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6 Upstream: Changing Environments, Changing Policy Session moderator Lourdes Rodriguez of the Dell Medical School at The University of Texas at Austin introduced this session with a focus fur- ther âupstreamâ on opportunities for changing environments and policies as a way to improve population health. Highlights from the two presenta- tions and subsequent discussion are provided in Box 6-1. POLICY AND ENVIRONMENTAL CHANGES TO IMPROVE HEALTH IN KLAMATH COUNTY, OREGON Jennifer Little of Klamath County Public Health in Oregon began her presentation with a brief overview of Klamath County. As she explained, Klamath County is a rural county about the size of Connecticut with about 66,000 residents. It is located in south-central Oregon near the California border. While historically Klamath County was a logging com- munity, the logging industry is no longer thriving, leading to high rates of poverty and a lack of living wage jobs. The county is newly focused on reinventing itself through recreation and renewable energy. The popula- tion is 78 percent white, 12 percent Hispanic, 4 percent Native American, and 4 percent mixed race, with nearly one in five people living in poverty. Little stated that Klamath County is a health professional shortage area that struggles to retain health professionals. The lack of availability of clinical care makes it even more important to prevent chronic diseases and other illnesses. According to Little, Klamath County has done a lot with limited resources, relying heavily on partnerships and aligning resources in ways that maximize funding and staff capacity. 43
44 MODELS FOR POPULATION HEALTH IMPROVEMENT BOX 6-1 Key Points Made by Individual Speakers and Participants â¢ K lamath County, in rural Oregon, has engaged in multiple partnerships and ini- tiatives focused on improving healthy food access, physical activity, tobacco control, educational attainment, and access to health care. (Little) â¢ Academic medical centers can use their respected voices to engage in up- stream efforts to improve public health through educating decision makers, convening the medical community, and visibly stimulating policy change. (Cofer) â¢ The University of Texas MD Anderson Cancer Centerâs engagement in a statewide Tobacco 21 policy in Texas provides a model for other academic medical centers to influence population health beyond their institutions. (Cofer, Hawk) â¢ Compelling evidence, stories, and relationships are essential for advanc- ing and implementing effective public health programs and policies. (Cofer, Hawk, Little, Rodriguez) â¢ Academic health centers must consider the political environment and local context in selecting health policy proposals that they will promote or endorse. (Hawk) â¢ Federal agencies could support or incentivize academic health centers to make an increased commitment to community action via regulations or fund- ing. (Hawk) Klamath Countyâs focus on policy and environmental change began in 2012, when for the second year in a row the county was ranked at the Âbottom of the state in the County Health Rankings. Little noted that the county continues to be near the bottom. This ranking served as a call to action for the âcore fourâ major health care players in the area: (1) the public health department; (2) Sky Lakes, the hospital system; (3) Klamath Open Door, the federally qualified health center; and (4) Cascade Health Alliance, the local Medicaid provider. To address the problem, the core four created a joint community health assessment and community health improvement plan. Each iteration of the plan since has been more focused and has involved more community partners. The Healthy Klamath Coali- tion was formed, which includes cross-sector representation from law enforcement, schools, local elected officials, the health care industry, and social services, Little explained. As a result of their efforts, in 2018 Klamath County became a ÂRobert Wood Johnson Foundation Culture of Health prize winner. Little pointed out that even though Klamath County is still near the bottom of the health rankings, the county is working toward better outcomes for all residents.
