Apr 19, 2017
In the ongoing debate over how to reform the U.S. health care system, there is increasing consensus that the care that people receive is just one of many factors that contribute to health outcomes. Policymakers, providers, and other stakeholders now recognize that a range of complex social factors — income; education; and where people live, learn, work, and play — also have a vital role in the health and wellness of individuals and communities. The Robert Wood Johnson Foundation (RWJF) has proposed that these social determinants of health must become part of our national conversation about health and that we must move toward a more comprehensive and integrated approach to health. To this end, in 2014, RWJF committed to the idea of advancing a national Culture of Health. The broad goal of the Culture of Health initiative is to improve health, well-being, and equity through activities in four different Action Areas:
While most agree that the leadership of health care providers will be central to the development of a Culture of Health, to date there is little clarity on how providers can best contribute to RWJF's initiative. Providers lack guidance not only on the steps they might take to foster a Culture of Health but also on potential barriers to success. To help fill this knowledge gap, RWJF contracted with the American Academy of Nursing (the Academy), which in turn contracted with RAND, to explore ways in which nurse-designed models of care are currently advancing a Culture of Health. With their focus on patient-centered care, their holistic view of patients (incorporating aspects of family, community, and work environments), and their emphasis on the promotion of health and well-being, nurses have a long history of providing care that is consistent with RWJF's vision of a Culture of Health.
This brief summarizes findings from case studies of three innovative nurse-designed care models, and it discusses lessons learned from these case studies that might inform our understanding of the health sector's role in building a Culture of Health.
Using data collected from an environmental scan of documents, an online survey, key informant interviews, and site visits, RAND researchers examined three nurse-designed care models that have been recognized by the Academy's Edge Runner program: CenteringPregnancy, INSIGHTS into Children's Temperament (INSIGHTS), and Family Practice and Counseling Network (the Network). The Edge Runner program supports innovative work that demonstrates a holistic approach to care and that remedies challenges in the delivery of health care or addresses an unmet need of a population. In selecting which Edge Runner models to study, the researchers sought variation in three factors: the degree to which each model felt it contributed to a Culture of Health, the type and number of barriers and facilitators each model encountered, and the diversity of populations served. Each model focuses to some extent on low-income, minority, or otherwise vulnerable communities, where financial and social resources are not generally readily accessible.
CenteringPregnancy is a facilitated group approach to prenatal care that integrates standard prenatal visits with group discussion and time for community-building. Each group session starts with expectant mothers recording their blood pressure, weight, and other biometrics, and then having an abdomen check by a nurse-midwife. Following this, a nurse-midwife facilitator leads activities and group discussions on a variety of topics, from stress management, to labor and delivery, to baby care. CenteringPregnancy was founded in the early 1990s by Sharon Rising, a certified nurse-midwife who — seeing individual prenatal visits as fundamentally inefficient, and understanding the value of social support in promoting health — brought together women who were in a similar stage of pregnancy.
INSIGHTS is a nurse-led, social-emotional learning intervention that uses puppets and an evidence-based curriculum to help parents, teachers, and students understand various temperaments and apply this understanding to behavior adjustment, interpersonal relationships, and problem-solving. INSIGHTS was founded by Sandee McClowry, a registered nurse, after a 1994 study in which she and her colleagues examined the interplay between child temperament, family socioeconomic status, and maternal characteristics, including stress levels. Their goals with this early intervention were to improve academic achievement, reduce disruptive behaviors, and enhance children's self-regulation.
The Network is a group of nurse-managed federally qualified health centers in or near low-income housing projects and medically underserved neighborhoods in Philadelphia and York, Pennsylvania. Founded in 1992 by Donna Torrisi, a nurse practitioner, these health centers offer integrated primary and behavioral health care, as well as health education classes and programs, such as yoga and meditation. On any given visit, patients are able to see a variety of providers — physicians, social workers, behavioral health specialists, legal aides, nutritionists, dentists, etc. — and the Network takes a preventative approach to the health problems of a neighborhood, offering programs and interventions to prevent lead poisoning, obesity, diabetes, smoking, cancer, or other conditions.
