Redefining health on the east side of Indianapolis
In 2017, Community Health Network Foundation received an Accountable Health Communities grant from the Centers for Medicare & Medicaid Services (CMS) to begin to tackle unmet health-related social needs—including housing instability, food insecurity, utility needs, interpersonal violence and transportation—of Medicare and Medicaid beneficiaries on the east side of Indianapolis. The effort is called Community Collaborations, and two years later, a team of Community Health Advocates is hard at work connecting men and women in need to community resources that can change lives and impact health.
What happens when the symptoms a patient describes to her doctor are not caused by a health issue? Sometimes, abdominal pain is not a sign of appendicitis—it’s hunger. Sometimes a headache is not part of a cold—it’s the result of financial stress. Sometimes a visit to the emergency department does not indicate a life-threatening situation—it’s loneliness. These are social needs that, if left unmet, can have serious implications on the health of individuals, families and a community as a whole.
On the east side, these social determinants are already impacting health. In fact, east side residents have an average life expectancy that is 7.5 years less than neighbors on the north side of the city.
Director of Community Collaborations Karen Lightbourne, who was raised on the east side and has an extensive background including both governmental and nonprofit service, says the program’s approach is all about shifting a mindset.
“Your housing is healthcare; your job is healthcare,” she explains. “We as a nonprofit health system need to embrace this and position ourselves to be at the table in order to impact the health of people in our community.”
Community Collaborations is mission work that addresses a moral issue, says John Kunzer, MD, president of Community Physician Network.
“It’s difficult to understand the choices that some people have to make,” he says. “To have to choose between putting gas in your car to take your child to the doctor or putting food on the table—to face that kind of choice—that in itself is stressful to your health.”
Since September of 2018, Community Health Advocates have facilitated nearly 5,000 screenings of patients at several Community sites, including Community Hospital East’s Emergency Department, the Washington Health Pavilion and a MedCheck. Patients with Medicare or Medicaid and who live in one of 15 zip codes around the east side are given a brief survey about their social needs. When a need is present, the patient receives a follow-up phone call or a meeting with a Community Health Advocate to determine the reasons behind the needs and to make a personal connection to community resources for help.
For Community Health Advocate Lead Crystal Schmerber, this work hits close to home—literally. Born at Community Hospital East, Crystal was raised on the east side and still lives in the community. Now she serves as an advocate for the neighborhood she’s known all her life.
That’s something Community Collaborations leadership determined is critically important to the success of the program. In fact, Community requires that all Health Advocates live in one of the 15 zip codes served through the CMS Accountable Health Communities grant. The reason is clear when you speak with them: It’s their passion for these neighborhoods.
“It’s who I am,” Schmerber explains. “There is a stigma associated with the east side, but there is a lot of good happening here. It’s the amount of goodness I see that drives me every day. It’s always in my heart.”
The program is continually looking for new perspectives and ideas. The formation of the Leadership Development Fellowship in Community Health brings together a group of Community leaders and a group of local leaders to tackle specific strategies related to social determinants of health. In addition, efforts are under way to explore how to enhance electronic communications between Community Health Advocates and United Way agencies to better serve clients.
With additional support, Community Collaborations can reach and connect more men and women to help in new ways—all with the goal of changing the health outlook of an entire community. It’s a big goal that Dr. Kunzer reiterates when he discusses what success will look like.
“Ultimately, are we able to redefine the meaning of health?” he asks. “This work is all about serving people. As Martin Luther King, Jr. said, ‘Life’s most persistent and urgent question is, “What are you doing for others?” ’ Our Community Health Advocates make a difference in the lives of people every single day.”