Family physician Mark Polisar, M.D., an attending physician at Montefiore's Williamsbridge Family Practice Center, examines Lucille Payne during a routine patient checkup. During the visit, Polisar asks Payne about her diet and exercise regimens, as well as her living conditions and mental state, to get a better sense of her overall health status.
Many family physicians are getting increasingly frustrated that, regardless of their efforts, their patients don't seem to get any better. What they are realizing, however, is that social and economic factors outside of their offices often play a predominant role in determining a patient's health status and outcomes.
In response, many family physicians are working with public health departments and community entities to provide a continuum of care for the patient both inside and outside of the physician's office. They are looking at the so-called social determinants of health to find an answer for ailing patients.
"We can accomplish a lot (for patients) in the treatment of diseases and diagnostic workups," says Steven Woolf, M.D., M.P.H., a professor of family medicine at Virginia Commonwealth University in Richmond and director of the university's Center on Human Needs. "But in terms of managing chronic illnesses or especially in preventing diseases in the first place, the biggest opportunities for making an impact often occur outside of the office setting in people's lives."
- Family physicians have taken a leading role in addressing the social determinants of health by partnering and collaborating with public health departments and other entities.
- The goal is to address the needs of patients both inside and outside of the physician's office, thereby providing a continuum of care.
- Family physicians are key players within that continuum of care, using their skills and expertise to reach out to their communities and bridge health care gaps.
Research is backing up Woolf's assertion. Two recent reports, for example, have focused renewed attention on the social determinants of the health. A March report(www.iom.edu) from the Institute of Medicine (IOM), points out that primary care and public health share a goal of promoting the health and well-being of all people. Yet, the two disciplines historically have operated independently of each other.
"But new opportunities are emerging for bringing the sectors together in ways that will yield substantial and lasting improvements in the health of individuals, communities and populations," says the IOM report, which was commissioned by HHS and other government agencies.
A second report(www.annfammed.org) that was published in the Annals of Family Medicine revisits the 1967 Folsom Report, which described health as a community affair and called for community action to improve health.
According to that article, health care reform efforts and the corresponding emphasis on patient-centered medical homes (PCMHs) and other community-based solutions have given policymakers, primary care advocates and public health leaders an opportunity to revisit and revitalize the recommendations made by the Folsom Report.
Family physicians have been quick to seize on these types of opportunities, often emerging as leaders in a growing movement to bring primary care, public health departments and community entities together to address the social determinants of health and provide a continuum of care for patients. Within this context, family physician practices and the PCMH serve as a nexus for care and information, as well as a bridge to outside resources, says Paul Wallace, M.D., chair of the IOM committee that wrote the report mentioned above.
"All of the concepts that are rolled up into the medical home make a lot of sense in the context of trying to reorganize the health care system to give patients a place where they can go to understand what all of this exploding literature of medical science means for them and to make sure the patients have access to community-based resources that could benefit them," says Wallace, senior vice president and director of the Center for Comparative Effectiveness Research.
Nicole Hollingsworth, Ed.D., senior director for Community and Population Health at Montefiore Medical Center, center, meets with, from far left, Mark Polisar, M.D., an attending physician at Montefiore's Williamsbridge Family Practice Center; Peter Selwyn, M.D., director of community health and wellness at Montefiore Medical Center; the Rev. Paul Peart, senior pastor of the New Testament Temple Church of God; and Jane Bedell, M.D., assistant commissioner of the Bronx District Public Health Office.
Although family physicians are central to that continuum of care and often can work collaboratively with their partners in the community, "It is important not to set up the primary care physician or the family doctor as an isolated point of failure," says Wallace. "It would be a big mistake to make this all about them. Rather, the goal is to clearly and securely position primary care and family physicians in this continuum of resources that exist within the community."
The Montefiore Medical Center and its primary care medical group in Bronx, N.Y., provide an example of how a health care system and its primary care physicians and other health care providers can reach out and partner with community resources to create a continuum of care.
