HLTH 2023: 3 Keys to Impactful Community-Centered Health Programs

This article is a reflection of remarks I shared at #HLTH2023 as part of a panel discussion on community centered approaches to population health and the integration of community-based organizations into the health care equation.

“Embracing a grassroots, community-centered approach to promote the health and well-being of populations is gaining significant traction. By focusing on initiatives like street medicine and localized efforts, we can start small and yet have a profound impact. What can we learn from the experiences and insights of individuals working on the ground and how can we put ourselves in their shoes? Integrating community-based organizations into the healthcare equation leads to a better understanding of the unique needs of the communities we serve. Through active community engagement and analyzing and implementing data-driven strategies, we can foster an inclusive healthcare ecosystem that addresses the social determinants of health and improves outcomes for all. As Mr. Rogers says, “Please, won’t you be my neighbor?” 

I had to chuckle when HLTH invoked a Fred Rogers quote to introduce our panel on how to best engage and work with local communities to improve overall health. He is one of the most famous sons of Pittsburgh, where Highmark is headquartered, and his enduring lessons of emotional intelligence, empathy, and curiosity about other people, are in themselves essential traits in impactful community-based work. Those traits, which he embodied in every episode of Mr. Rodgers, are what got children (and their parents) to trust that he cared about them and their development. Which brings me to my first and most critical key to success. 

Key #1: Trust is at the center of success (and failure) 

Everyone knows the proverb — if you want to go fast, go alone, if you want to go far, go together. But before anyone will go anywhere with you, you need a basis of trust. In many of the most at-risk and marginalized communities, intergenerational experiences of disinvestment, racism, and other forms of systemic disadvantage have left a chasm of trust. The health care “system” is not immune to that trust deficit, and the politicization and confusion around health information during the pandemic certainly didn’t help.   

In many black communities, the history of institutional racism on the part of the government and the healthcare system still reverberates in the disparities we see today. It has also resulted in a trust crisis that makes engagement difficult. According to a survey from the Kaiser Family Foundation, Black adults are 19% less likely than white adults to trust “doctors” and 14% less likely to trust “local hospitals”. 

Trust is barely better in many of the predominantly white and rural areas we serve. With the decline of key sectors like coal and steel, and the correlated closing of rural hospitals, we’ve also seen a decline in trust with these populations.  

Rebuilding trust requires a serious commitment that starts with elevating community partners, and reinventing our health infrastructure to better incorporate and recognize the value those groups create. Here are some of the things we’ve learned:  

Trust and Community Benefit Organizations: Not all relationships with community benefits organizations are created equal. There is certainly a time and purpose for philanthropy and corporate giving. But when we talk about community centered approaches to closing care gaps, or better yet, getting upstream to better understand and prevent those gaps from ever happening, creating longitudinal relationships with Community-Based Organizations (CBOs) who often have a deeper ability to connect with the populations we serve is key.   

Highmark Health , with our provider system Allegheny Health Network (AHN), a local faith-based organization called Project Destiny, and support from other partners has done exactly this. This collaboration, known as Thrive18, connects individuals and families to resources, breaking down barriers to health, and because of it was built on the basis of trust — has a 90% engagement rate with the people we serve. This video gives a feeling for how the community health workers use that trust. And that trust is helping members and patients take the important steps needed to improve outcomes and bend the cost curve.  

Trust between partners is earned over time. This happens by creating relationships and models that are mutually beneficial, and successfully merge the missions of each organization.   

Trust and Providers: People have trust in their doctors. We recognize that when we actively partner with providers to make referrals, engagement rates are higher. We also recognize the challenges providers face coordinating care across multiple payers and the competing incentives that are burdensome in being able to identify and address barriers to health.  

Value-based care arrangements advance trust, which is one way to support health care professionals in providing the best care to our members and their patients.  

Cultivating and hiring talent from the wide range of communities we serve is another key element of building trust within the provider space. People are more likely to trust their provider and have a better experience when they share a similar identity with them. That is one reason why our hospital system just expanded a talent attraction program to increase the number of diverse candidates for AHN employment opportunities across various health fields.   

