Robert Graham Center Forum

Three Cities Take Custom Approaches to Population Health

August 04, 2015 11:44 am Michael Laff Washington, D.C. –

Nick Macchione, M.S., M.P.H., director of San Diego County's Health and Human Services Agency, explained how the county tackled obesity rates among local students during a policy forum in Washington, D.C., last week.

When one patient needs medical care, the problem can often be solved with a visit to a physician. However, larger population health concerns are unlikely to be solved without looking closely at a map.

Building on the concept that where one lives is one of the strong indicators of future health, three cities are tackling population health in their own distinctive ways.

San Diego, Detroit and Richmond, Va., are tackling population health at the community level by targeting specific health needs and devoting resources to change outcomes. Health officials from each area spoke about their work last week at a forum titled "Achieving the Triple Aim: Linking Clinical Health Services and Public Health to Improve Outcomes & Costs."( The forum was hosted by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.

San Diego: Poor Health Habits

In 2007, poor health habits were costing San Diego County $4.6 billion, not including lost work productivity, so officials decided to examine what the area's specific problems were.

Story highlights
  • During a recent policy forum, a San Diego County health official described the county's success in reducing obesity rates in the Chula Vista Elementary School District.
  • A second speaker noted that although the Detroit area has medical resources in place, care is not reaching segments of the population that need it most.
  • In a third project described, population health researchers at Virginia Commonwealth University mapped low-income areas in Richmond block by block to identify where health costs are the highest.

"Your ZIP code is more important than your genetic code," said Nick Macchione, M.S., M.P.H., director of San Diego County's Health and Human Services Agency.

Health officials identified three poor health habits: lack of exercise, poor diet and smoking. They decided to focus on one major health problem at a time.

One particularly notable achievement was recorded in the Chula Vista Elementary School District, which has about 28,500 students -- many from low-income backgrounds -- at 45 schools from kindergarten through sixth grade. In 2010, 40 percent of the students were either overweight or obese.

Officials introduced a number of changes aimed at students' eating habits. Schools were encouraged to promote games rather than fattening foods to celebrate birthdays, part of a larger emphasis on more physical activity during the day. Parents received cooking lessons and were advised about proper diet. The school lunch menu shifted to offer more nutritious foods, requiring a major adjustment among students who were unhappy to see cheese nachos leave the menu, Macchione recalled.

In four years, obesity rates dropped by 13 percent. At the same time, students' grades improved, school attendance increased and teachers noticed greater engagement in the classroom.

"It's not just about improved health," said Macchione. "It's about improved social well-being and health."

Beyond the schools, the initiative also provided nutrition consultation for individuals who receive food stamps. "We want people who are coming in for food assistance to be healthier," Macchione explained.

Detroit: Neighborhood-level Solutions

Despite being home to six of Michigan's largest hospitals, its largest health system and a wide range of specialists, Wayne County routinely ranks at or near the bottom of annual state health statistics in virtually every category, including morbidity, mortality and clinical care. Physicians and facilities are in place throughout the area, but access and overall awareness about patient needs have been low, so now officials are looking at solutions on the neighborhood level.

"We were so focused on the sick care model that we weren't spending any time on population health or morbidity," said Chris Allen, executive director and CEO of Authority Health, formerly the Detroit Wayne County Health Authority.

Allen expressed frustration with the emphasis on emergency care, specifically mentioning advertisements he heard touting bigger ERs or promising free care for patients who wait more than 28 minutes in the ER.

"Why are we doing this?" Allen asked. "With all of the resources we have, we're not moving the needle on population health at all."

To illustrate the problem, Allen noted that although Detroit has the highest number of dialysis centers to treat those with end-stage renal disease in the country per capita, 43 percent of ER visits there are for complications related to diabetes or prediabetes. Despite having appropriate medical resources in place, care is not reaching segments of Detroit's population that need it most.

"We're real good on the back end, and now we need to be more creative on the front end," he said.

Now Allen is focused on opening wellness centers throughout the Detroit area that will focus on specific chronic conditions depending on neighborhood needs. The centers are expected to open in three years. In addition, medical residents will receive two years of certification in population health, including time spent visiting Detroit's neighborhoods to learn about specific health needs.

Richmond: 'Primary Care Desert'

Population health researchers at Virginia Commonwealth University (VCU) mapped out low-income areas in Richmond block by block to identify where health costs are the highest. The process, known as "hot spotting," pinpoints the highest utilization areas for ER and hospital visits. The researchers also engaged in "cold spotting," identifying neighborhoods that lack essential social health needs such as employment opportunities, education, grocery stores and safe sidewalks.

Katherine Neuhausen, M.D., M.P.H., assistant professor in the Department of Family Medicine and Population Health at VCU, said efforts were focused on East Richmond, an area she called a "primary care desert" because of its high concentration of public housing.

VCU officials discovered when reviewing the maps that the highest volume of hospital discharges was recorded nearest to public housing projects or homeless shelters. They also discovered that mental illness and substance abuse account for high percentages of ER visits -- 27 percent and 9 percent, respectively -- among public housing residents.

The next step in the initiative, said Neuhausen, will be to bring the area's health institutions together to address the hot spots identified on the map -- an imposing challenge given what she called a legacy of mistrust among local health systems.

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