A Menu Approach to Public Health: Empowering People to Take Responsibility for their Health Choices

By Tracy Neary, Director of Mission Outreach and Community Benefit, St. Vincent Healthcare

For nearly twenty years, St. Vincent Healthcare, a care site operated by the Sisters of Charity of Leavenworth Health System (SCL Health System), the Billings Health Clinic and RiverStone Health, our local health department, have been working together to address complex community wide health issues by adopting intervention strategies identified through a recurring CHNA.

A significant early collaboration came in 1994 when the CHNA showed access to prescription medications was a major issue for our community. We created a medication assistance program (MAP) that helped patients who couldn’t afford prescriptions obtain them.

Last year, MAP advocates, funded in part by St. Vincent Healthcare, assisted approximately 1,200 people with accessing medication worth more than four million dollars. What began as a single access point has expanded to a dozen locations across our community.

The initial collaboration, which began in the early 1990s, between the three organizations became more formal with a Memorandum of Understanding in 2001 to create “The Alliance”. Chief executives of our two competing hospitals and the public health department committed organizational expertise in planning, communication, advocacy, community benefit and clinical services to help lead community efforts to improve health.

Through a CHNA, we found there was a significant need for mental health services, as hospital emergency departments were being inundated with people who didn’t really need medical care but were admitted because of a mental health crisis. Knowing that emergency rooms are not typically the best place for mental health interventions, we created a joint partnership with the two hospitals to build the Community Crisis Center (CCC), the first licensed out-patient crisis management program in Montana.

Now, the CCC is staffed 24 hours per day, seven days per week with a combination of registered nurses, licensed mental health therapists, and mental health technicians. During an outpatient visit, clients are stabilized and assessed to facilitate the development of a crisis management plan.

The CCC has successfully reduced inappropriate utilization of local emergency departments, decreased the number of short-term inpatient hospital admissions, and has been a driving force in reducing the inmate population at the Yellowstone County Detention Facility.

Additionally, the CCC offers crisis intervention training to law enforcement officers in the region. Officers learn how to recognize mental health distress and de-escalate individuals rather than interacting with people in a way that escalates anxiety. Law enforcement officers credit the training with helping them more effectively respond to situations involving individuals with mental health disorders, especially those in suicidal situations.

One of our crisis intervention program officers, off duty at the time, was driving across a bridge and a man was on it threatening suicide. The officer was able to talk the person down without anyone getting hurt.

This is one example of how a community program has a wide-reaching public health benefit. Instead of the individual hurting himself and/or others, no one was hurt and the appropriate part of our community’s medical system (the mental health portion versus an emergency department) was involved.

In 2005, RiverStone Health underwent an assessment of the public health system’s performance in the 10 Essential Public Health Services established by CDC. The assessment was conducted using the National Public Health Performance Standards Program (NPHPSP), also established by the CDC. A key outcome of that assessment was an understanding of the need to perform a community health assessment and develop a community plan. The Alliance then sponsored the 2006 CHNA where childhood and adult obesity, heart disease, diabetes, nutritional intake, unintentional injury, and chronic depression were identified areas of weakness. Physical activity, nutrition, and well-being were selected as the areas of improvement because of their inter-connectedness and their collective benefit on our community’s health. The results moved us to thinking about longer term population health improvements through policy, system and environmental change strategies. We began by creating an operational work plan, “The PITCH.” The Plan to Improve the Community’s Health (PITCH) focuses on physical activity, nutrition, and well-being. PITCH is intended to increase awareness and knowledge of, as well as access to, healthier lifestyles in Yellowstone County.

This plan was developed with a broad variety of community stakeholders who participate in achieving the identified goals as part of a broad coalition. With the support of the Robert Wood Johnson Foundation, one of the most impactful early Health Impact Assessments (HIA) we completed was with our city/county master growth plan. Results of the HIA led to the adoption of a new health section within the plan in 2008, which set the foundation for later success in adopting a complete streets policy for Billings. This accomplishment was supported in large part by our work with Action Communities for Health, Innovation, and EnVironmental ChangE (ACHIEVE).

As one of the ten original participants in the Healthy Weight Collaborative, a project of the National Initiative for Children’s Healthcare Quality (NICHQ) and HRSA, we partnered with primary care providers to better document body mass index (BMI) in medical records and, if a BMI was too high, offer a patient-directed healthy weight plan. The efforts have created new collaboration between providers and community organizations.

The partnership has also launched an effort into the worksite by developing physical activity and nutrition guidelines. We found that it is important to create a menu approach of evidenced-based practices that have been shown to increase physical activity (i.e., promoting use of stairwells, on-site exercise classes, etc.). The menu option allows businesses to pick and choose which policies are appropriate in their environment and also empowers employers. A similar project, the “Healthy By Design” (HBD)  endorsement, was developed as a way of promoting events in Billings that are designed with health in mind. This endorsement is done through an application process and each application is reviewed and evaluated by a team of experts. There are five criteria: safety; nutrition; physical activity; prevention and wellness; and environmental stewardship.

As we look to the future and our interconnected health system, we see a community that is Healthy By Design with active people working to improve their own health and the health of those around them. It is a dream we plan to realize by continuing our work to identify unmet health needs and leading efforts to coordinate a community based response. We recognize the critical importance of key stakeholders in economic development, private business, city government, education, strategic planners in addition to traditional health partners. Our website, www.healthybydesginyellowstone.org includes our CHNA, work plans, accomplishments and a variety of tools we have developed to achieve our vision.