Transitioning from health care to a broader domain of services

Clinicians and the organizations in which they practice are moving beyond episode-based health care delivery and into the communities in which they exist, delivering services that would normally seem outside the scope of medical practice.

One of the most interesting aspects of the transformation occurring in medicine is the effort that some organizations have committed to reexamining the scope of their business. As payment and delivery reform change the landscape of clinical care, some have expanded their reach beyond the delivery of health care into the realm of promoting overall health. As an internal medicine trainee taught to care for patients holistically, I am encouraged by many of the early changes occurring around me.

The domain of health care involves what occurs within our clinic and hospital walls, for example, vaccinations, cancer screenings, and care during episodes of acute illness. In contrast, the domain of health requires clinicians to move beyond those walls into the surrounding communities, working with partners to address aspects of health such as food options in schools, the adequacy of services for pregnant women and the elderly, and the like. This movement equates to increased focus on public health and social determinants of health.

While health practitioners have always espoused an ethos of compassion and community involvement, explicit organizational focus has not always been placed there. Recent policy and payment changes, however, are now providing tangible incentives and frameworks for carrying out these ideals.

Some organizations, such as Montefiore Medical Center in New York City, have served as promising early examples of this effort. Recognizing that housing instability is a major risk factor for frequent, repetitive emergency department use (widely recognized as a poor way to receive ongoing care and a major source of cost for health care systems), the organization created a system to help place patients into transitional housing units. It has also extended services into homeless shelters and worked with a public school district to campaign for low-fat options to be introduced. Of importance, Montefiore has managed to do this while protecting a respectable operating margin.

A number of other institutions have started similar initiatives, all with an understanding that expanding the scope of health care may prove better for our country's patients and the organizations that serve them. They are expanding their community outreach programs and using their outpatient clinic networks to offer health promotion programs and services for their patient populations. Many enlist different versions of community health workers who help patients navigate the health care system and also coach, advise, and follow up with them. A pioneering few have even brought patient members onto steering committees and advisory boards to better understand local community needs.

Admittedly, early examples are far from perfect, and as health care organizations extend their reach into communities, they must answer several important philosophical and economic questions about the extent of their responsibility. Risk assumption and community outreach will mean very different things for organizations of varying sizes and resources, as well as for different populations with different demographics. These aspects must be carefully considered when creating new incentives and policies.

However, the effort is laudable, and other types of health organizations appear to be catching on as well. In a move away from its long-standing focus on access, disparities, and health services research related to chronic disease, The Robert Wood Johnson Foundation, one of the nation's most prominent health philanthropy organizations, has refocused its efforts on building a culture of health through the consolidation of human capital programs and the creation of new partnerships and opportunities. Some private insurers have implemented studies and programs that focus on health rather than health care-related activities.

The private sector has also begun getting in on the action. CVS Caremark made a significant change by announcing that it would stop selling tobacco products in some locations. Food companies are also stepping into the fray, with companies such as The Campbell Soup Company partnering with a foundation to promote health by improving access to healthy grocery store offerings.

While early results are promising, it remains to be seen whether or not these changes will create lasting differences in overall health. Research must continue to evaluate the value and cost savings associated with emerging programs, and organizations must be able to maintain viable business propositions as they refocus their business scope. Continued support from funders and private sector partners will likely be necessary to maintain this early momentum. The medical community must also carefully consider if and how to train future physicians so they can incorporate these changes into their future practices.

I am hopeful that many of these efforts will make tangible impacts. Ultimately, the movement toward a more health-focused future represents the promise of more cost-effective, higher-value care, and also of better health. For trainees, the convergence of economic and policy pressures also represents a new career pathway for channeling the compassion, humanity, and community-mindedness that drew many to medicine in the first place.