Nashville General Hospital CEO Joseph Webb created an eponymous health equity model in 2015 to work toward improving care the public health system delivers to low socioeconomic status patient populations.
Today, the model has contributed to key health metrics, notably higher numbers of people controlling blood pressure and A1C levels.
Health Evolution Editor-in-Chief Tom Sullivan interviewed Webb about what inspired the model, its various components and what’s next for Nashville General’s work advancing equity.
What are the principles your model is based on?
Webb: The U.S. is the only industrialized nation that does not recognize health care as a right. I want to be clear that this is not a knock, it’s a fact. Health care isn’t a right so each area has to fend for itself and create its own policies because a pandemic or epidemic will attack the weakest link. We saw it with AIDS, chronic conditions and now COVID-19. The weakest link are the people and communities in the lower socioeconomic status because they often don’t have policies or infrastructure that guarantees access. What we have to do then in our communications with populations in that socioeconomic status that cannot afford care is mitigate the effects. How do you address that? You have to create models that regardless of socioeconomic status there is high quality patient-centered care. That care also must be coordinated because those individuals who don’t have access only seek care when they are sick or in an emergency.
Five to 10 percent of our population drives 60-70 percent of the costs and that usually falls in the lower socioeconomic status group and that population falls largely into the care of a public hospital. So hospitals have to create an environment that embraces the population by making sure they are comfortable coming to you, establishing programs to treat people and educate them about their condition.
Q: To achieve that, what does the Webb Health Equity Model consist of?
Webb: We take the chronic care model, community resources and self-care and we use those with the patient-centered medical home model and patient-centered specialty practices. We take the standards from those and that creates the operational activities, like a patient referral process and follow-up to track patients throughout the care process.
Q: How is Nashville General addressing the self-care element?
Webb: One of my mantras is “the best care you are going to receive as a patient is the care you give yourself.” Among the most critical elements we have to deal with is health literacy — the ability to listen to your physician and understand how to apply it — because, unfortunately, only 12 percent of the US has a high level of health literacy. Among lower socioeconomic patients that percentage is probably less because it correlates with education. That in and of itself is the most critical element for caring for this population. We integrate health literacy into our chronic care model for patients and their families as well and we have evidence-based models in place to care for our population.
For example, individuals with lower socioeconomic status often have food insecurity. When someone tests positive for food insecurity, we refer them to a doctor who will write them a prescription from our food pharmacy to start the healing process. We created the food pharmacy based on the premise that food is medicine. It’s located in the hospital, set up like a grocery store, so people who need it can access food for hypertension, diabetes, cancer.
We also created the Congregational Health and Education Network because spiritual leaders can have a major impact on how people view aspects of their lives when they are seeking health care. CHEN today consists of more than 100 congregations and 15,000 members. It’s based on the premise that you cannot achieve health equity until there is a more equitable distribution of care so we focus on educational attainment. As education elevates, the social determinants become less impactful so we focus on areas with the strongest correlation to improved outcomes.
What are some of the results achieved since 2015 when you started this work?
Webb: We track key metrics, blood pressure control, A1C blood sugar and what we see statistically is an increase in the number of patients who are controlling blood pressure and A1C. Another key success that was not expected is that through our food pharmacy, while we were focusing on making sure people with chronic illness had proper healthy food, it’s also beneficial to our cancer patients. When a patient is going through chemotherapy, they have to maintain a certain weight level and if they fall below that they have to cease chemo until they get their weight up. All our cancer patients now have access to high calorie food through the food pharmacy — helping them maintain weight means the cancer survival rate increases.
What have been the biggest challenges?
Webb: Public hospitals tend to rely partially on taxpayer dollars and that’s always going to be a challenge because of competing priorities for those taxpayer dollars. That creates a more political environment. So we are constantly navigating environmental threats of what will be available. Our strategy is to become as self-sufficient as possible by attracting customers who can pay to offset those who cannot pay.
What’s next in terms of Nashville General’s work to advance equity?
Webb: The challenge is for public entities to focus on areas that truly make a difference in our communities: hypertension, COPD, diabetes. An individual’s care is their connection to health, without health nothing else matters. Our goal is to make sure the burden doesn’t fall on those populations with lower socioeconomic status. Health equity is a social justice issue. It’s never going to go away. Those individuals need access to the same level of health care as anyone else to maximize and attain their full life potential. The good thing is it really doesn’t change a lot. Those chronic conditions are the ones that are really going to make a difference.