Health disparities among Chicago hospitals' most pressing public health concerns .

Northwestern Memorial Hospital, Chicago

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Hospitals and health systems across the U.S. are tasked not only with addressing patients' medical issues, but also the social and economic factors that affect people's overall health.

Within the Chicago area, organizations have similar public health concerns — including health disparities related to where residents live and social determinants of health such as housing. And many are taking a team approach to effect change citywide.

Here, leaders from Chicago hospitals and health systems spoke with Becker's Hospital Review about the most pressing public health concern facing their organizations and how they're addressing it. Here is an overarching look at public health — in leaders' own words.

Brenda Battle RN, BSN, vice president, urban health initiative and chief diversity, inclusion and equity officer at the University of Chicago Medicine

The top challenge

Chicago is an incredibly diverse city with many complexities and many inequities and disparities. This is borne out in data. For example, according to the NYU researchers, who examined life expectancies in neighborhoods in the 500 biggest U.S. cities based on data from the Centers for Disease Control and Prevention from 2010 to 2015, in the affluent Streeterville neighborhood on the North Side, Chicagoans live to be 90 years. But, if you go nine miles south to Englewood, where many of our own patients come from, the average life expectancy plummets to about 60 years.

Given the University of Chicago Medicine's location on the [the city's] South Side, it's critically important that we focus our work on the very real health challenges facing our patients and our neighbors. To understand what those are, we utilize our community health needs assessment, which is comprised of both primary (surveys and focus groups) and secondary data elements (public health and other data), to help identify the needs within our community. The CHNA identified pediatric asthma and adult diabetes, community violence and the social determinants like food insecurity, employment and access to health, particularly mental health services, as the top challenges facing our community.

How your organization is responding

We use the CHNA, along with input from community members to help us make decisions about where to commit resources that can most effectively improve community members' health and wellness.

And, we partner with others in the community to address these priority health challenges. An example is the South Side Pediatric Asthma Center, which is a multi-institution partnership to reduce asthma disparities in our community.

According to data derived from our CHNA, over 20 percent of children in our community have asthma, which is almost twice the percentage of the rest of Illinois. Six of the nine neighborhoods with the worst asthma outcomes are on the South Side of Chicago, right in our backyard. Children's asthma is a huge concern for our community and has very real affects — because kids with poorly controlled asthma are more likely to miss school, be hospitalized and have to visit the emergency department.

The South Side Pediatric Asthma Center was launched in 2017. It is a collaboration between South Side healthcare providers that is powered by the University of Chicago Medicine. It identifies children with asthma and connects them with their primary care medical home for ongoing care and treatment. We utilize community health workers who are doing in-home visits to identify environmental factors that may be triggering asthma attacks and help parents make simple changes. We also provide standardized and easy to understand asthma education materials for parents and children, as well as provide asthma education to schools and day care center staff, parents and the community. The SSPAC offers an Asthma Resource Line, which is a free number to call for questions about asthma, resources in the community, and to get connected to child's primary care medical home.

Five healthcare institutions serving patients on the South Side of Chicago currently comprise the SSPAC: The University of Chicago Medicine, which functions as backbone institution; La Rabida Children's Hospital, St. Bernard Hospital and federally qualified health centers — Friend Health Center and Beloved Community Family Wellness Center. The goal is to expand the SSPAC to each FQHC and hospital on the South Side of Chicago.

Debra Carey, interim CEO of Cook County Health

The top challenge

For Cook County Health, the biggest public health issue is making certain that all residents have access to the highest quality of care. Despite more and long overdue coverage options for many of our patients, thousands of Cook County residents remain uninsured making our 180-year mission of caring for the un- and under-insured extremely important. Until we get to a state of universal and affordable health coverage for all, there will be an ongoing need for safety-net organizations like Cook County Health to ensure that everyone has access to care. Too often, the uninsured ignore early warning signs of disease and arrive in our emergency rooms and clinics when the diagnosis requires expensive care like a surgery or hospitalization and often an unknown or negative impact on their life. Unfortunately, many juggle issues around their resources and income and have to make decisions about when they get healthcare based on the resources they have. I do not believe that anyone should ever have to stand back and not get the care they need. I think in a country with the wealth that we have, individuals should not be put into that position, and the best way to do that is to make sure everyone has access to both coverage and care.

