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Health Resources in Action is making Public Health headway in Massachusetts

An interview with Dr. Lisa Wolff, vice president of Boston-based Health Resources in Action

The state of healthcare can be a source of stress for clinicians, even in Massachusetts, which is currently ranked as second healthiest state in the nation. Yet Lisa Wolff, vice president of Boston-based Health Resources in Action, believes that we live in an era of opportunity, in Massachusetts and in the nation as a whole. The opportunity stems from the partnerships that are being forged between healthcare and public health, and between these entities and organizations that have not traditionally been considered health-related. Transportation, housing, food, and economics: They’re all connected. Partnerships make it possible to shift from a focus on illness to a focus on the absence of illness.

Health Resources in Action is a public health institute, one of many nonprofits around the nation. HRiA runs several programs for the Massachusetts Department of Public Health and contracts with many organizations to provide some form of technical assistance: helping with tasks like research and evaluation and capacity building. The goal is not just to go in and carry out some research but to train people at the organization so that they can better carry out their own research in the future. This type of organization is not unique to Massachusetts. The Public Health Institute in California has a similar mission, as do a number of other public health organizations around the nation.

Massachusetts has seen some successes in areas like smoking cessation and air quality. Smoking cessation programs delivered under MassHealth, the Massachusetts Medicaid program, have been widely lauded; the Centers for Disease Control has noted a reduction in cardiac-related hospitalizations and a significant Return on Investment, or ROI.

The city of Boston has its own victories, having made public housing smoke-free. By putting this policy in place city-wide, it has not only limited exposure to second-hand smoke but provided an incentive for smokers to quit. In this area, Boston is viewed as a national model. Boston has an active public health commission, Wolff notes, one that views itself as a “brain trust”. But the smoke-free policy was the work of many advocates, including the tenants themselves.

Boston, and Massachusetts as a whole, are very fortunate, Wolff says, to have such excellent academic healthcare institutions. Hospitals have traditionally dealt with the acutely ill within their own four walls. But HRiA can sit at the table with leaders from local hospitals -- Boston General, Brigham and Women's -- and discuss the social determinants of health. This isn't the case everywhere, even though it is widely known that economic factors have a tremendous influence on health at the population level.

Advocating for Population Health

Upstream is one of the buzz words in public health. Health crises are the result of a cascade of decisions and actions, and organizations are most effective when they start far upstream of the rapids. However, actions are driven by cost. Some investments are made with the hope of seeing returns decades down the line, and this can make it tough to garner public support. Why would people be moved to put policies in place that support healthy habits today? The burden of chronic disease won’t be eased tomorrow.

Wolff states that health advocates need to continue their focus on the long-term but also shine a light on the small subset of health concerns where there can be dramatic short-term gains. One example is childhood asthma. People with asthma are often high healthcare utilizers. They show up in the emergency room because they are having trouble breathing. This type of illness management is costly as well as stressful. But an action plan that identifies and eliminates triggers can render these visits unnecessary. Wolff notes that these issues can be handled in a cost-effective way by utilizing professionals such as community health workers.

Navigators have a role, too, in health management. When institutions like the Dana Farber Cancer Institute utilize navigators to help patients figure out their transportation issues, they’re saving money: the money that is routinely lost to missed appointments. They’re also making other aspects of living more manageable for the most challenged -- like finding stable employment.

There are still up-front costs associated with putting policy in place. When asked how clinicians can use data as a talking point, Wolff notes that she is a social epidemiologist, and epidemiologists love numbers, but she recognizes this isn’t the case with a lot of people, including those who shape our policy. Still, they can be moved by stories. In the case of asthma, it can help to learn about one child, “Joey”, and how he used to end up in the emergency room regularly. That story will help policy makers understand what it's like to live with childhood asthma, and what it's like to live with asthma that’s under control. At this point, it may be useful to stress that there are 85,000 Joey's in the state. At this point, the number is more alive.

Sometimes it helps to focus on improvements in quality of life in the present tense. Take childhood obesity. Heart disease is a potential consequence, but one that may not show up until today’s policy-makers are gone. Still, there is research establishing the link between childhood obesity and educational participation and achievement.

Wolff stresses the importance of authenticity. If someone works as a healthcare professional, they can start with the people they see on a day to day basis, and then extrapolate outwards. They may see a few people each day who have similar challenges, but they know there are many more. With costs, too, it can be useful to attach figures to something tangible. The numbers are simply too big to wrap one's head around. Wolff suggests emphasizing what we could be doing with that money if we weren't spending it on healthcare.

Those who do like data will find plenty on the HRiA site (https://hria.org). But professional organizations, from social work to nursing, count advocacy among their roles. Wolff notes that these organizations provide talking points for members. Clinicians don't have to go it alone.