Alec Bojalad

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Red rocks, copper mesas and verdant patches of green dot the landscape of Washington County in southwestern Utah. The rusted hills of the Red Cliffs Desert loom to the north. The Virgin River to the south trickles on at its own inexorable pace, eroding the rock around it into ethereal art. To the east, Zion National Park is a natural metropolis unto itself, with thriving networks of rocks, hills, rivers and vegetation creating one of the country’s most picturesque vistas.

Southwest Utah is nature’s reminder to humanity that it can never be nature’s equal as an artist. The county seat, St. George, is evidence that we’ll continue to try anyway. The city is populated with the familiar, lovely landmarks of a thriving municipality dropped into the otherworldly landscape: a town hall, baseball fields, pristine, well-paved parking lots and reservoirs dug into the rugged earth well enough to pass for lakes. It’s as if someone built Main Street on Mars.

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Naturally, St. George is one of the tourism capitals of the Southwest. Visitors come from all across the country to take in the scenery. The city’s economy is growing. Home sales, commercial investment and the population are all on the rise. Like the nearby majestic red rocks, however, sometimes the imposing grandeur covers the cracks at the bottom.

Despite the booming economy, St. George has a higher percentage of persons and children living in poverty than the state average. This and other social factors contribute to unfavorable health outcomes for the disadvantaged.

“This is a population with two faces on it,” Southwest Behavioral Health Clinical Director Michael Cain says. “We have a high number of people that don’t have much in the way of income. A visitor comes and sees the recreational side of our community, but you have to live here to know about the other side. They need the kind of services that we have, and they need more of them.”

 that as much as 60 percent of an individual’s health profile can be attributed to social, environmental and behavioral influences. These social determinants of health include a person’s access to transportation, family and social support, level of education, income and housing stability.

Zip code has an unduly large influence on health outcomes, and the figure above confirms that social determinants are a very real — and very pressing &mdash; issue. That’s why Cain’s Southwest Behavioral Health and more than a dozen other Utah organizations have banded together to address those determinants.

The Utah Alliance for the Determinants of Health is made up of healthcare, community and government-based organizations working together and sharing information to provide holistic, scalable solutions to improve the health outcomes of Utah citizens. The Alliance is embarking on a three-year, $12-million project to find ways to improve the social determinants of health for SelectHealth Medicaid members.

“I look out my window and see one neighborhood to the east and one neighborhood to the west, and there’s a life expectancy difference of 10 years,” Intermountain Healthcare Senior Vice President of Community Health Mikelle Moore, MBA, says. “It’s not because people don’t have access to healthcare theoretically — because we’ve helped create that access. We think there’s more we need to be doing to address people’s health needs.”

Intermountain is Utah’s largest not-for-profit hospital system, and its $12-million investment jumpstarted the creation of the Utah Alliance. Their journey has taken the Alliance, like many tourists before them, to the red rocks of St. George.

Intermountain collaborated with Medicaid to find two Utah communities in which to roll out this new model. Weber County, with Ogden zip codes 84401 and 84403, and Washington County, with St. George zip codes 84770 and 84790, were chosen after data revealed each had higher instances of second-generation welfare recipients, use of food assistance programs and use of mental health services. So far, about 3,000 people have been enrolled in St. George and roughly 5,000 in Ogden.

The group began with a collaborative needs assessment launched alongside state health departments and community-based organizations. Since then, it has also initiated a program called Neighborhood Pulse, in which researchers visit 15 homes and spend a few hours with subjects in Washington and Weber counties to better understand each community.

The process remains in its early stages. Intermountain and its associates are gathering information on how to best address these social determinants.

Solving Utah’s Substance Abuse and Suicide Problems

Chief among the health outcomes these stakeholders want to improve are food insecurity and substance abuse, precisely because social determinants of health play an outsize role in the resolution of each. St. George, in particular, has a higher opioid overdose death rate than the state average.

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“We’ve been talking about the idea of what we call a person’s recovery capital,” Cain says. “What are the things that it takes to help someone recover from addiction and sustain it over time? Treatment is obviously important, but what really makes the difference is the world in which they live. The research says that if they have a better world around them, their chances of recovery are much better.”

Often, the outcomes of not having stable social infrastructures are dire. Utah is part of what’s referred to as the “Suicide Belt,” an area of the country that extends across much of the Mountain region. According to a June 2018 

, Utah’s suicide rate ranked fifth in the nation, with 21.8 suicides per 1,000 individuals. And in 2016, suicide was the leading cause of death for Utah youth aged 11 to 17 in 2016. Utah Gov. Gary Herbert even launched a task force earlier this year to address the problem.

Although the cause of Utah’s elevated rates of substance abuse and suicide are complex, the Alliance believes that unfavorable social determinants contribute. To combat this issue, the project aims to build more connected care communities and then provide them with the proper resources. Moore points out that the availability of food resources isn’t the issue in St. George and Ogden, but 

 is. Utah has plenty of resources to address the needs of people in its communities. Those resources just aren’t being applied in ways that support the population holistically. The systems in place to assist communities in improving the social determinants of health are increasingly “siloed” and isolated.

