a series about the growing gap in life expectancy between rich and poor New York.
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There’s a saying in Brownsville: ‘Never Ran, Never Will.’ Part defiance, part rallying cry, the slogan is the emotional counter weight to the prevailing idea that the people living in Brownsville are helpless – lost in a swirl of violence, low-paying jobs, lousy schools and bad health. Life in Brownsville is hard, and it can be dangerous, but the flip side to the battered pride of Brownsville’s “never ran, never will” is the hardcore determination that endurance in the end will be its own reward.
In a community survey conducted this past summer with 525 residents and representatives of CBOs in Brownsville and East New York, what surprised surveyors the most was how resilient the respondents were when asked about what they thought were the barriers to good health. They completely rejected the idea of that they were helpless, says Roger Green, executive director of the DuBois-Bunche Center for Public Policy at Medgar Evers College, which ran the survey in conjunction with a team of researchers from Pratt and MIT.
Instead, the respondents cited a host of suggestions for improving housing, and tackling unemployment and entrenched health care problems, like asthma and respiratory illness.
Some of the results were predictable, some were surprising: Sixty percent of the respondents cited violence and nearly 50 percent cited police misconduct as the top two stressors in the community. Only 30 percent thought the housing stock in the neighborhoods was “decent,” only 20 percent reported that the surrounding environment was “good” and a full 80 percent of the respondents reported that they thought that the community “does not respond well to stress.”
But rather than throwing up their hands at the problems, the respondents offered a range of possible solutions: from instituting a community chef program to help people to shop and cook healthy, to expanding the network of farmer’s markets, using hospital rooftops for urban farms and contracting with farms in upstate New York to bring in healthy produce to be distributed at food pantries and subway stations. Other ideas included expanding access to mental health services, therapy, yoga and meditation, as well as setting up community exercise groups and wellness training, to help residents avoid unnecessary trips to the emergency room.
“If we can employ young people to begin to do renovation in housing, where you have mold and mildew causing respiratory illness,” that’s a way to tackle a health problem and a social problem at the same time, says Green. If someone is unemployed and they have high blood pressure, being out a job is likely to exacerbate that. In a health enterprise zone – one of the suggestions of the survey – “we can draw down resources form the state Department of Labor in conjunction with the Empire State Corporation to help build a network of healthy urban farms,” he adds.
The survey respondents’ call for a holistic approach to solving the health problems of the city’s most disadvantaged neighborhoods comes as financial pressures mount on medical providers to find a different way of doing business.
Take the problem of avoidable hospitalization. Rates of avoidable or preventable hospitalization for conditions like asthma and diabetes are indeed much higher in neighborhoods like Brownsville and Mott Haven than in wealthier parts of the city.
According to a 2015 state DOH analysis of emergency room visits, city residents went to the ER at a higher rate than the rest of state: 369.85 and 297.11 visits per 1,000 persons, respectively.
Five years ago, the state DOH, under the auspices of Gov. Andrew Cuomo, convened a series of task forces to come up with recommendations on how to control Medicaid spending. Those recommendations formed the backbone of the Medicaid Redesign Team, whose proposals eventually led in April 2014, to New York State receiving an $8 billion waiver based on the proposed improvements to the state’s Medicaid system. The waiver, known as the state Delivery System Reform Incentive Payment, is supposed to improve access to care for Medicaid patients, control medical costs and reduce avoidable hospital admissions by 25 percent by 2019. DSRIP also calls for greater focus on population health and community-level approaches.
As part of the waiver process, DSRIP money is being allocated among 25 health care systems across New York State known as performing provider systems, or PPS.
Dr. Amanda Parsons, vice president of community and population health at Montefiore Health System, who has been working on DSRIP initiatives for the Montefiore Health System PPS, says that in practice, this has meant “focusing not just on the disease of diabetes, for example, but also making sure that we have some processes in place to do a better job of screening for the social determinants of health like housing and security, poverty and other stressors, and then linking people up to resources.”
Life Expectancy from Battery Park to Brownsville
A timeline of projected lifespans
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To that end, Montefiore, one of the eight PPS’s operating in New York City, has hired three certified diabetes educators — individuals trained to provide health education to diabetes patients – to improve health outcomes for people with diabetes. For Parsons, this is an example of progress: In the past, she says, similar services would not have been paid for with state funding and providing education for how to manage diabetes would remain the sole responsibility of physicians, even though, she notes, “we know from literature that patients don’t learn that well from their doctors.”
Parsons emphasizes the importance of local intervention, particularly in bringing changes to neighborhood environments that would make healthier lifestyles more accessible for residents. One initiative Montefiore is currently working on is an effort to change the types of foods available at bodegas across the Bronx. “We can explain to a person, you have to eat fruits and vegetables, but when they go home to their local environment, and all they have for several blocks is their bodega, and there’s no fruits and vegetables in their bodega, that’s a problem,” Parsons says.
Calls for a deeper partnership
Such an effort—working with bodega owners and coming up with alternatives to popular foods—is both time-consuming and costly, and for Parsons, highlights the need for hospital systems to strengthen ties with community-based organizations. Dr. Marilyn Fraser, CEO at the Brooklyn-based Arthur Ashe Institute for Urban Health, agrees.
“People that are trusted and have the relationships with community members can identify the community priorities better than someone that’s looking in from the outside,” she says. When it comes to increasing opportunities for healthy lifestyles in low-income neighborhoods, a large part of that, Fraser adds, is involving people familiar with the culture of a given community, which are likely people and organizations that already have roots there.
