Investing in healthy cities

What does it mean for a health system to invest fully in its community? Dozens of health care organizations across the country are learning that the commitment goes beyond typical community benefit programs and requires innovative thinking about partnerships. It’s a mindset shift for many health care leaders but one that could be the future of sustainable, preventive population health.

With those goals in mind, in May 2016, the Robert Wood Johnson Foundation, in partnership with the Reinvestment Fund, launched Invest Health, an 18-month initiative aimed at transforming how civic leaders collaborate to help their low-income communities thrive, with particular attention to such social determinants of health as access to healthful food, safe and affordable housing, and employment. The partners awarded a total of $3 million — $60,000 each — to 50 midsize American cities in 31 states.

“We know we need to change how we achieve health in America, and we saw Invest Health as a way to convene leaders across sectors to collectively problem-solve by learning how health care, community development and finance could work together,” says Abbey Cofsky, managing director with the Robert Wood Johnson Foundation. “The Reinvestment Fund has long been involved in community development, and we saw this partnership as an opportunity to make use of their reputation and expertise within a learning community infrastructure. There was no existing playbook — this has been a chance for cities to learn from their partners and for us to learn from them.”

A new dialogue

The Reinvestment Fund is a community development financial institution that brings together investors, foundations, government officials and community organizations to invest in infrastructures that improve the long-term quality of life in low-income communities. For more than 30 years, it has funded affordable housing, grocery stores, schools and health centers in underserved areas — investments that traditional banks typically find too risky.

“In large part because of the [Affordable Care Act], there has been increasing momentum around community development and health outcomes,” says Amanda High, chief of strategic initiatives with the Reinvestment Fund. “The Robert Wood Johnson Foundation has been a critical thought leader in that conversation and, although we’ve supported healthier communities since our beginnings, we haven’t [previously] been in a robust, direct dialogue with health systems and similar stakeholders. We are mission-driven lenders, and with Invest Health we are asking: ‘What does health equity mean? What maintains a system of disparities? And what levers need to be moved to improve that disinvestment over time?’”

Each Invest Health awardee city was asked to form a team of five key stakeholders, including representatives from the public sector, community development and an anchor institution — typically academic- or health-related. “Health systems are natural partners for what it takes to effect this type of change,” High says. “They have relationships that allow them to tap those with other types of expertise, such as real estate, purchasing and policy, as well as access to unique data to refine our initiatives.” Team members also came from public schools, local philanthropies and chambers of commerce, among other city-specific sectors.

Over the initiative’s 18 months, all 50 teams convened several times as a larger learning community, sharing knowledge, challenges and successes, as well as working with Invest Health faculty advisers and coaches.

Why midsize cities?

Invest Health cities launched their community improvement efforts from a base of varying levels of experience. “We chose midsize cities for this effort, not only because they have enormous needs to improve health and address poverty, but because they are small enough to get things done,” Cofsky says.

Some cities already had established initiatives and partners, while others met for the first time as an Invest Health team. Those with more experience have been able to “charge ahead,” High says, but those new to such multisector collaborations have often brought original perspectives to the table. The combination of seasoned and nascent groups “pushed all the teams to look with fresh eyes at problems they thought they understood in new ways,” High says.

One such seasoned Invest Health city is Grand Rapids, Mich., where Spectrum Health has long been involved in community benefit programming with multiple civic partners. “We examined our census tracts and decided to focus on a specific geographic area,” says Jeremy Moore, Spectrum Health’s director of community health innovations. Targeting southeast Grand Rapids, the team identified five priority areas: affordable housing development, food security, economic security, improved birth outcomes and lower infant mortality.

“We then asked, ‘What are the interactions that will create something better, using investments?’” Moore says. “Once you identify who’s already doing good work, you bring them to the table and ask, ‘What do you need?’ That allows equally passionate people to have powerful conversations.” The team eventually decided to further hone its focus on housing and employment.

