Beyond Hospital Walls: The Link between Health and Community

Pictured above: Sam Marks, Executive Director of LISC NYC, and Dr. Oxiris Barbot, First Deputy Commissioner at the New York City Department of Health and Mental Hygiene. Photo by Ricky Flores.

As part of LISC NYC's April 2018 health equity convening, two leaders shared their reflection in the emerging collaboration between community development and health. Sam Marks is executive director of LISC NYC. Dr. Oxiris Barbot is first deputy commissioner at the New York City Department of Health and Mental Hygiene.

Q. On a personal level, what brings you to this work? Are there particular experiences in your own background that inform or inspire your commitment to health equity in our neighborhoods?

Sam Marks: I grew up on East 96^th Street in the 1970s and ‘80s. At the time 96^th was this incredible barrier between the wealthy Upper East Side and East Harlem, El Barrio. So I was always navigating the dividing line between what looked like two different worlds—in terms of race and ethnicity, culture, and income, but just as starkly in terms of the built environment, things like housing and infrastructure. I could hardly fail to notice that 96th Street was the point on Park Avenue where the MetroNorth rail lines emerged. Look south from 96^th Street, and you see some of the grandest pre-war apartment buildings housing some of the most affluent people in the city. Look north, and you see largely walk-up apartment buildings and public housing.

For much of my career I’ve been working to bridge just this kind of divide. That’s what we do at LISC. We assemble resources to revitalize under-resourced neighborhoods, beginning with the physical and the concrete.

Dr. Oxiris Barbot: My early experience has also been profoundly influential. I’m a proud Nuyorican, born at Bellevue, a world leader in public-service medicine for literally centuries, and I lived in the Patterson projects in the South Bronx for my early years. As a teenager I went off to study at Yale. So I have navigated the dividing lines Sam speaks about, and I experienced firsthand the everyday struggles people go through when they live and work and raise families in a disinvested neighborhood. When I talk about substandard housing, it’s something my family members have experienced.

As a child, I always wanted to be a doctor. And I wanted, from the beginning, to pursue social justice in that work. I’ve carried that sensibility through my career, whether providing quality primary health care in an underserved community or helping to operationalize our work at the Department of Health to address health inequities.

Q. People often associate community development with housing and the built environment, while they think of health care as having to do with treating patients. Can each of you tell us how your own field has taken on broader goals and evolved toward this moment of collaboration? 

SM: In the early days, community development was all about physical change, rebuilding abandoned and distressed neighborhoods. As one of the nation’s first community development intermediaries, LISC’s role was to assemble capital and align a complex array of partners—financial institutions, philanthropy, civic leadership, community organizations, and city government—to accomplish this rebuilding.

Over time, our partners working in the neighborhoods began to move beyond a narrow focus on real estate to consider community needs more holistically. We at LISC did the same, maintaining a strong presence in technical assistance and financing for physical redevelopment, but also taking on economic development and jobs, educational opportunities, local leadership development—and community health.

In this new comprehensive approach to community development, we’re always looking for places where LISC’s role as intermediary can add value. Our CEO Maurice Jones has made addressing health disparities a central priority. We have some excellent program models here in New York City that we can build on. Reflecting on their progress will inform us in a key next step, which is to develop best practices for achieving and documenting health-related outcomes.

The health care and community development sectors speak different languages and see the world quite differently. We at LISC believe we can be instrumental in bringing them together, much the same way we brought disparate parties together to revitalize neighborhoods forty years ago—by translating, building organizational capacity, and developing systems and programs that allow for collaboration.

OB: Our healthcare delivery system is built to provide care for the sick, not to support prevention. As medical advances to address communicable diseases over the last one hundred years have improved life expectancy, chronic diseases have replaced them as the leading killers of Americans.  

I would argue that preventing chronic diseases is more complicated than preventing acute communicable diseases and requires focusing more intensively and for longer periods of time on what happens outside of clinical walls. Indeed, as we have moved to embrace prevention, health care necessarily began to look beyond the clinical setting to the far broader scope of our patients’ lives—their neighborhoods, their environmental exposures, the socioeconomic status that influences their access to everything from education to nutritious food. These are what we call the social determinants of health.

These determinants bring us to the issue of equity. It’s clear to us at the Department of Health that social inequity and income inequality are the major drivers of health disparities—they’re why people in one neighborhood can expect to live a decade or more longer than those in another neighborhood not far away. We’ve taken a particular interest in housing as a good place to introduce scalable interventions to redress health disparities. And that of course brings health care into a realm shared by the community development sector.

