By: Stuart M Butler PhD and Caryn Hederman
Stuart and Caryn both have a long and distinguished history in the healthcare policy field and with Convergence projects related to health and wellbeing and are now leading the Convergence Collaborative on Social Factors of Health. After months of convening leaders across social sectors, the Collaborative released a Blueprint for Action titled Health Starts Here containing consensus solutions that address upstream influences on individual and community health, often called social determinants of health or health-related social needs. In this issue of Convergence Corner, Stuart and Caryn dive into what the process of achieving consensus looked like behind the scenes.
THE LANGUAGE AROUND SOCIAL FACTORS OF HEALTH
We faced a divisive challenge from the start of the project: what to call the issue at hand. Commonly known in the health field as social determinants of health (SDOH), the term refers to the factors outside of medical care that influence a person’s health status. The use of the term SDOH varies across the political spectrum. Conservatives talk about specific social needs that affect health but generally avoid using an umbrella term. Progressives tend to use umbrella terms which vary a great deal, including health-related social needs and more structural social drivers of health. Everyone seems to dislike, yet understand the meaning of, SDOH.
Using terms that press people’s political hot buttons discourages them from paying attention to the important issues at hand.We knew it could take months to address this language challenge alone, so, while we used SDOH to help everyone understand the issues we hoped to address, we made clear that it was just familiar shorthand. For the project, we developed the new term “factors” to create a more inclusive environment where everyone felt comfortable discussing the topic.
As project leaders, it is always important for us to be aware of the terminology people use and the potential ways it can alienate certain voices. Language is crucial to these conversations and taking it into account helped us focus the group on policy steps to create positive changes.
BUILDING TRUST AROUND SOCIAL FACTORS OF HEALTH IN LOCAL COMMUNITIES
Building trust when it comes to health is not easy. In communities, there is often suspicion across health, housing, social services, and other sectors. Outside of the Collaborative, we’ve encountered moments where communities bluntly stated, “We don’t want to deal with health systems; we don’t trust them.”
For these reasons, at the start of the Collaborative, we intentionally made it a point to ask people from different sectors to explain the purpose of their involvement and why they personally thought it important. We asked them to share why participation was helpful for them, and to explore honestly together what their needs and objectives might mean for improving social factors of highest priority in their communities. Through asking probing questions and making space for honest answers, we started to build trust and were able to better understand what might have remained unsaid in the beginning.
Take, for example, the concept of “community hubs” coordinating social services and resources for their communities. We learned through this Collaborative that deferring to trusted institutions within a community to perform this service can challenge health systems’ business models, because it requires sharing, and in some cases, ceding, control over health system resources with local populations. Communities are often skeptical about the intentions of corporate and government stakeholders. However, creating a community hub model can drive positive changes as partners to improve individual health and the health of their communities.
For partnerships to work, those changes must be developed carefully to ensure that community leaders are the ones driving change. Community leaders are understandably concerned about non-local leaders coming in from the outside and dictating new initiatives around health when the communities themselves are typically best placed to know their highest needs. Despite the best of intentions, external “savior” behavior generates suspicion, so the Collaborative made sure to center a primary policy objective of communities driving the change throughout the consensus-building process.
COMING TO CONSENSUS ON THE ISSUE AND SOLUTIONS
Consensus-building is the core of every Convergence project. There are moments of tension during every Convergence cycle. For this Collaborative, for instance, we faced fears that f health systems fund initiatives around social factors of health, with only a limited pool of funding, it could reduce funding for necessary medical treatments because money is diverted to social factors, like housing and food. We had to move past these obstacles through better understanding or compromise to begin creating the vision of a future reality that Collaborative members wanted.Fortunately, because we had built trust and understanding, we were able to move past these first obstacles fairly quickly.
An important and optimistic message for policymakers arose from our work: reaching agreement on effective ways to nurture improvements to social factors of health was perhaps the easiest consensus we’ve experienced throughout our time with Convergence.
THE POWER OF ADMINISTRATIVE CLARITY
We’ve been working in the health policy field for many years, looking at relationships within the healthcare field and related policy structures. But through this project, we learned just how much administrative change can accomplish and be done even without a huge overhaul. People tend to think that making progress in the healthcare field is always going to be a legislative battle. But there is a lot that can be fixed by simply enhancing administrative clarity. Organizations are trying to work together and use money from different programs to improve healthcare. However, they are aware it can be a criminal offense to misuse federal money. So, organizations need to be sure their innovations are legal – or they won’t even try them. But when they call 4-5 federal auditors in Washington, and receive 3-4 different answers, the uncertainty often leads to a lack of progress. So,the most basic consensus solution we agreed on is that federal agencies need to come together to agree on what can and cannot be done using money from different programs and communicate clearly which innovations are permissible and which are not. Indeed, several of our proposals are focused primarily on clarification.,
LOOKING AHEAD
We are now working to get the Collaborative’s Blueprint for Action and consensus solutions into the hands of decision-makers who can move the solutions forward, in part by connecting people to advance the participants’ consensus solutions. There are many avenues for this work to move forward, including replicating this project at the state level to get more on-the-ground action or create a spin-off project focused on certain populations (ex. families, young children, Medicaid recipients, faith communities) to dive deeper into the key solutions to improve wellbeing for those vulnerable groups. We’ve been pleasantly surprised by the excitement of the participants in this project. Convergence Collaborative participants own their work together. We are not here to force something that is different from their shared priorities. Our job is to help guide the group forward and find ways to overcome areas of disagreement. We are excited about the possibilities, which is why we are looking for more funding to advance the Collaborative’s efforts.
Generous support from funders, CommonSpirit, Episcopal Health Foundation, and Kaiser Permanente, made the Convergence Collaborative on Social Factors of Health possible. Their partnership contributed to “setting the table” for the Collaborative with their thought leadership, ideation, and support for the Convergence process, which catalyzed consensus and helped to build understanding across the Collaborative. And we are also grateful to UnitedHealth Group Office of Health Equity for helping us to promote and implement the Collaborative’s consensus solutions. Support for the Collaborative, however, does not constitute endorsement of specific consensus solutions made in this Blueprint for Action.