To increase the amount of affordable low-income housing in the target area, the team sought support from LINC UP, a local nonprofit organization dedicated precisely to community improvement in the southeast part of the city. In presenting its report to gain LINC UP funding, the Invest Health team had a further realization: “A light bulb went off for us that healthful housing is as important as affordable housing, so we’ve also focused on home remediation — getting rid of problems like asthma triggers and lead removal,” Moore says.

Similarly, understanding that employment is directly linked to health outcomes, the Invest Health team analyzed what basic income levels, along with social service support, would allow area residents to live healthier lives. As Grand Rapids’ largest employer, Spectrum Health’s human resources department was able to supply considerable data to answer that question. “We can’t expect people to get healthier without focusing on their wealth,” Moore says. “We know intuitively that when we invest in pulling people out of poverty, there are health benefits.”

Changing plans

In contrast to Grand Rapids, the Tennessee city of Jackson and its anchor institution, West Tennessee Healthcare, centered grant funding on a single project. The city's Invest Health team wanted to renovate a historic but largely vacant high school in east Jackson. The team originally had envisioned turning the school into a wellness and fitness center with an additional farmers market. But in door-to-door surveys in the low-income neighborhood bordering the school, student canvassers from team member Lane College learned that its primarily elderly residents had more basic needs.

“They were concerned with safety, education and life skills,” says Lisa Piercey, M.D., executive vice president, West Tennessee Healthcare. “They told us they wanted a safe place to socialize and learn — we didn’t even realize the number of elderly who lived in this blighted area.” Canvassers received numerous requests for adult education and computer literacy, as well as to mentor neighborhood teens. The team now plans to create a mixed-use facility that includes a senior center, job-training services, a demonstration kitchen, a community history center and mentoring activities to engage local youth, anticipated to improve neighborhood safety.

“Our plans morphed after asking the community what it wanted,” Piercey says. “It became very apparent that the aging population was the business case, and that solidified the most valuable use of the space.” As the team moves to seek investors and funding for the renovation, Piercey says constructive criticism from the Reinvestment Fund has helped shape its success. “They challenged us to think more broadly about social determinants of health, beyond just the building itself,” Piercey says. “We learned that we had to expand our scope to lift the project, engage ancillary stakeholders and look at the community as a whole. That’s been a valuable lesson — learning to merge everyone’s needs to serve a greater purpose.”

Lessons learned

Reflecting on the concluded initiative, High says the Invest Health teams varied widely in the number and types of issues they chose to work on and the ways they approached them. “We had hoped that community development team members and health systems would come to understand each other's models and learn how to harmonize their visions and tactics,” she says. “The most distilled part of that nexus has been between health system and investor team members — and there [have] been a lot of genuine ‘aha’ moments on both sides of the table.”

She adds that the partners’ periodic all-city meetings have contributed to broader team building. Anchor institutions have discussed common concerns with other anchor institutions, public health officials have compared notes with other public health officials and so on, creating nationwide sector-based teams in addition to the city-based teams — another overarching goal for Invest Health.

“The value proposition is to build relationships that create the potential to work together in new ways over time,” Cofsky says. “We’ve learned that success has to do with leaders who are focused on mission. This is an opportunity to learn how the whole is bigger than the parts, and that a larger agenda can be a focus for creating change.”

“Health systems can benefit from understanding that CDFIs like the Reinvestment Fund are really good at gathering different capital streams and partners together into one structure,” Moore says. “They have been underused in the health care space — and this work would be much harder without this type of partner.”

Cofsky and High say their organizations plan to convene a national summit later this year with all 50 teams to see how they have sustained their momentum and how they envision their future. Lessons from the program also will be disseminated through the Invest Health website.

“The Invest Health model is effective when we go beyond engagement to community organizing,” High says. “Organized people plus organized capital plus longitudinal data equals a field of possibilities grounded literally and figuratively in ways to achieve equity. This work is thrilling and daunting — and it’s an entirely different way of doing business.”

Laurie Larson is a contributing writer to Trustee.