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Can a Scalable Model for Improving Community Health Emerge from the Desert?


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

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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.”

Research suggests 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 — issue. That’s why Cain’s Southwest Behavioral Health and more than a dozen other Utah organizations have banded together to address those determinants.

A Targeted Social Approach to Healthcare

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.

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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 Kaiser Family Foundation report, 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 access 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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