Montefiore is driven by a social service mission that promotes partnerships and collaborations with outside entities. And that mission flows throughout the organization, helping to define the patient/physician relationship and serving as a way to carry the work of Montefiore out into the community in a continuous cycle to bridge gaps in care.
"We have a range of interventions that we have put in place for addressing patient needs," says Nicole Hollingsworth, Ed.D., senior director for community and population health at Montefiore Medical Center. "For us, the interventions are framed in the context of trying to be in the community beyond the walls of Montefiore."
The organization's interventions range from providing blood glucose monitoring in churches to running teddy bear hospitals for young children in domestic violence shelters to ease any fears they may have about seeing a physician. Many of the patient interventions originate in the physician's exam room, often resulting from the give-and-take between physicians and their patients.
For example, family physician Mark Polisar, M.D., an attending physician at Montefiore's Williamsbridge Family Practice Center who is leading the site's community health initiative, regularly queries his patients about their diet and exercise regimens. He also asks about their living conditions and their mental state to get a better sense of their overall health status.
The nation's family physicians can play a critical role in addressing the social determinants of health by stepping outside of their clinical domains and becoming agents for change within their communities, according to experts interviewed by AAFP News Now.
"Physicians can play a very powerful role because they have a certain credibility when they extend themselves beyond their clinical domain and speak to the need for changes in the environment from the physician's point of view," says Paula Braveman, M.D., professor of family and community medicine and director of the Center on Social Disparities in Health at the University of California, San Francisco.
Family physicians can help address the social determinants of health on three separate but distinct levels, says family physician Steven Woolf, M.D., M.P.H., professor of family medicine at Virginia Commonwealth University in Richmond and director of the university's Center on Human Needs.
The first level involves addressing the social determinants of health on a one-to-one basis by becoming acquainted with a patient's living conditions and whether the patient will be able to adhere to the physician's instructions given his or her home environment. "When you send a patient home with instructions for how to care for a fracture or diabetes, you need to be thinking about their home situation to determine what supports the patient needs or whether you need to get a social work consultation," says Woolf.
Family physicians also can try engaging with their local communities to help enhance health. A family physician living in a town with a major employer might be able to work with the employer on developing a health program for employees to increase opportunities for exercise or a healthier diet.
"Physicians have a great deal of credibility and cachet among policymakers and the general public," says Woolf. "It is really an untapped opportunity for physicians to make an impact on local policy by testifying at hearings and meeting with officials and appearing on local television networks and doing interviews to push for changes in local conditions."
A third way family physicians can address social determinants of health is by being involved with the AAFP or local constituent chapters. Activities can include testifying on Capitol Hill and before state legislatures to explain that health is determined by more than health care -- the absence of supermarkets and healthy foods, for example, can lead to heart disease or diabetes, according to Woolf.
"One of the major needs within the overall care experience is for the patient to have consistent messages," says Paul Wallace, M.D., chair of an IOM committee that wrote a report on integrating public health and primary care. "A key part of that is to have the family practice doc fluent in not only the medical evidence but also in terms of the community infrastructure and resources."
Montefiore also has launched an intervention known as the Collective Action to Transform Community Health, or the Bronx CATCH Initiative, in several of its medical sites to work with the local health department and other entities to promote healthier eating options and to make the parks and recreation areas safer for physical activity.
"There has been a lot of enthusiasm out in the community to try and see if we can jointly change some of the healthy options that the local food establishments offer and to jointly work on making the parks safer and easier to use for our patients," says Polisar.
The Williamsbridge Family Practice Center is one of two sites within the Montefiore medical system that serve as outpatient training facilities for family medicine residency programs, which has made it possible for the center to employ the services of family medicine residents and medical students for the CATCH Initiative.
One of the students surveyed the area last year to produce a map that lists all of the local food stores, supermarkets and restaurants, and now, the family practice center is assessing the establishments for the healthiness of their menus, foods and food displays. One of the family medicine residents has conducted a written survey that gauges the eating and food-buying habits of the center's patients, and she presented the survey findings at a recent CATCH Initiative meeting that included health department officials, as well as church and community leaders.
