6

Investing in People and Partnerships to Create Healthy Communities

The final panel session, moderated by Catherine Baase of The Dow Chemical Company (Dow), focused on engagement of the business sector in community health. Although the discussion on previous panels focused on applying a health lens to the business sector, Baase noted the need to also apply a business lens to the health sector. Jon Easter, senior director for public policy at GlaxoSmithKline (GSK), described how the company has redefined its philanthropic focus from access to health care, to access to health. Vera Oziransky, project manager at The Vitality Institute, discussed the findings from a forthcoming report on engaging businesses and community groups in effective cross-sector collaboration. Highlights from this session are provided in Box 6-1.

GSK: BUILDING HEALTHY COMMUNITIES

GSK is a global health care company that discovers and develops medicines, vaccines, and consumer health care products. GSK’s mission is to help people do more, feel better, and live longer, Easter said. To achieve this mission, GSK recognizes that it must address health challenges where they start—and that is often outside the doctor ’s office and in the communities where people are born and raised, live and work. Easter described how GSK has moved upstream—beyond medicine and into communities—to address the complex and interconnected individual, environmental, and social determinants of health.

Redefining GSK’s Philanthropic Focus

To better understand what it means and what it takes to build a healthy community, GSK leaders set out on a national listening tour, hosting town halls in Denver, Colorado; Philadelphia, Pennsylvania; and St. Louis, Missouri; issued a national survey; and convened a national advisory council.

Easter shared some findings:

• The national survey found that Americans believe a variety of community factors are very important to their health, including parks, education, and healthy food options. People who valued these community factors the most had the least access to them.

• The community conversation in Philadelphia revealed the importance of committed leadership and broad engagement in improving community health.
• The community conversation in St. Louis made clear that successful collaborations start and end with data.
• The community conversation in Denver uncovered that there are already several successful interventions under way, but GSK and other businesses have an opportunity to help foster deeper collaboration and greater “collective impact.”
• The national advisory council of health care leaders challenged GSK to go “beyond the check” and bring more business resources, such as the skilled volunteer service of GSK employees, to bear in charitable partnerships. Easter cited the GSK PULSE Volunteer Partnership as an example. This program provides up to 100 high-performing GSK employees each year with as much as 6 months of paid leave to serve as volunteers full-time at a nonprofit organization that is addressing health challenges.¹

The lessons throughout the national survey, the listening tour, and the national advisory council confirmed for GSK this connection between health and community. Easter said the more GSK understands this connection between health and community, the more it can work to improve community health. Easter referenced the “What Works for Health logic model,” developed by the Robert Wood Johnson Foundation (RWJF) and the University of Wisconsin Population Health Institute as part of the County Health Rankings and Roadmaps.² This logic model makes clear that 80 percent of our health is influenced by factors outside the physician’s office, including factors upstream in communities.

Easter explained how all of these insights have influenced the dramatic redesign of GSK’s philanthropic focus in the United States, from access to health care, to access to health. GSK is now committed to building healthy communities and is doing so through its GSK IMPACT Awards and Grants.

GSK IMPACT Awards and Grants

The GSK IMPACT Awards program is a long-standing charitable program, Easter said, that was initially focused solely on access to care. The scope of the program was expanded and suddenly the company was

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¹ See http://gskpulsevolunteers.com (accessed September 17, 2015).

² See http://www.countyhealthrankings.org/roadmaps/what-works-for-health (accessed September 17, 2015).

working with organizations it had never worked with before, on new issues such as healthy eating, active living, and affordable housing. The company also set up a new charitable grant program, the GSK IMPACT Grant, to partner side by side with organizations on a shared vision of community health and to empower their work.³ Easter emphasized that the grant program was designed not to layer new programming on nonprofits, but to broaden and deepen proven interventions already under way, and to foster greater collaboration. It is a bottom-up approach guided by the Collective Impact model⁴ outlined in the Stanford Social Innovation Review by John Kania and Mark Kramer of FSG (Kania and Kramer, 2011).