The Alliance’s best asset in tackling issues like substance abuse, suicide and food insecurity is the concept of an alliance itself. The model that the Alliance is establishing is based on tactics included in the Accountable Health Communities model created by CMS. Its greatest advantage is collaboration. Healthcare providers work alongside health insurers and organizations that specialize in housing, food and other social issues. Every organization shares on-the-ground information, so that the picture of the community’s needs and how to meet them becomes clearer.

“It’s not that there is too much information,” Moore says. “It’s that there is just different kinds of information. In healthcare, we’ve made a lot of progress on synthesizing. But if you go outside of healthcare, it becomes really challenging. Our systems don’t speak to one another. Housing has a different system from healthcare and so on. One thing that we will be demonstrating is a technology solution that enables communication between different agencies.”

What’s Next for This Social Determinants of Health Model?

The Alliance envisions the work in Utah as only the beginning. The scale is small but can grow bigger. It’s designed to do exactly that.

“We envision, through this work, demonstrating the value of greater alignment,” Moore says. “Our idea was to create a model to respond to the needs we know exist in the communities that we serve but also create an economic model that’s something we can scale and replicate. We want this work to be relevant outside of Utah.”

Before the project does that, however, it must prove that the program can work in St. George, Utah, where among the rocks, rivers and ridges is a population of individuals whose social determinants frequently govern their health outcomes before they ever enter a healthcare facility.

“Intermountain would like to see this become a model for the nation,” Cain says. “Personally, my goal is to make this work for the people we serve. If outsiders take a look and like it, that’s great. But my first concern is the immediate need in our community.”

If the model does work, that’s good news for many other corners of the country. After all, there are tons of tourist towns with cracks in the foundation — social and medical problems that simply can’t be seen by those who are merely hiking through.

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A group in Utah wants to improve social determinants of health in two cities &mdash; and then everywhere else.

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This is a feature story from our June 2018 issue. Our bimonthly print magazines are available 

Andy Dunn, MD, says the features that make Wyoming beautiful also cause healthcare issues. But the state has a high-tech solution.

“I’ve seen a patient who had maggots in his face,” Andy Dunn, MD, says at the end of a long Monday.

He didn’t see that patient that particular day, mind you. He has simply seen the unfortunate situation before. Dunn is a family practice physician and the chief of staff at the Wyoming Medical Center in Casper, the second-biggest city in a state that is anything but cosmopolitan. He’s the medical director for 2 primary care centers, 2 associated urgent care centers, and the continuing education unit, an observation-and-training arm of the hospital.

Dunn played baseball in college and briefly in the minor leagues. You can tell because he litters his dialogue with coach-speak like “stay after it.” He takes what he calls a Norman Rockwell approach to medicine, referencing the artist’s painting of a doctor listening to the “heartbeat” of a young girl’s doll. Dunn is upbeat and energetic. Even when talking about the maggots.

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“The guy was a rancher, and he had maggots in his face for weeks and just wouldn’t come to the doctor,” he says. “Finally, his family made him, and I can’t even describe it. I thought someone was playing a trick on me. His skin was waxy and looked like waves. Grossest thing I’ve ever seen. I just took tweezers and was trying to pull all these maggots out. I know I didn’t get all the maggots before he went to hospice. It was amazing.”

Dunn tells the maggot story not for shock value. Rather, it’s an example of a challenge facing healthcare professionals in the state of Wyoming. He describes this “cowboy mentality,” which essentially means that citizens just don’t want to go to the doctor. That’s a problem for population health because it can be hard to track and maintain in a populace too busy or disinterested to see a physician. An even bigger challenge for population health, however, is that there isn’t much of a population in Wyoming to begin with.

Wyoming is the 10th-largest state by size and the smallest by population. The US Census Bureau estimated in July 2017 that the state was inhabited by 579,315 people, down from 585,501 in July 2016. That sparse population, spread out over a vast land area, creates a unique circumstance for the effective application of population health studies. It might be true that Wyoming has a rancher or cowboy mentality that discourages going to the doctor. But even for those who want to go, doing so can be a difficult proposition.

“It’s very sparse out here,” Dunn says. “Communication is a lot harder than you think it should be. When you spread out the population, it’s really hard to get consistent preventive screenings. Primary care is like you’re the ringmaster of a 3-ring circus or are trying to herd cats. We have triple-bypass patients who live 2 to 3 hours away. They have to travel back for follow-up appointments or face complications.”

Distance and time have always been concerns in Wyoming healthcare. In the modern biotech era, however, the Wyoming Department of Health is developing new tools to mitigate those concerns.

James Bush, MD, is the Medicaid medical director at the Wyoming Department of Health. He first got the idea to modernize how Wyoming citizens track their own healthcare at a community theater, of all places. He was playing R. H. Macy in a production of 

he noticed how attached some of his young costars were to their phones.

“People would come offstage and start immediately looking and playing with apps. Then they’d go back onstage. They couldn’t be away from their app for half a minute. Basically, I have been of the opinion that kids or younger people these days live and die on these apps,” Bush says.