UPSTREAM 45 Little described several of Klamath Countyâs health initiatives. The county has been particularly focused on improving food systems. As she explained, the Blue Zones Project health improvement framework recog- nizes that people spend the majority of their time within 5 miles of where they live. Such areas became the target for food system improvements. Klamath County wanted to take advantage of being an agricultural com- munity and ensure access to products produced locally. The local food bank created an initiative called the Produce Connection, which had the initial goal of distributing 60,000 pounds of fresh produce throughout the community. The program was so successful that the following year they moved 600,000 pounds of produce. In 2018, the program distributed 1 million pounds of fresh produce through multiple distribution sites, including health care clinics, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) offices, job training program sites, and parks. In addition, as Little explained, a food systems committee was established and the Klamath Farmers Online Marketplace was created, which operates as an online farmersâ market in which producers such as rÂanchers, farmers, and beekeepers post their available products on a weekly basis and consumers reserve items for pickup. The county has a goal of making the marketplace more accessible to low-income residents. Supplemental Nutrition Assistance Program participants are able to use their benefits, although only a small number are taking advantage of the opportunity. The county is also considering how to increase fresh, healthy foods in its correctional facilities. The Klamath Promise, Little outlined, is an initiative focused on increasing high school graduation rates. She noted that the county has poor graduation rates, largely because of chronic absenteeism. Some of the absenteeism, she pointed out, may be caused by health problems such as lack of dental care, illness, or parents who are unable to take time off from work to take their children to the doctor. The initiative is focused on reducing barriers to going to school, promoting high school graduation, or attainment of a GED. Little explained that the health department prioritized educational attainment because of its importance for health outcomes. Klamath County has also engaged in changing tobacco control policy. As Little explained, the county has expanded access to tobacco cessation resources, is considering how to prevent youth from initiating tobacco use, and creating tobacco-free environments, including tobacco-free gov- ernment properties, fairs, and parks. The county is also working on creat- ing a tobacco-free downtown, although they have received some push- back from residents. Efforts to require tobacco retail licenses, which allows the government to regulate retailers and reduce sales to youth, have been successful. Little noted that because about one in three tobacco retailers
46 MODELS FOR POPULATION HEALTH IMPROVEMENT had been found to be selling to youth, tobacco retailer education and enforcement is a priority. The county aims to change the built environment to create more places for people instead of cars. For example, Little described, the county passed a complete streets policy and is working to improve connectivity of existing walking and bicycle routes. In addition, the mayor created a â10-Minute Walk Campaignâ with the goal of ensuring that all county residents are within a 10-minute walk to a park. The local law enforce- ment has partnered with public health in improving park safety, and the hospital and Medicaid provider have invested tens of thousands of Âdollars to beautify and improve use of the parks. Little concluded by describing a partnership between the public health department and the health system. The Oregon Health & Science University opened a rural campus in Klamath Falls, which includes a medical residency program and clinical students who complete rotations in the community. The program has increased access to health profes- sionals including physician assistants, nurse practitioners, dietitians, and pharmacists, who also become involved in community health projects. Little expressed hope that the program will encourage some of the stu- dents to want to practice in rural areas like Klamath Falls. CHANGING THE ENVIRONMENT TO PROMOTE HEALTH OUTSIDE THE FOUR WALLS OF THE MD ANDERSON CANCER CENTER Ernest Hawk and Jennifer Cofer of the University of Texas MD ÂAnderson Cancer Center spoke about how their large cancer center is attempting to advance population health outside of the walls of its institution. MD Andersonâs Cancer Control Strategy Hawk began by explaining that MD Anderson is a traditional aca- demic medical center involved in research, clinical care, and the education and training of future medical providers. However, for the past 40 years, the organizationâs mission has included a commitment to cancer preven- tion and control. To fulfill this part of its mission, MD Anderson dedicates about $25 million per year to prevention research, provides clinical pre- ventive services in about 50,000 patient visits per year, and trains about 200 future health care professionals at a time. In addition, the organization is working to more simply define cancer control in language that can be understood by all 22,000 employees and to better execute its strategy. As Hawk described, MD Anderson defines cancer control as Âevidence-based actions in three domains to effect meaningful, lasting,