Easter described the work of the first GSK IMPACT Grant winner, a network of organizations in Denver, Colorado, with a shared vision to drive healthy eating and active living for low-income youth in three Denver neighborhoods. The network worked in a mutually reinforcing fashion, and was continuously communicating, which Easter noted are hallmarks of the collective impact approach. What set this effort apart, he said, was the way they engaged the local teens in leadership development, letting them come up with ideas that would attract their peers into the recreation centers. With the grant from GSK, they were able to fund the teens’ ideas and bring the programs to life. At several of the recreation centers, the participation rate has increased 1,000 percent. Denver Parks and Recreation is now exploring how to scale up this youth leadership approach across the city at other recreational centers.

Easter shared two key insights from this process. First, it is not merely about collaboration; it is about collective impact. There needs to be a structural framework that provides backbone support, continuous learning, and mutual reinforcement, he said. Second, a youth engagement strategy is essential. Instead of just serving young people, engage them as leaders in making their communities healthier.

Care Coordination

Although addressing community-based factors is critical for improving health outcomes, and GSK is doing that through its charity, said Easter, it is also important to address clinical care challenges, especially access to care and quality of care issues. Easter explained how GSK is working

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³ See http://us.gsk.com/en-us/about-us/us-community-partnerships/gsk-impact-grants (accessed September 17, 2015).

⁴ The five conditions of collective success are (1) a common agenda, (2) shared measurement systems, (3) mutually reinforcing activities, (4) continuous communication, and (5) backbone support organizations. For more about the collective impact approach and philosophy, see http://ssir.org/articles/entry/collective_impact (accessed October 7, 2015).

on this clinical care front through a care coordination initiative. Easter noted the lack of coordination and the fragmentation of care in the current health care system. Care is reactive and episodic, and often leaves patients confused, he said. New health care models, including care coordination models, are being validated and implemented. He shared an example of one such model in North Carolina, where GSK has a corporate campus.

More than a decade ago, Community Care of North Carolina (CCNC) was building a medical home infrastructure before most people really knew what patient-centered medical homes were, Easter said. They built local community-based support functions across all 100 counties in North Carolina. Social workers, care managers, behavioral health experts, psychiatrists, pharmacists, and others were pulled together to support providers and hospitals in a care coordination network. An analysis by Milliman revealed nearly $1 billion in Medicaid cost savings for the state of North Carolina between 2007 and 2010 through this care coordination model (Cosway et al., 2011).

As a community partner in North Carolina, GSK decided to have its employees engage in a care coordination model. It has been nearly 5 years, and GSK has been very pleased with the impact on the quality of care for employees, Easter said. GSK employee participation is also helping to drive the critical mass for care coordination, and helping to define how to drive and improve care coordination.

CCNC approached GSK for help to proactively identify populations at risk for negative outcomes. Data scientists and statisticians from GSK worked with the CCNC population health experts, and built predictive analytics to identify at-risk patients, specifically, those at risk for significant drug therapy problems that would result in hospitalizations. The tool, called Care Triage, was tested in several care settings within North Carolina as well as other states, and its use continues to expand. Easter pointed out that the development of this tool was borne out of trust and mutual engagement.

Data generated using the tool showed that patients with chronic diseases were seeing their primary care physicians about twice per year, but were visiting their community pharmacy 30 times each year. Because a population health strategy should engage patients where they are, said Easter, this discovery led to the building of a community pharmacy enhanced services network. Pharmacists are used to dispensing medications, but are not regularly providing enhanced medication management services, he noted. CCNC was awarded a $15 million federal grant to study community pharmacy in the medical neighborhood, and to proactively identify vulnerable patients at risk to facilitate these new population health activities. The University of North Carolina Eshelman School of Pharmacy has now come on board as a partner, managing the

evaluation of this grant, helping to provide the best practices, and driving progress in the pharmacy networks.

Aligned objectives and trust are both critical for this kind of work, Easter concluded. This is a journey, he said, and “we must learn to walk before we can run.”

BEYOND THE FOUR WALLS: COMMUNITY AND WORKFORCE HEALTH

Oziransky discussed the findings from a forthcoming report by The Vitality Institute.⁵ Over the prior year, The Vitality Institute conducted quantitative and qualitative research, funded by RWJF, to make the linkage between workforce and community health, understand existing community–employer partnerships, and determine what strategies employers use to improve the health of communities and their long-term profitability.