Researchers found that all three Edge Runner models advance RWJF's vision of a Culture of Health by promoting equitable communities through inclusion, collaborating with diverse partners and major hospital systems, broadening society's view of health and health care, and fostering social support systems. To one extent or another, each model stressed the importance of responding to the unmet need for social supports in the face of increasing social decay and the fraying of once-prominent social networks. Collectively, these programs look beyond the physical health care needs of their patients, taking into account the needs, stresses, and overall health of the communities they serve.
While the Edge Runner models prioritize activities that further the goals of all four of RWJF's Action Areas, there was a particularly strong focus on the fourth Action Area (strengthening integration of health services and systems). All three Edge Runner models define health holistically and share a common goal of "demedicalizing" wellness through the integration of physical, mental, emotional, and mind/body care. The CenteringPregnancy model integrates health education, an emphasis on emotional health, and group discussions of topics not typically defined as medical concerns — relationships, parenting, coping with fears of the unknown, etc. — into prenatal care; the INSIGHTS model recognizes the intricate connection between academic success and the physical and emotional well-being of children; and the Network model integrates a wide range of services into primary and behavioral health care, recognizing the value of a "whole-person" orientation.
All three Edge Runner models displayed a commitment to improving their patients' health self-efficacy — the belief in one's ability to succeed in a given situation — and all three support the philosophy that engaging people, families, and communities in addressing their own health needs and enabling them to be self-advocates is an essential component of making health a shared value. By addressing health disparities, both through the services they provide and by empowering community members and engaging them in the decisionmaking process, all three Edge Runner models also demonstrate the role that health care providers can play in promoting and enhancing equity in their communities.
The researchers paid particular attention to the facilitators and barriers that these nurse-designed care models encountered in promoting a Culture of Health. Notably, each Edge Runner model has at its helm an impassioned and dedicated "champion" nurse, whose ability to deftly navigate organizations at both the community and institutional levels and whose vision of collaboration are key to fostering a Culture of Health. Being bilingual — that is, being able to speak the different languages, whether literal or cultural, of diverse populations and stakeholders — was also invaluable, as it enabled all three Edge Runner models to gain the trust of community members and thus understand and respond to their specific needs. Broad community support was another important common factor in the success of these models.
A persistent struggle for each model was identifying sustainable and scalable sources of funding, particularly for community-level programs — many of which have no clear funding streams — that address social determinants of health. Other barriers include a societal predisposition toward individual care and patient privacy, rather than more open, group-oriented care; financial or staffing constraints that prevent schools or community organizations from making behavioral health concerns a priority (over basic safety and education); a tendency on the part of health care providers to stay "inside the walls," rather than venture out into the community; and an inconsistently trained and skilled nurse workforce.
The Edge Runner case studies offer important examples of work that promotes a Culture of Health among individuals, families, and communities, and they present a useful context for examining how other health care providers can do the same in their respective communities. RAND's findings here make clear the importance of developing close cross-sector and community-based partnerships, and it may be that health care providers can play an important role in advancing RWJF's Culture of Health initiative by helping communities identify their own unique resources and by promoting individual and community self-efficacy. While there is much to be learned from nurse-designed care models about how the health sector can best participate in and promote a Culture of Health, these case studies also shed light on other critical issues that warrant further research. Going forward, it will be important to help providers identify consistent funding sources in order to sustain the scope of their programs. Current trends in domestic health care policy that make providers responsible for overall patient outcomes, such as accountable care organizations, offer potentially promising approaches to making community-level interventions more sustainable. Finally, health care workforce development should emphasize interdisciplinary learning and collaboration to ensure that providers are prepared to be skilled partners and leaders in building a national Culture of Health.