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The way to healthier cities goes beyond healthcare

Improving urban health outcomes requires dramatically better access, and a commitment to addressing the underlying social and environmental factors.

By Shaina Doar

Care lab red cross

Stephen Groeneveld / Flickr

UPDATE (October 2017): Care Lab is now Cityblock Health. Read more about Cityblock's vision for urban health here.

The U.S. spends more on healthcare per capita than any other OECD nation, but it still ranks low on many health measures, including life expectancy. These high costs stem largely from a system that traditionally focuses on treating acute medical conditions, which tends to be far more expensive than taking preventative measures and investing adequately in social services. Those patients with the most complex needs, both medically and socially, are driving the costs and achieving worse outcomes.

As social activist Geoffrey Canada said in a talk just this month: "Health disparities are totally un-American." So why do we tolerate such catastrophic outcomes for whole swaths of our population, at such enormous financial and human cost?

We tend to think of health as a medical problem, but the roots of many health issues are social or environmental factors that can't be seen from within the walls of the doctor's office. Non-medical factors account for 60 percent of a person's health outcomes --- more than genetics or health care delivery. For many people, these factors are closely tied to the urban environment. Unreliable transportation results in millions of missed medical appointments each year. Poor air quality contributes to respiratory illness and infant mortality. Limited access to healthy food can lead to obesity and diabetes. Housing costs and financial stress can create anxiety that exacerbates other problems.

Ignoring these social or environmental factors until they become acute medical problems can end up costing the healthcare system billions of dollars a year. Historically, the system hasn't done a great job addressing these underlying health determinants, because healthcare providers have worked on a "fee-for-service" basis, with an inherent incentive to provide more reactive medical care. But better payment models are starting to incentivize providers to share in the cost savings that come from more proactive care. Such "value-based payment" mechanisms are becoming more common, and signal an opportunity for new, creative ways to step outside the traditional model of care.

As part of our thought experiment into the future of cities, Sidewalk's Care Lab has been imagining how care delivery might look in the digital era. We believe the right data and tools can strengthen trust and connections between caregivers and patients. With more context, more coordination, and a better understanding of needs, care of the future can go beyond reactively treating medical conditions to proactively improving a person's health.

It starts with access

A healthcare desert is an area with very few primary care clinics. They tend to exist in lower-income areas with larger minority populations. In Sidewalk's home city of New York, for example, large parts of Brooklyn, the Bronx, and Upper Manhattan have been designated "shortage areas" by the federal government (the technical term for deserts). Tragically, these neighborhoods tend to be home to patients with multiple chronic medical conditions who need care the most.

The result of poor access is care that's reactive, expensive, and inequitable. Nobody wins --- not the doctor, not the patient, not the community, and not the healthcare system.

Others have been thinking about making care more accessible for some time. Urgent care companies like CityMD and primary care clinics like One Medical have made strides in improving the patient experience with same-day appointments, short wait times, and fast diagnostics. But we need to bring a similarly patient-centric approach to more areas --- especially those with least access to care.

We think we can go a step further. Imagine remote monitoring (with built-in privacy protection) that streamed data directly from patient to care team, sending alerts when a worrisome condition is detected. Or the ability to reach out to a clinician 24/7 for a consultation over phone, text or video. Or a whole team of care professionals using digital communication tools to seamlessly work together, in collaboration with community-based organizations, to get patients the care and services they need. Or using all of the social and medical data at our disposal to anticipate needs and proactively bring patients into the clinic before illnesses escalate.

Nothing can replace person-to-person interactions. But digital technologies can make each interaction easier, more compassionate, and more effective.

But it goes way beyond access

Policy makers, caregivers, and others in healthcare have long understood the connection between social needs and healthcare. In their terrific 2013 book, The American Healthcare Paradox: Why Spending More Is Getting Us Less, health policy scholars Elizabeth Bradley and Lauren Taylor made a compelling case that underinvesting in social services --- like food, housing, and behavioral health --- may explain how the U.S. spends so much more on healthcare and gets worse outcomes compared to peer nations.