Employers are struggling to meet the burden of rising health care costs, Oziransky said. The majority of chief financial officers (60 percent) and human resources professionals (70 percent) report health care costs as a main financial concern. For example, Starbucks recently reported that they spend more on employee health care than they do on coffee, while Chrysler, Ford, and General Motors reported that they spend more on the health care of their workforce than they do on the steel they use to make cars. More than 90 percent of large employers offer workplace wellness programs, but few link these programs to the community. This is a major barrier to effective workplace health promotion, she said.

Making the Linkage Between Workforce and Community Health

The Vitality Institute report includes case studies of companies that are making the link to community health promotion and investing “beyond the four walls.” Bath Iron Works (BIW), a subsidiary of General Dynamics, is a ship manufacturer and is one of the largest companies in Bath, Maine. They understood that to promote the health of their workforce, they had to extend their health promotion strategies into the community. In partnership with L.L.Bean (another large employer in Bath, Maine), the two companies invested in diabetes prevention programs for their workforces, dependents, and community members. GE is another company, like BIW, that understands that the health of their workforce

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⁵Beyond the Four Walls: Why Community Is Critical to Workforce Health was released on July 28, 2015. See http://www.thevitalityinstitute.org/projects/community-health (accessed July 31, 2015).

mirrors the health of their community. When interviewed by the Vitality team, Alan Gilbert, director of Global Government and NGO Strategy, GE healthymagination, said that “GE was spending upward of $2 billion on health care costs. We knew we had to go outside the workplace to create lasting change, and this meant partnering with stakeholders in Cincinnati, where we were spending a significant portion of our health care dollars and also had some of our largest manufacturing plants.”

Community health promotion can address drivers of health beyond the workplace through community policies that promote health, address the social determinants of health and the built environment (e.g., housing, green space for exercise, access to healthy food), and drive social networks, norms, and values toward health, Oziransky said. Lack of attention to community health will work against any investments made in the workplace, and will undermine efforts in workplace health promotion.

Oziransky noted that while local health data are frequently used in discussions in the public health sector, they are rarely used when trying to engage employers. Health varies tremendously across U.S. counties (e.g., the prevalence of obesity). Health also varies across workforces. For example, workers in manufacturing, transportation, public administration, and health care sectors have higher risks for obesity and hypertension. Workforces in the arts, entertainment, recreation, and accommodations and food services have lower health risks for obesity. Although health clearly varies across counties and workforces, the relationship between workforce sectors and community health is not well understood.

For quantitative analyses, Oziransky and her colleagues looked at health data from more than 3,100 counties, including smoking rates, obesity, physical inactivity, and diabetes, as well as death rates from cardiovascular disease.⁶ These data were then correlated with the percentage of employment across sectors in those counties. The data show that four employment sectors are more likely to be located in counties with poor health: manufacturing, transportation and warehousing, public administration, and retail trade. Oziransky pointed out that these are some of the same sectors that are known to have high-risk workforces, which she said demonstrates the linkage between the health of the workforce and the health of the community.

Overlaying a map of obesity prevalence across U.S. counties with a map of manufacturing sector concentration, for example, highlights the

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⁶ Oziransky and her colleagues used 2014 County Health Rankings data to specify the proportion of adult county populations who were obese, physically inactive, smokers, or diagnosed with diabetes. Because the prevalence of cardiovascular disease is not available at the county level, they relied on the 2008-2010 Centers for Disease Control and Prevention data on county rates of death due to heart disease for adults more than 35 years old as a proxy for the heart disease burden.

association (see Figure 6-1). Oziransky emphasized that correlation is not causation, and this cross-sectional analysis cannot determine whether these sectors are actually causing these outcomes in those counties. A study of longitudinal data is needed, she said, to elucidate these observed associations further so that targeted interventions can be developed.

