How can Main Street, America, move the needle in a city’s population health and wellbeing? It begins with a solid, organizational structure built for the long term.
I fondly call my hometown, Nashville, the “Silicon Valley of Health Services.” With 18 publicly traded national health care companies headquartered here with annual global health care revenues of over $70 billion, our city takes health seriously. One in 10 workers in the Nashville metro area are health care providers, nurses, or health aides. Even more work in the broader health sector, such as health management, financial, and legal roles. We have two outstanding medical schools, six schools of nursing, a dental school, and two schools of pharmacy. Our city is in the business of providing multiple health services to every state in the country.
Here is the cruel irony. When you compare us to similar cities, the health of Nashvillians is poor. We smoke at rates higher than Charlotte. We have blood pressure rates that exceed those in Austin. Our obesity rate surpasses Cincinnati’s. Our infant mortality rates are not even competitive. Our babies are more likely to die in their first year of life than in countries like Croatia, Serbia, and Qatar.
How can that possibly be? One of the things they didn’t teach me in medical school is that health services delivered accounts for only 10 to 15 percent of a population’s health status. We can build the best hospitals, provide the richest health plans, and I can be the best heart surgeon possible, but behavior and how and where people live, eat, work, and play have a far greater impact on an individual’s health.
Discover your community’s health
I first learned how poorly my city compared to others when I ran across the Robert Wood Johnson Foundation’s annual County Health Rankings. It was a rude wake up call. As a doctor and one familiar with our city’s reputation as a health services capital, I proudly represented Nashville as a senator in Washington. We could not possibly be that bad. But we were.
It was clear that Nashville’s recent national publicity as an “it city,” exploding with new restaurants and creative music and attracting a huge influx of dynamic, young people, would not be sustained for long without a solid foundation of good health.
So I along with a handful of other interested citizens set out to determine what could be done to change the trajectory of a city’s health equity and its people’s well-being. And this sparked an idea that has become a robust community initiative to build a countywide, collaborative health movement. It’s called NashvilleHealth. But we didn’t get to this point overnight.
First, we began investigating other cities’ population health initiatives to see what we might adopt. We sought advice from national leaders in the field of regional health transformation. And then, to learn about the many existing, but too often siloed, efforts underway to address Nashville’s health needs, we intensively engaged our local community. In fall 2014, we convened a town hall to discuss intervention options.
From this early groundwork, it became clear that Nashville was unique (as headquarters to the many national health care chains, for example) and would best benefit from its own Nashville-developed solution.
High level leadership, comprehensive local engagement, and a clear mission
Highly visible and effective CEO leadership would be fundamental. In the summer of 2015, we were fortunate to have the experienced and highly respected former head of the Nashville Health Care Council, Caroline Young, step into the role of Executive Director for NashvilleHealth. She and a few volunteers began a formal listening tour, and in a little over a year, a small and nimble NashvilleHealth team had held over 200 community meetings uncovering issues, interests, challenges and success stories from a vast array of local entities and national partners.
The next essential element was to clearly define a concise and easily-communicated mission statement to articulate what the organization stands for, its values, and what it wants to achieve. For NashvilleHealth, our mission is to substantially improve the health and well-being of Nashvillians. The goal is to make Nashville one of the healthiest places to live in the state and the nation by achieving measurable gains in the health of its residents. It’s a tall order, but one that we honestly believe is achievable through a focused, sustained effort grounded in action and implementation, not just diagnosis and white paper recommendations.
Essential early partners
Importantly, our fledgling organization recognized from the outset the importance of strong governance, legal standing, nonprofit status, transparency, and accountability. To that end, we partnered with our resourceful and highly respected Community Foundation of Middle Tennessee for the initiative launch. By facilitating administrative support and grant management, the Community Foundation provided the organizational structural backbone to allow us to hit the ground running
We also made it a priority to build strong partnerships with our region’s respected academic institutions. Such relationships inherently bring objectivity and unbiased data analysis; it brings a critical eye and peer review; and in my experience it brings knowledge and a source of continued innovation led by curious minds. A great example of this collaboration is our partnership with the Vanderbilt University Department of Health Policy (VUHP), led by Dr. Melinda Buntin, our partner in evaluation and metrics.