UPSTREAM 47 and measurable improvement at the population level outside of their clinical population. The three areas of action are policy, public and profes- sional education outside of the institution, and services in the community beyond the institution walls. One of MD Andersonâs priorities outside the walls of their institu- tion is reducing tobacco use, the leading cause of preventable death, disability, cancer incidence, and cancer mortality in the state of Texas. In addition, as Hawk highlighted, tobacco use is a modifiable risk factor that can be controlled with increased funding and resources. Therefore, MD ÂAnderson has committed to using its resources and reputation to elevate the importance of reducing tobacco use both on its campus and in the surrounding community. Hawk explained that to determine how MD Anderson would engage in tobacco control, 18 faculty members and staff with relevant exper- tise were convened, resulting in a lengthy document outlining evidence- based actions that had been taken by other tobacco control leaders at the population level. MD Anderson established three goals similar to those of the World Health Organizationâs (WHOâs) Framework Convention on Tobacco Control (WHO, 2003). The goals are (1) reduce the preva- lence of tobacco use at the population level, particularly among youth; (2) reduce the proportion of nonsmokers exposed to secondhand smoke; and (3) increase quit attempts by existing smokers. To implement programs that address these three goals, MD ÂAnderson relied on both internal research and the broader evidence base. The orga- nization decided to operate at three levels: within its own institution, within its state and local region, and outside the state. Hawk concluded by describing the organizationâs broad approach to addressing tobacco control. This includes extension of a cessation program to providers out- side the institution that has trained about 400 individuals. It also included work to establish tobacco-free policies in the 14 institutions across the University of Texas system. Previously, three of the campuses had no tobacco policy. MD Andersonâs Engagement in Texas Tobacco 21 Cofer described MD Andersonâs role in the Texas Tobacco 21 initiative as an example of how the cancer center has engaged in policy work. She noted that Tobacco 21 is a nationwide campaign to raise the tobacco sales age to 21, based on evidence stemming from a 2015 Institute of Medicine (IOM)1 report that predicted such a policy would save lives, reduce lung 1 As of March 2016, the Health and Medicine Division continues the consensus studies and convening activities previously carried out by the Institute of Medicine (IOM).
48 MODELS FOR POPULATION HEALTH IMPROVEMENT cancer, and reduce deaths (IOM, 2015). MD Anderson and other part- ners established and worked in a coalition for several years to educate lawmakers on the potential impact of a Tobacco 21 policy in Texas after similar legislation had been passed in other states. After a failed 2017 attempt at a statewide policy, work began at the local level in San Antonio and surrounding areas. This involved forming a Texas Tobacco 21 coalition in partnership with other advocates. As a state institution and cancer center, MD Anderson was a respected voice, but restricted to serving in an educational capacity as a non-lobbying organization. Hawk provided testimony at committee meetings and other subject-matter experts met with legislators to educate them on the poten- tial impact of the policy. As Cofer explained, for MD Anderson to weigh in on a high-Âprofile, impactful policy such as Tobacco 21, the organization had to have approval from its leadership, including the president, the government relations department, and the compliance and ethics division. Support for the policy also had to be cleared by the University of Texas System and Board of Regents, and it was adopted as one of MD Andersonâs legislative priorities. The University of Texas System became a member of the coalition. Cofer also outlined the many actions MD Anderson took to expand the Texas Tobacco 21 coalition from 13 to 100 partners in 2 years. As she explained, the coalition included diverse membership, with public health groups leading the advocacy efforts. Other partners included childrenâs health groups, health systems, medical societies, statewide health and wellness associations and coalitions, the state association of business and local chambers of commerce, institutes of higher education, school districts, institutes for mental health and substance use, drug and alcohol coalitions, and health departments. Cofer noted that the nontraditional partners were particularly powerful messengers. As a state academic health center, MD Andersonâs role was to engage health systems and coalition partners, participate in education at the community level, sup- port press conferences and other visible activities and events with mem- bers of the medical community when asked, and garner the support of the medical community to promote the policy. With respect to challenges, Cofer stated that working on a tradition- ally progressive public health policy in a conservative state led to dif- ficulty in moving the policy through the legislative process. She noted that having champions among conservative leaders who were committed to reducing death and disease from cancer was particularly important. Reaching consensus on policy language among all coalition partners was also challenging. Ultimately, the Texas Tobacco 21 bill passed in May 2019 and was signed by the governor in June 2019, although Cofer acknowl- edged that some concessions were made in getting the bill passed.