Oziransky and her team also interviewed more than 70 business leaders and community groups over the course of the past year, and identified three non-mutually exclusive strategies that businesses are using to invest in the health of their communities and the sustainability of their business. Oziransky described three strategies relative to a company’s profit and loss statement. On the low end relative to income is strategic philanthropy, which is tax exempt. On the high end relative to profit and loss is a shared value strategy. This is a core part of the business, she noted. In the middle of the profit/loss spectrum is a corporate social responsibility strategy. Oziransky elaborated on the shared value strategy.

Shared Value

Goals of shared value include boosting competitiveness and strategic market positioning (Porter and Kramer, 2011). The company is producing products and services that will benefit society, either through improving health or the social determinants of health. At the same time, said Oziransky, the company expects these products and services to be profitable and that they will drive savings in the form of lower employee health care spending.

One example of shared value is an extended corporate health strategy, such as that undertaken by BIW. They took their strategy to promote health within the four walls of the workplace and extended it to the community, investing where their employees live and work. As mentioned earlier, BIW also understood the overlap between L.L.Bean’s population and their population, particularly because spouses often worked at each one. BIW partnered with L.L.Bean to invest in the health of their workforces, their dependents, and their networks in the wider community. BIW has calculated the net projected savings it hopes to accrue in the next 5 years from enrolling high-risk employees in the diabetes prevention programs. Although the initiative only started in 2014, BIW has already observed that employees enrolled in these programs have lost about 7 percent of their body weight, Oziransky said.

Challenges in Practice

The Vitality Institute report also describes the challenges identified in linking workforce and community health. Many companies interviewed

had business divisions that were operating in silos, which reduces opportunities for impact evaluation, Oziransky said. In some cases, one division was implementing the intervention in the community, while other divisions in the company actually had the health care, engagement, and productivity data. By not linking their datasets, the company divisions were unable to see the impact on the community, and how that translated to the workforce and the business.

The community groups interviewed were doing good work on engaging businesses on workplace health promotion, but they rarely engaged businesses in expanding beyond the four walls of the workplace. Oziransky said this impedes the creation of shared value between businesses and the community.

Another challenge is that many of the companies interviewed were only using short-term, process-oriented evaluation frameworks, resulting in a failure to attribute health improvement to interventions. Oziransky said it is critical to know whether the programs being implemented are achieving their goals, but it is also necessary to understand the impacts in the community and on the business so it can be determined what works, and scale up going forward.

Transforming the Current Landscape

In conclusion, Oziransky said that to transform the current landscape, employers need to understand that to a large extent, the health of their workforce mirrors the health of their communities. Employers need to partner with stakeholders in the community to extend their corporate health strategies beyond the four walls of the workplace. Oziransky said that employers also need to evaluate the impact of their initiatives. They can partner with local research institutions, universities, or nonprofit local hospitals that have conducted community health needs assessments, she suggested. If a community is already working with local employers on workplace health promotion, said Oziransky, the community should push to engage them beyond the four walls of the workplace.

DISCUSSION

Participants discussed further the engagement, or lack thereof, of companies in policy and advocacy. There was also discussion of health in all business practices, in particular, raising awareness of what activities can impact health, and bringing together the various parts of a company engaged in activities that impact health. Discussion also explored whether increased employee productivity might be part of the business case for a corporate focus on health.

Business Participation in Public Policy

George Flores of The California Endowment raised the issue of business representation in public policy. Although some companies choose not to actively participate in public policy debates for a variety of reasons, he said it would seem to be in the interest of business to have a point of view and, in many cases, to take a position on or advocate for those policies that would improve the health of their workforce and the communities they serve. Easter agreed, and said that GSK is active in public policy. The company is working upstream to ensure that, as the country moves toward value-based care, it is understood that cost has to be a component of achieving value, and that quality measures are essential in new models of care and payment. Other policy areas the company is focused on include how to best enhance delivery and prevention across large populations. He noted that there is also policy work done at the trade group level (e.g., Biotechnology Innovation Organization, Pharmaceutical Research and Manufacturers of America). Oziransky said the interviews conducted by her team revealed that for some multinational companies, the policies in some countries where they operate were actually opposed to the workplace policies the companies were trying to implement (e.g., policies about tobacco use). Baase added that Dow is involved with the advancement of population health in general, and with policy and advocacy. She suggested that many corporations might believe they are not sufficiently informed to participate in policy debates. A role for partnerships and collaborations could be to help partners understand the key issues and messages, and to develop policy advocacy strategies.

