How Communication And Data Can Help Solve The Growing Health Divide

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When you consider moving to a new neighborhood, many thoughts probably come to mind. One of those may be, “Will this be a safe place for my family to live?”

Thanks to careful research by your local police department, you can look at maps that show you which communities have experienced increased rates of crime. By developing data in targeted neighborhoods that need the most attention to prevent and fight crime, law enforcement is not only able to make our communities safer and residents more informed, but it also uses our human and capital resources more efficiently.

Imagine applying the same principles to health care. Today, 1 percent of the US population accounts for 28 percent of overall health care spending, and 5 percent of the US population is responsible for more than half of all health care spending, according to the Agency for Healthcare Research and Quality.

While these numbers are startling, we see a tremendous opportunity to create a positive change. Just as law enforcement uses data to analyze and map out crime “hotspots,” the health care community can do the same to hone in on the heaviest users of the health care system in communities across the country—and that could help improve health outcomes and decrease spending.

We know that a person’s zip code has a greater impact on their health than their genetic code does.

Look at our nation’s capital. In Washington, D.C., ten out of the city’s more than 200 zip codes account for 83 percent of total D.C. resident hospital discharges. More specifically, residents in Ward 8 have the highest obesity rates and are least likely to exercise or consume the recommended daily servings of fruits and vegetables.

Map of Washington, D.C., Wards

Source: District of Columbia Office of Planning

A Localized Treatment For High-Risk Populations

Our organizations, the Aetna Foundation and the Brookings Institution, believe neighborhoods within cities have the power to be health hubs and create a long-term, positive health impact. In Washington, D.C., work is being done to connect clinical and community resources through a Health Insurance Portability and Accountability Act (HIPAA)–secure technology that allows for two-way communication between community-based agencies and health care providers about high-risk populations.

The DC Connect Project, supported in part by the Aetna Foundation, strives to build a virtual community of resources, including information on clinical providers, aging support services, housing, nutrition, transportation, and family support groups through a privacy-protected, patient-centered technology, along with intensive support for residents in need through case management as well as peer-to-peer supports.

For some context, more than 161 high-risk patients have been identified with at least one of the following criteria:

  • Recently hospitalized in the past six months
  • More than two emergency department visits in the past six months
  • A provider has screened the patient and answered “yes” to the following question: Would you be surprised if this patient died in the next six months?

The following chart illustrates that just these initial identification strategies also revealed complex additional community needs that are not traditionally dealt with by the health care system.

High-Risk Patient Characteristics (percentage seen in total of 161 patients)
Disease Types Congestive Heart Failure 13%
Hypertension 55%
Depression 23%
Diabetes 18%
Pulmonary Disease 11%
Chronic Renal Failure 8%
Cancer 12%
Identified Community Needs (top needs identified) Problems navigating health services 42%
Transportation issues for medical visits and associated costs 23%
Concerns about falls at home 18%
Food insecurity 12%
Worries about dying alone 9%
Employment insecurity 7%
Housing instability 5%

Scalable Impact

The DC Connect Project currently addresses high-risk populations in the District of Columbia. With support from the Aetna Foundation, the project will help to improve and streamline a community-based effort that can be scaled for greater impact in more cities in the United States. We encourage and support the development of similar models that will improve the health of communities and neighborhoods across the country.

Community partners play a significant role, but it’s a two-way process. Many times, community partners are the first to identify health needs or issues, and often they also have the trust of community members, particularly in vulnerable populations.

Together, we’re working on a shared vision—to bend the cost curve while improving the quality of care and bringing together community partners to provide resources to high-risk populations that need them most.

We all have a role to play when it comes to improving the health of our communities. By working together to identify “hotspots,” we can create a healthier world—one person, one neighborhood, one community at a time.

Related Resources:

“Defeating The ZIP Code Health Paradigm: Data, Technology, And Collaboration Are Key,” by Garth Graham, MaryLynn Ostrowski, and Alyse Sabina, GrantWatch section of Health Affairs Blog, August 6, 2015.

“Zip Code Overrides DNA Code When It Comes To A Healthy Community,” by Anne Warhover, GrantWatch section of Health Affairs Blog, January 30, 2014.


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