A lot of [uncompensated care] is [a result of] individuals who can't get insurance right now for some other reason, but their income would definitely make them eligible for some of the different plans that are out there. Some also are working individuals, and the cost of health insurance is still causing major issues and problems for them, not only from premiums but also from some of the out-of-pocket expenses like copays and deductibles.

How your organization is responding

In 2017, we looked at the total amount of dollars for all hospitals in Cook County, and all of the hospitals [combined] reported $554 million in charity care. Of that $554 million, two [Cook County Health] hospitals — [John H.] Stroger [, Jr. Hospital of Cook County] and Provident [Hospital of Cook County] — reported $273 million of it. One of the things we have been doing is publicizing this, so everyone is aware how much we at Stroger and Provident are providing in terms of services directly to uninsured patients.

Cook County Health does not have unlimited resources, and so we are advocating for solutions to this challenge, talking with local, state and federal officials about the need for expanded (and affordable) coverage as well as additional resources. Cook County Health has employed a number of strategies to attract insured patients to help offset the cost of charity care from renovating our health centers to increasing access and capacity.

Karen Teitelbaum, president and CEO of Sinai Health System

The top challenge

What we see as the biggest public health issue is the opportunity to reduce health disparities. Our communities are plagued disproportionately with poverty and crime, gun violence, housing, food insecurity, chronic disease. So, for us, the big public health issue is the entirety of the challenges that are created by health disparities.

Sharon Homan, president of the Sinai Urban Health Institute

How your organization is responding

Because of our research institute that's housed within Sinai Health System — Sinai Urban Health Institute — I think we have a deep grasp of the underlying structural racial disparities that lead to these great inequities. We provide initiatives, and we are very active in the advocacy and informing policy at the state and federal levels. But we're also leaders in stimulating initiatives like West Side United, [a collaborative on the west side of Chicago], that aim to address the generations of structural racism that we see in the city. We're seeing some promising results from that.

As an example, one of the studies in 2008 coming out of the Sinai Urban Health Institute was about the disproportionate mortality [rates] in breast cancer mortality for the women in our community. I couldn't understand why anybody [on the West Side of the city would] be dying of breast cancer at twice the rate as the rest of Chicago, as the study found. So I spoke with our director of the institute at the time and his response was that women in our communities [on the West Side], faced with financial pressures and realities, are making the decision of, "Do I get my mammogram or go to work?" When do they come in? Later, when they feel a lump in the breast, and it's already advanced. I had not connected all the dots on how such disparity directly impacts health. So, we put interventions in place that help women get into treatment sooner, like training breast health navigators who help women get transportation, get childcare during the time they can come in for their mammogram. We were able to quantify improvements in staging of breast cancer from there. That's one example of how we treat these public health issues.

Omar Lateef, DO, CEO of Rush University Medical Center

The top challenge

The 85-year life expectancy for a resident of Chicago's downtown drops to 69 years just six miles away on the West Side. While violence is often blamed for this disparity in life expectancy, more than half of the early deaths in under-resourced communities are actually caused by common conditions like heart disease, cancer, stroke and diabetes. These death gaps are unnatural, unjust and must be addressed by improving the economic conditions in the neighborhoods we serve, not only the health conditions of the people who live there.

How your organization is responding

Because inequities are so deeply rooted in our social systems and structures, a team approach is required. We are coordinating our efforts and resources with other health systems, community residents, nonprofit organizations, government agencies and faith communities. Instead of simply treating the illnesses that are a result of these inequities, Rush is working to create healthier communities.