“When we’re talking about changing foods and behaviors, it’s something that takes a long time and oftentimes a grant will only fund a part of that,” she says. “We need to know in a culture what things people may eat—knowing what it is first of all, and then knowing how to provide a good substitute.”
Anthony Feliciano, Director of the Commission on the Public’s Health System, a community-based health advocacy organization, says both within the DSRIP process and in the state’s health system more broadly, community-based organizations have not been given enough of a place when it comes to planning and implementing projects. The CPHS is part of a coalition of 55 community-based organizations called Communities Together for Health Equity, which is lobbying for the state to devote specific funding to community-based projects in DSRIP. This is crucial, Feliciano argues, to better connect primary care providers with community members. “There’s no real infrastructure for that currently,” he said. “All the money is going into hospitals.”
Lisa David, president and CEO of Public Health Solutions, a nonprofit organization that conducts public health research and offers neighborhood services around the city, agrees that attention to social determinants and community-level work has not been given enough emphasis in DSRIP, and said she isn’t optimistic that will change as the project continues. Healthcare delivery, she says, is fragmented in ways that go beyond funding and beyond DSRIP specifically, and those issues make addressing the scope of factors that go into health difficult.
In one of Public Health Solutions’ neighborhood maternal health programs in Queens, for example, she explains, “we’re dealing with these young families, and to the extent that they need legal assistance or immigration assistance or there’s a domestic violence problem, we have very warm referral relationships with all these organizations in the community.
“But the fact remains, I don’t actually have any information about what services they’re getting because every program has HIPPA limitations on what information can be shared across the organizations. So, it’s imperfect by definition,” she says. “I don’t know if they get their problem solved, and that’s incredibly challenging.”
Dr. Anna Flattau is chief clinical officer at OneCity Health, the Health + Hospital performing provider system, the city’s largest PPS. She says fragmentation won’t be addressed until discussions around integrated healthcare delivery include more than just medical care. “When we talk about an integrated delivery system, we don’t just mean integrating primary care and specialists and the hospital and home nursing services,” she says. “We do mean that, but we also mean integrating social service providers whose work is essential to the health outcomes of our patients.”
A scramble for solutions
Which gets back to the cross-disciplinary insights from Roger Green’s survey. The question is whether these different streams of innovation—directives from the state on the way government funding will be structured, wisdom from communities and providers on how integrated health care ought to be with efforts to empower communities and make the city more just—can work within a healthcare system that is still primarily on treating the ailment of the moment, not the legacy of social wrongs.
“I come in for diabetes, but in my background, I need nutrition. I may not have health insurance. Am I being looked at as a complete person and offered all of those other types of services?” asks Denise West, deputy executive director of the Brooklyn Perinatal Network. “How does a person come into care at one location and get the other services that they need throughout the health care system?” she asks.
West says that the poor health outcomes that residents in north and central Brooklyn are still experiencing need to be understood within the context of both the social pressures in the neighborhoods – homelessness, poverty and unemployment—as well as the fragmentation of care: people not being able to get to the doctor, or the same doctor, or follow up with a specialist, because one can’t be found.
Connecting those fragmented dots, and finding and maintaining a funding stream for those organizations that work on the ground in communities and understand all the barriers to good health is a large part of Dr. Karen Nelson’s job as chief medical officer for the Maimonides Hospital-led performing provider system, known as Community Care of Brooklyn. There, Nelson is tasked with developing, implementing and ensuring ongoing oversight of the clinical and care management programs that encompass six hospitals in Brooklyn, 600,000 Medicaid beneficiaries*, 800 community-based organizations and 4,600 practitioners.
In terms of working with community-based organizations, “a big part of what we are doing is figuring out how to fund them,” says Nelson. With a state mandate to reduce preventable hospitalizations by 25 percent in five years, the 25 provider systems around the state are trying to use the funding to improve care in their communities, and set up a way to continue to pay CBOs for their work when DSRIP funding is over. As Medicaid moves away from fee-for-service payments to the new model of value-based payments, the challenge for all the community-based organizations is to figure out how to value what they do so they can continue to be reimbursed.
“We have over 800 organizations that are community-based organizations, they are part of the PPS, so part is this is how can everyone work together better?” says Nelson.
To that end, says Nelson, Community Care of Brooklyn PPS is looking to organizations that are working in the northwest and the southwest, who have figured out how to create payment structures for insurance reimbursement and who have come up with novel ways to connect patients to healthcare systems when there is little or no access to primary or specialist care.
What the hospital system looks like today “is not what it is going to look like in five years,” says Nelson, and even though hospitals are “huge” in the health care landscape, in reality, says Nelson, “patient care takes place in the community.”
There is a lot that can be done for people far from the reaches of a doctor’s office, says Nelson. “The worry is, what’s sustainable? CBOs could contribute a lot to health and we have to figure out” how to pay them to keep doing it, she says.
The overwhelming question now for health care in Brooklyn is how to set up a system where all the disparate elements can speak to each other, and create a monetary value for their work that can be reimbursed by insurance companies. Of the twin effects of Medicaid reimbursement transition as well as the election of Donald Trump, “it’s a bit of a crap shoot,” says Nelson. “We are at a moment that is not easy.”
With reporting by Janaki Chadha
* Correction: Because of an editing error, the original version of this article originally reported that this network included 300,000 doctors.