Finally, in many of the community-based interventions we support across various populations and SDoH domains, community health workers are the glue to engage and connect individuals to care. Our experience does not seem to be unique; one study indicated every dollar invested in community health care workers by Medicaid payers resulted in a $2.47 return on investment. Community health workers are culturally attuned, because they are from the community and understand all kinds of barriers to health, which results in higher levels of trust. Community health workers are central to a variety of our models — as direct employees of our health system, employees of our provider partners, and sometimes through funding and support for community organizations to hire community health workers.

Trust and Government: In an era of constant threats of government shutdowns and record low approval ratings for elected officials, this seems like an oxymoron. But we are very fortunate to have some forward-thinking public health officials in the communities we serve, and we’ve forged productive working relationships with our local representatives over the years. For example, the departments of health and human services in Allegheny County, Pennsylvania, have been excellent partners in data sharing to better evaluate, measure, and consistently improve community health programs. No one sector can possibly address health disparities and social determinants alone, but as the largest health care consumer in the country by an order of magnitude, government has a massive stake in advancing evidence-based programs. Furthermore, the government can earn back some of that trust by consistently and transparently cooperating with civil society and industry on these issues.  

At this point, I trust that you are ready for me to move on to the second ‘key to success’.  

Key #2: Programs must be informed by data and lived experiences of the community  

Highmark Health serves members within a unique footprint of urban, suburban, and rural areas in Pennsylvania, West Virginia, Delaware, and New York. We recognize that each of these markets present varying needs when it comes to social, behavioral, and physical health, and tailor our response in each area accordingly.   

British mathematician Clive Humby famously said, “data is the new oil,” due to both its importance in the modern economy and the fact that without being refined and processed into something useful, it is not inherently valuable. We leverage a robust set of public data sets, as well as our own member and claims data to understand social vulnerability and presence of chronic conditions in our communities. We are maturing to use specific data inputs to direct care interventions for non-medical drivers of health.  

However, that data alone can’t give us the rich, lived experience of the neighborhood. It doesn’t necessarily tell us, “Well since that grocery store closed down last year you either have to take the bus across town or go to the bodega.” It won't tell you, “When that bus route changed, I can’t get to my doctor, so I just go to the ED.” Or “Everyone knows Rev will help you out if you have some problems — you just go see them.” Having established community partners is invaluable to gaining those incites that help us apply human centered design principles and build trust around any proposed program or intervention.   

We can use data to identify and prioritize certain problem sets, but the solutioning phase must marry those data insights with deep human experience from the communities we hope to serve to be effective.  

Key #3: One size does not fit all   

The very fact that we are having this conversation points to the reality that just because an approach is effective in one community or with a certain member population, does not mean it is scalable across the board, or even to members with the same surface level demographics. While there is endless buzz about how technology is going to disrupt the health care sector (which we need), things frequently go wrong when tech evangelists view the “health care sector” as one giant market opportunity and fail to understand it is hundreds and hundreds of micro-markets with different incentives and populations.  

Just because both Pittsburgh and Buffalo are rustbelt cities that have long histories of massive health, social, and economic disparities for their Black communities does not mean the challenges and lived experience are the same, and so the solutions will necessarily be different as well. For example, Buffalo’s relationship with food insecurity is further complicated by the trauma of the racially motivated massacres that occurred at a Buffalo supermarket in May of 2022. Whereas in Pittsburgh, the innovation and technology economy boom that is propelling the city into a leadership role in the modern economy has exacerbated many of the long-standing economic disparities in the region. Those are just examples at the city level; community health initiatives require that kind of local understanding at the census tract level. 

That is why I titled this article “keys to success” and not “a playbook” for success. As much as we strive to develop scalable programs, we also have a deep understanding and are committed to adjusting to meet the needs of the communities we serve.  

Taking these keys to success all together, I am reminded of another Fred Rogers quote: “What really matters is helping others win, too, even if it means slowing down and changing our course now and then.”   

Communities, health systems, government, employers — everyone wins in a world where we have better and more equitable community health. But getting there requires slowing down to adapt to what the data, our partners, and our members are telling us and build the foundation of trust that is the bedrock of any successful community initiative.