Ronald Ackermann, MD, director of the Institute for Public Health and Medicine at Northwestern Medicine

The top challenge

As a large healthcare system affiliated with a top medical school, we struggle with the sobering fact that living a long and healthy life in Chicago is determined far less by the quality of your healthcare than by where you live. One recent study by New York University found that average life expectancy differed by 30 years between Chicago's "healthiest" and "sickest" ZIP codes. Our neighborhoods do experience differences in access to high quality healthcare, but the dramatic difference in life expectancy was driven more by issues such as poverty, safe and affordable housing, childhood education, and exposure to violence and other forms of toxic stress. These social influences shape our behaviors, our biology and even our genes, causing us to experience worse health.

How your organization is responding

Chicago's hospitals want to do something about this. Naturally, our instinct is to draw upon our strengths as educators, researchers and healthcare providers. Unfortunately, we are finding that our science and amazing advances in healthcare take us only a very small distance toward improving health at a neighborhood level. We are learning to engage with other healthcare organizations, businesses, elected officials, public health agencies, neighborhood organizations, community leaders and many others to align forces and concentrate on more "upstream" areas such as childhood education, expansion of employment and career development opportunities, mentoring programs, collaborations to break cycles of violence, and even food access and housing. These are new areas for our hospitals and medical school, and we are trying to learn and improve. Our Institute for Public Health and Medicine is trying to encourage and advance this work, as well as to engage with community members and stakeholders to evaluate what is working and how to improve. Northwestern Memorial Hospital, Lurie Children's Hospital, the Feinberg School of Medicine and other schools at Northwestern have historically worked independently with different community partners, so we also are now trying to align our efforts to have greater collective impact.

Will Snyder, senior vice president and chief advocacy officer of Amita Health

The top challenge

First, we are fortunate in Chicago to have a collaborative and engaged healthcare community and a phenomenal public health department. This led to the creation five years ago of the Alliance for Health Equity, one of the country's largest hospital and community partnerships. Together with over 30 hospitals and 100 community organizations, we have not only conducted a community health needs assessment covering almost 9 million people, but we have worked together on sharing data and interventions to address the highest priority issues from our neighbors. Both the data and the voices of our neighbors pointed us to unstable housing as one of the biggest public health issues in our region. Any integrated approach to improving health and well-being must include housing needs. Uncertain, unsafe or unaffordable housing can be a stressor for so many individuals whether they be experiencing homelessness, a mental health condition or even a respiratory illness. Because we believe health can begin with stable housing, by addressing those needs we have a unique opportunity to make direct impact on the social determinants of health.

How your organization is responding

There are at least four pathways to address housing's impact on health: stability, affordability, quality and safety, and community.

Amita Health operates a supportive housing facility through the Alexian Brothers Health and Housing Alliance. It provides stable housing with wraparound services for homeless men living with HIV/AIDS. We believe supportive housing can be a platform for recovery and wellness, and meaningful de-institutionalization.

Regarding affordability and community, we partnered with Mercy Housing Lakefront to build a 70-unit affordable senior housing complex on an unused parking lot at our hospital in Kankakee, Ill. This partnership was identified because in the surrounding community, one in five seniors lived alone and of those over half were severely rent burdened. We know that seniors living alone have a higher likelihood of falls and poor reported mental health. This partnership helped move vulnerable individuals into stable, affordable housing while also connecting them to a medical home and a community. There is already a waiting list and an interest to build more units near the hospital.

Lastly, poor housing conditions are associated with a wide range of health conditions including respiratory infections, asthma and lead poisoning. We did an analysis of asthma inpatient admissions for our safety-net hospital on Chicago's West Side and found that almost all patients were coming from ZIP codes with high rates of old housing stock and building violations. Together with Elevate Energy and the Green and Healthy Homes Initiative, we designed an intervention where patients could have a home health inspection. If asthma triggers were identified, they would be remediated. All of the homes in the pilot had mold or other triggers. Since the triggers were remediated none of the patients have been back to the hospital for asthma. Healthy homes are crucial for healthy living.