Rubin asked about the willingness of companies to put their money and their power behind various policy and environmental initiatives (e.g., ballot measures; administrative regulations; local, city, or state initiatives). Oziransky said that companies interviewed by her team were not asked specifically about any work on policies. Responses to other questions asked did reveal that companies are seeking to make an impact on policies. For example, some companies were working with local stakeholders on education issues, understanding the connection between education and their workforce pipeline.

Jeffrey Levi of Trust for America’s Health observed that large pharmaceutical corporations such as GSK have reach across the entire health care system, including relationships with individual providers. He suggested that companies could invest in educating those within the health community, as well as the public, about population health and the value of business engagement in community health. Easter responded that pharmaceutical employees do work to educate providers, pharmacists, care managers, and others, but these activities are highly regulated by law. Promotion and education must remain siloed, and salespersons on

office visits cannot engage in discussions about issues such as policy development or philanthropic activities. GSK is certainly focused on the importance of policy, collaboration, and aligned objectives to create and drive upstream factors that lead to better health. This is why, he added, the company is participating in activities such as this Institute of Medicine workshop.

Health in All Business Practices

Raymond Baxter of Kaiser Permanente highlighted the need not just for a health in all policies approach, but a health in all practices approach (products, supply chain, conditions of employment, environmental impact on the community, impact of pricing, etc.). He recalled the presentations about businesses that are changing their practices to produce health (see Chapter 3).

Based on her interviews with companies, Oziransky said that a company’s shared value strategy often comes together with its corporate social responsibility strategy. There are numerous ways in which businesses are looking within the four walls of the company to evaluate what they are doing or producing, and how that impacts their communities. Many of the companies interviewed were engaging with communities to help transform those communities, and some of those companies, particularly the manufacturing companies, were also trying to change their practices. Several food manufacturers, for example, were working to transform the community to create demand for healthier products, and at the same time, working to reformulate their products to be healthier and meet those demands. Technology companies interviewed were considering how to provide services that meet the health needs of the communities. For example, Qualcomm’s Wireless Reach Initiative provides wireless access to people in rural and underserved areas, and the company has partnered with the National Institutes of Health to evaluate the outcomes of this new connectivity on health and health care.

In some cases there is a recognition across an organization that health is a broader construct, and that corporate strategy around health has numerous touch points, Baase said. Often, however, anything related to health is referred to whomever is in charge of health care for that company (e.g., human resources), while other parts of the company handle activities such as corporate giving, social responsibility, education, or sustainability. Companies may be engaging in activities that contribute to population health, but they may not be identified as such, or may not even be aware that they are contributing. There is an opportunity to stimulate cross-fertilization of these activities within companies, she said, and to raise awareness of what contributes to health (i.e., broaden the health

lens in the business community). Baxter agreed, and stressed the importance of putting somebody in charge within businesses of making sure that everybody who needs to be engaged is engaged. He also suggested that experts in population health have an obligation to help businesses understand what levers they can influence, and which levers would have the greatest impact on population health.

Health and Company Productivity

Maggie Super Church, an independent consultant, observed that much of the discussion about making the business case has focused on cost savings, either short or long term, through a variety of interventions. She asked if companies are also considering the relationship between health and productivity. She noted that a recent publication suggested that 20 minutes of walking outside during the middle of the day had measurable impacts on productivity for the balance of the day for that person. This requires, of course, that one have half an hour for lunch, and a decent place to go walking. Easter said the GSK initiative in Denver, for example, is a collective impact model looking at individual outcomes, organizational outcomes, and community outcomes. Community outcomes include holistic changes in the community, such as adding more sidewalks or recreation areas. Oziransky suggested that assessing the connection between health promotion activities and productivity should not be challenging. Companies could, for example, tie together data on employee engagement and productivity with data from wearable activity-tracking technology.

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