Q. More and more we’re seeing health care institutions and community development groups come together to address the social determinants of health. In forming these cross-sector partnerships, what are the biggest challenges?

SM: One obvious challenge has to do with funding. Resources are of course limited in both health care and community development, but perhaps the bigger challenge is that the money flows in two completely separate systems that are also highly complicated.

Settling payments with public payers and private insurers is a notoriously time-consuming process even for medical institutions that have employees wholly devoted to the task. So community-based organizations (CBOs) may be doing work that, for example, prevents avoidable hospitalizations and actually saves the health care system money. But in order to get funded as part of that system, these CBOs need help building their capacity so they understand Medicaid’s contracting and billing procedures.

OB: A related challenge is that the two sectors have different systems for collecting and analyzing data. In both fields, people have strived hard in recent decades to make sure our work is evidence-based—that we’re offering interventions and services that are proven effective—and to be accountable by tracking outcomes.

But our skills sets are different. So we in health care know all about outcomes related to, for example, diabetes and asthma; we know what markers to look for in assessing an intervention and how to collect and analyze those data. Community development people might know how to measure something like social cohesion, and understand the body of research linking social cohesion with other positive outcomes for a neighborhood. As we advance collaborations between the two fields, part of our work is to identify specific outcomes we’d like to achieve and what information we’ll need to collect to monitor progress. In doing that we can draw on expertise from both sectors.

Shared metrics of success then flow from this development of common language and evaluation of outcomes. Our early work with healthcare delivery systems and CBOs indicates that this is a pivotal area for understanding each other’s ‘business models’ and agreeing on ‘what has worked.’

Q. What should our models be? Can you give us an example of an exciting new tool or project that brings together the health and community development sectors? How will it advance health equity?

OB: I’d like to highlight an initiative that’s based in housing. Over the last few years Harlem Health Advocacy Partners has offered wellness activities, health coaching, and help navigating health insurance enrollment and billing to residents in five public housing developments in East and Central Harlem. It’s a project developed collaboratively by the Health Department’s Center for Health Equity and the New York City Housing Authority, along with the Community Service Society of New York and NYU-CUNY Prevention Research Center.

The basic premise of the intervention is leveraging economies of scale so that health coaching and other services provided through the initiative at the individual level can be amplified and reinforced by group activities delivered at the developments. We focused on five developments whose residents suffer a higher burden of chronic health conditions. One in five eligible residents took advantage of health coaching, getting guidance to better manage conditions like diabetes, hypertension, and asthma.

We are excited to report that these simple interventions do bring us closer to health equity. In the first two years of the program, the number of participants reporting their diabetes was controlled increased from 55 percent to 76 percent. Those reporting good overall health increased from 46 percent to 74 percent. That’s close to the self-described health status of age-matched white New Yorkers, the group most likely to enjoy and report good health.

SM: We are starting a very promising new program, thanks to a new grant from the New York State Health Foundation, which is going to allow LISC NYC to tackle exactly the challenges we’ve been talking about, head-on. Our initiatives on healthier food and housing have had two major constraints. One, we measured program outputs—how many people participated, how conditions changed, etc.—rather than true health outcomes. And second, while the start-up phases of these projects were funded generously by philanthropy, we have found it challenging to find more sustainable sources to maintain and expand them beyond their pilot phases.

The new initiative will create a New York City collaborative that joins health care providers with CBOs offering housing services in parts of Brooklyn and Queens. This coalition will plan, pilot, and implement housing interventions such as counseling or eviction prevention—along with new systems that will permit the CBOs to receive health care referrals, evaluate health benefits and, ultimately, make a value proposition and bill medical payers for their work.

We’ll be working with two local provider networks, OneCity Health and NYU Langone Brooklyn PPS. The New York Academy of Medicine brings evaluation expertise to the partnership. And our partner CBOs—Bedford Stuyvesant Restoration Corporation, Make the Road New York, and RiseBoro Community Partnership—are trusted change agents in the neighborhoods where they work, places where those ‘social determinants’ like dilapidated housing create real challenges to health.

Our aspiration is not only to establish a research-validated, sustainable funding stream to pay for services that support health in these neighborhoods, but also to create a model for other communities to do the same.