Matthew Davis, MD, MAPP, Senior Vice President and Chief of Community Health Transformation for Lurie Children's Hospital of Chicago

The top challenge

We've found through our work with Voices of Child Health in Chicago and the Chicago Department of Public Health, in asking hundreds across city about children's health and wellbeing, that emotional and behavioral concerns really dominate the top 10 list of what adults are worried about for youth today in our city. Whether that's stress, depression, suicide or drug abuse, tobacco use and alcohol abuse — all relate to behavioral health. The public understands what challenges and a high level of concern these problems bring.

When it comes to stress for kids, that often translates into daily challenges in behavior for parents and other caregivers as they relate to kids. Children may have more difficulty relating to their friends. They may have a somewhat sudden change in the foods they like to eat. They may have a change in their sleeping at night, or they may have regression or change in behavioral achievements, such as potty training or the ability to master tasks at school. In other words, stress can show up in many ways for children that can sometimes masquerade as other problems.

It's always important to understand the context of the concerns that parents and other adults identify about kids' health. We know that the community conversations we're having today in Chicago and across the U.S. have a stronger theme of interpersonal conflict over the past few years. Kids pick up on the tone and content of the conversations that adults have around them. As grownups, we always need to keep in mind that kids are listening to us and watching us. How we process what's going on around us can help, or sometimes cause problems for, the kids in our lives.

When it comes to behavioral health concerns for children and adolescents, the symptoms are sometimes less obvious than those for physical health issues. That makes it especially important to take time with our kids to talk about how they're feeling, and how they're emotions might be affecting their friendships, their relationships in their family and also their interactions in places such as school, day care and other community settings.

Also, in today's era of ubiquitous social media for kids, their exposure to the stress of other children can amplify the stress they're feeling inside themselves. It's important for parents to recognize how essential it is for them to keep an open line of communication with their children about how online content affects their health and wellbeing.

How your organization is responding

To address behavior and emotional concerns across the city, at Lurie Children's we know that we must use a multipronged, multi-location approach that builds on our clinical activities and expertise and extends out into neighborhoods to reach clinicians and children's families and to partner with community-based institutions and organizations. For instance, we have programs that partner with school teachers to help them identify and respond to symptoms of trauma and stress in children in the classroom. We have programs that bring multiple community-based organizations together to strategize and learn from each other about how to address stress among groups of youth at the neighborhood level to help them deescalate and avoid episodes of violence. We've also expanded access in our psychiatric and behavioral health program to pilot new approaches that use group therapy programs for some youth with behavioral health concerns and train community pediatricians to recognize and respond to behavioral health symptoms in their young patients.

Addressing behavioral health is increasingly central to practicing pediatrics, not only in Chicago, but across the U.S. Pediatricians have varying levels of comfort and expertise in managing behavioral health concerns for their patients. Therefore, we have developed a training program to help practicing pediatricians get more comfortable and confident in managing children's mild symptoms. What that allows us, as a healthcare system, is to have our specially trained child psychiatrists and psychologists focus on children with the greatest needs rather than managing children whose symptoms are mild enough that they can be supported by a community-based clinician. We know that one of the pediatric specialties with greatest scarcity of experts is child psychiatry. Therefore, we need to be smart as a healthcare system for our patients and expand the capacity of other clinicians to manage children's behavioral health when those children's symptoms are mild enough to be safely managed outside of the psychiatry clinic.

As with all health concerns, children's behavioral health can be or is often affected by social factors such as food insecurity, housing insecurity, poverty, and challenges with insurance coverage and access to care. At Lurie Children's, our Healthy Communities program works with community partners to address the social influences in a comprehensive way that extends beyond the walls of a health system into neighborhoods where kids live, learn and play.

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