"We are essentially prescribing for our patients a healthy diet and exercise," says Polisar. "But when you go into the actual neighborhood, it is almost impossible to do -- you can't get good fruits and vegetables. When you go into almost all of the restaurants, most of their food is fried, very salty. It is no wonder that a huge percentage of our patients have high blood pressure, diabetes and high cholesterol."
"As a physician, it is very frustrating," he adds.
Williamsbridge Family Practice Center, meanwhile, is planning to develop a website that will list establishments that provide healthy food options, thereby giving the establishments the Montefiore stamp of approval, which could carry a lot of weight in the community, according to Polisar.
"We would go to one of the corner stores and say, 'We notice that right when we walk into your store, we see a bunch of candy and junk food and the water is back on the floor,'" says Polisar. "We will say, 'If you are able to move the water to a better place and to stop selling whole milk and to offer low-fat options and fruits and vegetables, we will then list your name on a website that we are developing and that will be publicized to all our patients.' Hopefully, the patients will shop preferentially at these places that have made their establishments more healthy," he adds.
Polisar and others also are planning to meet with members of the local police department and officials from the parks and recreation department to work on ways to make the parks safer for exercise and recreation.
"I know in talking with my patients that they don't feel safe sending their children to the park without going themselves," says Polisar. "The parents often are working one or two jobs and they can't do that. The kind of exercise that many of us take for granted around our homes and our own communities -- our patients can't really get that."
Initiatives such as the CATCH Initiative are not the sole purview of large medical systems or well-funded medical practices, either, according to Polisar.
"I did not have the resources to do this," he says. "I had been thinking about doing this for at least 10 years, ever since I was in Rhode Island, where they had a program like this that was well funded."
Polisar and others were able to put the program together by "working creatively" -- by partnering with the local health department, for example, while also relying on medical residents to help with the project.
"Frankly, I did not think this was ever going to happen," Polisar says of the project. "This is one of those things that you sort of put into the back of your mind and say, 'Wouldn't it be nice if we won the lottery -- maybe then we could do this.'"
But as Polisar met and talked with health department officials and other potential community partners, there was a growing consensus that "our goals were in sync."
"We have developed a potentially very potent, life-changing, community-changing kind of an organization," says Polisar. "I would tell people not to be afraid to follow that kind of a dream because it can happen if you can find the right partners."
That lesson has not been lost on the Spanish Catholic Center, a community health center with locations in Washington, D.C., and Wheaton, Md., that strives to provide a holistic health care experience for its patient population, according to family physician Marguerite Duane, M.D.
The Spanish Catholic Center primarily serves a Latin American immigrant population, and, for the past few years, it has made a push to focus on lifestyle issues to address underlying medical conditions, says Duane, who stepped down as the center's medical director June 1. "The most common chronic diseases we see are hypertension, diabetes and heart disease," she notes.
With grant support from the local health department, the Spanish Catholic Center created a program called Pasos Saludables (Healthy Steps) to work with patients on their eating and exercise habits. As part of the program, employees at the center hold nutritional and fitness programs on Saturdays, encouraging patients to make small but significant changes in their lifestyles.
Employees also take patients grocery shopping at a nearby supermarket, walking with them through the aisles to help them identify and buy nutritional foods and explain to them why they should choose one food item over another based on nutritional content.
The Washington, D.C., center also partners with a local farmers market to give patients access to fresh nutritional foods. Patients who complete three Pasos sessions receive a small gift certificate that is matched by the farmers market and can be used to purchase fresh fruit and vegetables.
In addition, the center has worked with the YMCA to hire a Zumba instructor who holds classes every Saturday afternoon in the center's waiting room. "We just clear out the chairs from the waiting room," Duane says.
The center also partners with medical students from Georgetown University School of Medicine to help with the nutrition and exercise classes. "Since medical practices may not be reimbursed or receive funding to address lifestyle factors, you need to be innovative in how you are going to address this," says Duane.
She urges family physicians to look outside the practice and into the community. "Health care is a community affair," says Duane, quoting from the Folsom Report.