Our commitment to build an initiative that would be sustainable for years to come, and—equally important—replicable by other cities across the country, led us to the mantra that “all we do or aim to do must be measurable.” If we can’t measure or quantify it, we likely can’t scale it and replicate it as a model for success. For that reason, the support of Dr. Buntin’s team has been exceedingly valuable. VUHP has given us a lens through which to better understand how to frame and measure our efforts, and will be our third-party evaluator as we begin to implement interventions.
After nearly a year of community outreach and a few corporate and philanthropic seed donations, we received funding from the Robert Wood Johnson Foundation in September 2015, as did Vanderbilt, to further build out our initiative.
A highly disciplined prioritization process
In September 2015, the NashvilleHealth and VUHP teams came together to engage in the priority-setting process. NashvilleHealth had a starting goal of targeting three health priorities via pilot projects in Nashville/Davidson County. We gathered and assimilated multiple data sets and conducted a comprehensive review of health priorities identified by all local stakeholders. From this process, a universe of 14 potential health priorities emerged.
To further narrow the number of alternatives, a further refined filter of nine criteria was applied:
- Is this a real and pressing health issue for Nashville?
- Do we have partner/sponsor interest in this area?
- Are there successful programs or an evidence base to address this issue? Can we model them?
- Are there measurable, achievable metrics? Are there data to monitor and evaluate progress?
- Do we have reliable data about this issue in Nashville?
- Does it address health equity?
- Is it novel?
- Are we able to show success in a timely manner?
- Is it scalable?
After extensive discussion and analysis, we settled on three initial priority areas:
- tobacco cessation,
- hypertension, and
- child health with a particular focus on infant mortality.
From there, we sought to determine the most current evidence-based models to consider for addressing each of the three areas. VUHP conducted extensive literature reviews to create summary documents of the best practices.
Expert advice: Distinguished national expert panels and local stakeholder ownership
To guarantee local ownership, while at the same time ensuring that we were drawing upon the very best, peer-reviewed expert advice in the country, we developed a disciplined, two-pronged approach. For each area of focus, we developed a national panel of scientific experts and distinguished thought leaders to produce recommendations specific to Nashville, and for each we developed an inclusive, local stakeholder working group who took those recommendations and revised and further substantiated them based on their more direct knowledge of local resources and realities.
In advance of each national expert panel’s meeting, NashvilleHealth provided a complete environmental and demographic scan of Nashville to give them a working understanding of current data and efforts underway in their field. The panelists were then asked to weigh in on a number of evidence-based intervention options within four domains: health care, community engagement, policy, and media. Their recommendations and insight formulated our “Prescription for Nashville.” We then shared each prescription with the regional stakeholder working groups to obtain their more locally informed insights into the feasibility of proposed strategies and next steps for operationalizing them. An implementation roadmap for each area is devised.
To ensure broad engagement and early credibility, we established a Governing Board which included our city’s leading employers, top health care providers, and key public officials. Oftentimes public health efforts fail to integrate the financial engines of cities, and this is a missed opportunity. The NashvilleHealth team intentionally sought out leading corporate executives in our county to serve on the Board to ensure business engagement. Americans spend a third of their time at work, and often cite lack of time as a reason to skip the gym or buy takeout instead of cooking at home. By encouraging Nashville’s employers to make health a priority in the workplace, it will give us a leg up in making health a shared value in the community.
Furthermore, the Governing Board is structured to promote our organization’s longevity and freshness. Board members have three-year terms. And because NashvilleHealth is a nongovernmental organization and not associated with any sitting elected official—like many population health efforts today—its funding and support should not be vulnerable to changes in our state’s elected leadership.
Reporting to the Governing Board is our action-oriented Steering Committee, which includes 24 passionate and engaged community, business, and government activists who work and volunteer in the broadly defined health space. They are the workhorse that drive implementation of our outcomes-based solutions. These committee members are each tasked to lead efforts within our three intervention areas.
Execution and implementation
Too many commissions stop at this point, listing recommendations but falling short of implementation. We are now in phase one of a multi-year plan of facilitating and ensuring execution of these evidence-based, locally vetted initiatives to improve overall health. What that looks like will be different for each health area — it might be maximizing reach and efficacy of youth smoking cessation programs that we know are effective, a hypertension education and treatment partnership with local employers and churches, or a safe sleep campaign that more broadly reaches caregivers beyond the infant’s mother.
But one thing is certain: if Nashville wants to maintain its status as the new “it” city of the South, it must foster a culture of health and well-being that makes our city one where employers want to hire and parents want to raise their kids. NashvilleHealth will help to make that a long-lasting reality.