The Wyoming Department of Health had long maintained several websites and would send out periodic surveys to citizens on a mailing list to help build a fuller population health program. Bush had his doubts that those efforts were having the desired effects, so he sought a partner who could help develop a healthcare app for the state of Wyoming.

He decided to focus on a simple, easy-to-measure goal first: prenatal development. He passed that idea along to one of the department’s recruitment vendors, who came back with a Bay Area start-up called Wildflower.

Wildflower CEO Leah Sparks started her career at McKesson Corporation in San Francisco, California. She worked as part of the company’s corporate strategy group before realizing that her real passion lay in building start-ups.

“I first started thinking about the company a few years ago when I was pregnant with my first child,” she says. “We actually incorporated when I was 6 months pregnant. It struck me when my husband and I were starting a family that this was a great opportunity to crack open the healthcare engagement conundrum.”

Wildflower received an investment through Rock Health, an accelerator, which put out a press release announcing its portfolio companies. Before Sparks knew it, Bush was calling from Wyoming, far from Silicon Valley and all its start-up glory, saying, “I think you can help with this.”

“A Medicaid population in the middle of the country was going to be our first client,” Sparks says. “It was awesome.”

The first app the pair developed was called Due Date Plus. It was designed to help women track their pregnancies from conception through birth. With the app, the Wyoming Department of Health was able to track 2000 pregnancies to completion, about as many pregnancies as Wyoming’s Medicaid population has in a year.

The department conducted a study that indicated that women who used the app went to more prenatal visits and had fewer low-birth-weight infants. For the cost of $110,000 for the launch of the app, Bush and his team estimated, the state averted $330,000 in costs it would have incurred from low-birth-weight deliveries.

Still, both Bush and Sparks saw pregnancy as just the beginning.

“When we first started, we knew we wanted to do more than pregnancy,” Sparks says. “By really listening to our clients in Wyoming, we heard that we wanted to continue to engage the family after the baby was born. That was what led us to extend the platform so you could move seamlessly from taking care of a baby to a toddler to an adolescent and beyond.”

Wildflower developed a new app that helped patients track their health from birth all the way through adulthood and on into eldercare. Bush envisioned it as an “owner’s manual” for healthcare. In a way, it was meant to be a lifelong companion.

The app, called Family Health by Wildflower, launched in December 2016. Users can download it for Android and iOS devices and then enter a Wyoming zip code to get going. The app then calibrates the information displayed for the user’s location. The main page features easily navigable icons for healthcare milestones, a weight tracker, a vaccination tracker, and information about all the publically available healthcare options around them.

“Leah actually went beyond my suggestions, and now the app covers from conception to death,” Bush says. “Every one of those milestones is in there. Every immunization is in there. Once you get into the teens, they get into sexual topics, drugs, tobacco use. Bullying is in there. Then as you get into your 20s and 30s, the topics are more appropriate for those ages. You have your adult immunizations in there.”

The Wyoming Department of Health orders and receives reports on the apps and which features are most popular. As of April 2018, the app had 111 active users. The most popular features were Highlights, Milestones, and Symptoms & Issues.

Bush says he doesn’t like spending public money on programs that don’t have easily definable concepts of success. For Due Date Plus, the definition of success was clear. There was a definite time period and a definite desired outcome: fewer low-birth-weight children. But because Family Health by Wildflower is designed to last the entirety of a patient’s life span, “success” becomes a bit harder to pin down.

For now, Bush and the Wyoming Department of Health will be focusing on increased early and periodic screening, diagnostic, and treatment (EPSDT) 

“When you’re talking about multiple generations, multiple years, it becomes a little harder,” Bush says. “Our primary focus right now is EPSDT. Is the number of well-child checks going to go up now? Are we able to track any other health outcomes or access to programs? Each of the public health programs is now thinking about how [they can] find success.”

There are still outstanding issues and oversights within Wyoming’s healthcare system. Blue Cross Blue Shield of Wyoming is the only private insurer offering plans in the state’s exchange this year. Wyoming has not accepted federal Medicaid expansion for 2018, and around 10% of the population is uninsured. Premiums are higher there than in most of the rest of the country, but the Affordable Care Act’s income-based premium subsidies keep coverage reasonable for most enrollees.

Still, the unique issue of managing care in a big state with a small population is something that can be mitigated by a simple piece of technology. And Bush believes Family Health by Wildflower will help.

“Our department of health is very forward-looking, and we understand that we can use technology to overcome some of our physical limitations,” he says.

“I can’t believe this is Wyoming. It’s really cool. We also get a lot of new parents who aren’t super compliant with their well-child checks. To show them the growth chart and the development milestones—that’s a big thing. Having the ability to say, ‘Hey, use this app. We’re going to communicate this way because we want to check on you, and this is much easier.’ Maybe even with the caveat, ‘You won’t need to see me as often.’” Even if that’s the case, Wyoming will be seeing plenty of these patients, if only through the data points that tell the medical story of a person and a population.

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