Intuitively, it makes sense. You can't get your heart disease under control if you don't have access to good food, for instance. The research bears this out. Hypoglycemic ER admissions tend to spike for low-income diabetics in the last week of each month, when their monthly food budgets run out. Studies have found loneliness to be as dangerous to mortality as well-established risks like being a lifelong smoker or drinker. Poor building conditions with health risks like lead poisoning disproportionately impact low-income families. So it's puzzling that we don't design care with greater context in mind, especially for the most vulnerable patients.

We have been inspired by existing models that think holistically about health (some that go back decades). The Camden Coalition in New Jersey, for instance, pioneered a "hotspotting" approach that identifies the most complex patients in a neighborhood, and deploys dedicated care workers to help them get the services they need --- made possible by integrated data systems that alert health providers to patients who need attention. City Health Works, based in Harlem, sends health coaches hired from the neighborhoods they serve into the homes of low-income patients with multiple chronic conditions, with the aim of building relationships and helping patients navigate the complexities of the healthcare and social services systems. The Commonwealth Care Alliance is a Massachusetts-based nonprofit care delivery system that selects the care team based on not only medical needs but also their level of engagement with the health system and their social context.

We see an opportunity for emerging technology to take such good ideas and amplify them. With mobile phones and even better digital tools, we believe we can get more care workers out of the clinic and into neighborhoods, enabling them to address people's needs on the ground. We can become smarter about how we collect data about a person's social circumstances --- whether empowering care workers to document what they see, or encouraging patients to engage with providers more directly. We can also improve coordination among social services agencies, and help these agencies exchange data with the health system from which they're currently cordoned off.

Broadly speaking, the lack of social-needs data being available to a wider care team is a key driver of why these needs often go unmet: we can't fix what we can't see.

The type of care we think is possible

When you reimagine neighborhood care in the digital age, we believe a new type of "whole person care" becomes possible:

  • Care that's accessible. Care should be available to city residents in the most convenient ways possible. We could imagine a much higher density of neighborhood clinics, home-based care, and fast and easy remote consultations. This would help "break down the walls" of the traditional care system to be more accessible --- and more effective.
  • Care that's personalized. Every person should have access to the right set of health professionals --- whose backgrounds go beyond medicine --- to deliver a care plan that works for them. Patients can be empowered by digital technology to remain connected with their care teams and engaged with their health over time.
  • **Care that's contextual. **A big part of physical, mental, and social health will be monitoring and addressing the social and environmental determinants at the root of so many problems. We believe care teams should be empowered to provide solutions and interventions for issues beyond strictly medical conditions. In other words, they should be able to "prescribe" from a larger toolbox that addresses the causes of illness.
  • Care that's smart. Patients shouldn't have to spend their time navigating the healthcare system and coordinating among care providers. And caregivers, whether social workers or doctors, shouldn't have to spend so much time on administrative work or trying to coordinate with each other. Digital tools that streamline workflows and have the ability to surface and share data quickly and easily can go a long way.
  • Care that's more affordable and equitable. We want to care for vulnerable patients with complex health and social needs in a way that is at least as good as the care the rest of society has access to. That becomes possible when you leverage outcomes-based payment models to align incentives between healthcare providers and patients who require care delivery that's more sensitive to social needs. It's also possible with new data that can accurately capture those needs and reliably measure outcomes.

We know that a new way to care for people with complex needs is not going to spring up overnight. We also know that seeing this change happen at scale will require lots of work, community by community. Technology is only part of the solution. Real, systemic change requires new funding arrangements that incentivize providers to address social and environmental health factors on a longer time horizon. That means policymakers have a big role to play in enabling value-based payment models that encourage the delivery of social services to address the root causes of poor health.

Further, deploying a new model of care will involve many stakeholders coming together in the modern city. That includes physicians, nurses, and other medical professionals; policymakers, urban planners, community organizers, and social service providers; engineers, designers, and privacy experts; and of course, it means patients. But this is precisely the group of people we hope to bring together at Sidewalk Labs to continue this conversation and help us explore its transformative potential.

This post was co-written by Mat Balez and Lindsay Ullman. The authors would like to thank Sidewalk colleagues Bay Gross and James Merkin for their helpful input, as well as Harvard health policy scholar Lauren Taylor.