UPSTREAM 49 In closing, Hawk noted that he was previously a program director at the National Cancer Institute, and federal agencies such as the National Institutes of Health and the Centers for Disease Control and Preven- tion can promote academic centers, such as cancer centers, making an increased commitment to community action. Hawk suggested that this could be done through regulations or funding. AUDIENCE DISCUSSION Rodriguez opened the audience discussion by asking the panelists to describe a situation in which relationships between organizations or sec- tors helped to advance or hinder their public health work. Little responded that relationships are particularly important in a rural county with lim- ited resources. For example, lack of clean, safe housing due to bedbug infestation and lack of housing overall are particular issues in Klamath County. To address the problems, the county established a Housing Task Force, including key stakeholders in areas such as public health, health care, economic development, and housing, to address how to encourage real estate investment and marketing. Little noted that the public health agency, the Medicaid program, and the housing authority are also jointly working on a proposal to create accountability regarding a response to the bedbug problem, obtain funding for the technology and service operators needed to remove the bedbugs, and provide tenant education regarding mitigation strategies. Little pointed out that the relationship is successful because the nontraditional partners trust each otherâs expertise. Cofer added that the relationships of the coalition members with legislators and state leaders was the primary strength of the Tobacco 21 coalition. Different coalition members had relationships with different legislative champions. She also described how MD Anderson was able to enlist its Board of Visitors, a nonfiduciary, appointed advisory board of volunteers comprising business and community leaders who advance the institutionâs mission to end cancer, in the Tobacco 21 effort. For example, Board of Visitors members also educated state elected officials in a num- ber of different settings outside the state capitol, such as social events back in their legislative districts. Hawk also described the importance of MD Andersonâs relationship with other entities across the University of Texas System. As he explained, the 14 entities often did not know much about each otherâs priorities and viewed each other as competitors. Under the leadership of one of the University of Texas System leaders, represen- tatives focused on population health from each of the 14 entities were convened on a quarterly basis, and each of the entities was tasked with developing a population health plan. Hawk noted that the result was a high-level blueprint for building relationships across the university.
50 MODELS FOR POPULATION HEALTH IMPROVEMENT Alyssa Crawford asked the presenters for their perspective on the types of research being done to influence policy makers or partners of the need for and type of action that should be taken and the best ways to communicate that evidence. With respect to Tobacco 21, Cofer noted that the evidence for the policy had already been marshalled in the 2015 IOM report (IOM, 2015), and The University of Texas at Austin had also conducted research on the impact of tobacco use locally. MD Anderson created a one-page infographic to explain the evidence and highlight the implications for Texas specifically, which it made available to other coali- tion members to also use in their education and advocacy efforts. Hawk added that when MD Anderson decided to make a stronger commitment to prevention about 5 years ago, it began by compiling a database of its actions related to cancer control recommended by its researchers and other leading experts, such as WHO and the Community Preventive Services Task Force. To implement its cancer control strategy, MD Anderson hired staff with specific relevant expertise in implementing these types of policies and strategies. He noted that faculty were experts in implementation science and research but not necessarily implementa- tion and dissemination itself. Hawk emphasized the importance of advo- cating for policies that are evidence based and having stories that support the policy and help to convince legislators of the need for action. Little responded that while data is important to their work, getting access to local data can be challenging because there are no epidemiolo- gists in Klamath County. She noted that the public health department relies heavily on the local university, which has a few professors willing to partner with and support them in gathering and analyzing data as needed. They also partner with the hospital system, but according to Little, it can be difficult to get the information needed from health care partners in a usable format. She also pointed out that legislators do not always understand that change in public health takes a long time, and an intervention may not be able to show results within a 1- to 3-year timeframe. Marc Gourevitch commented that a health system such as MD ÂAnderson engaging in public policy and working with partners at the state level is an ideal example of an upstream action to improve public health. He asked Hawk and Cofer if MD Anderson was considering engaging in similar efforts to affect other drivers of poor cancer outcomes, such as poor diet and physical inactivity. Hawk responded that it does plan to work on other issues, but it needs to consider the political environ- ment in the state and choose policies that are appropriate for the context. He also noted that change takes time. For example, MD Anderson had been working to advance a comprehensive smoke-free law in Texas for 12 years, whereas they were successful in advancing a Tobacco 21 policy
UPSTREAM 51 in just two legislative sessions. Cofer added that colleagues in her depart- ment are also engaged in place-based initiatives to address poor diet and physical inactivity in towns outside of Houston. She concluded with a call to action to challenge other cancer centers to engage in similar upstream efforts to improve public health.