Bridging the public health-healthcare divide for better outcomes
By Kathleen Noonan
The following is adapted from a commencement speech by Kathleen Noonan, Camden Coalition of Healthcare Providers CEO, at the University of Pennsylvania Master of Public Health graduation ceremony on May 20, 2019.The public health field has an opportunity right now to influence the traditional healthcare model in ways it has not in a very long time, and this critical moment should not be wasted. Historically there has been an unspoken divide between public health and healthcare with public health focusing on populations and communities, and healthcare focusing on the medical care of individual patients.In point of fact, there is no reason for this divide to exist. For too long the training for careers in public health seemed to run parallel to and stop short of challenging the primacy of the medical model even when we know that many people in our country are not staying healthy or maintaining a healthcare regimen that keeps them healthy.Much of what we think of as healthcare in the United States, and thus much of what concerns public health experts, derives from a model that is designed to solve individual medical problems, and to treat the medical problem as the beginning and the end of the analysis. This has resulted in a healthcare system that focuses on diagnosis and illness, and not prevention, health, and wellbeing.Moreover, the solutions that are offered through the medical model often target isolated symptoms and health events, which tend to create fragmentation in care delivery.The divide is best captured in the relatively recent discussions of “social determinants of health.” It is a buzzword in health policy right now. It describes living conditions like poor or unstable housing, poverty, food insecurity, and limited access to care navigation and management supports that are often the cause of or exacerbate the clinical problems that patients face. This is not news to public health practitioners or to the social services field. We’ve known this all along.It isn’t really news to the traditional healthcare field, either, but there is finally attention being paid to the impact of social and environmental conditions on health. What’s noteworthy is the beginning of a movement to build a bridge across the divide with healthcare policy incentivizing practices and services that act on social determinants in very new ways. Hospital systems are starting to develop housing, remediate food insecurity, and provide transportation – all the ecosystem development factors that we know are critical to health and that have traditionally been the purview of public health.What does this mean for public health practitioners and planners? This is an opportune moment for public health professionals to engage in and drive forward the discussions about social determinants and bring to them a broader social service, behavioral health and care coordination perspective that will change the way traditional health services are organized, financed and delivered. It also means bringing to the discussion a focus on prevention and effective upstream interventions for families and communities. Concretely, this means that moving into your new roles as public health practitioners, you will get to have opinions on things like whether the practice standard should limit clinicians to only asking about food insecurity when patients come in for diabetes management. Shouldn’t this basic question be asked at every exam or primary care visit and in all emergency room settings? You can also ask why medical provider networks don’t routinely screen for depression, drug misuse or violence in the home.Perhaps you could bring a new perspective that points out the healthcare cliff that happens for adolescents. Today, the standard of care in pediatrics is for young children from birth to age three to be seen by their doctors 10 times, with all of these visits now paid for by both private and public health insurers. Teen well visits, on the other hand, are required and paid for only once per year by payers and utilization is very low with teens presumed to be healthy. What if you suggested the creation, staffing, and financing of a new healthcare outreach model or new access points for teens and young adults? These might not be doctor-driven or even take place at the doctor’s office. You could call for an investment in prevention and wellness for young adults.Whatever the reasons for the historic divide between healthcare and public health, you now have an educational credential that empowers, gives you license, and actually even requires you to think about, question, and offer solutions to the limitations of the medical model. In other words, your training gives you an opportunity to reconceptualize healthcare based on population and community needs — the social determinants of health. The reason I know that there is opportunity for you to build new bridges between medicine and public health is because the organization I am privileged to lead — the Camden Coalition of Healthcare Providers — does this every day. Our mission is to spark a field and a movement in Camden and across the nation through our work on the ground in New Jersey and through our National Center for Health and Social Needs to improve the wellbeing of individuals with complex health and social needs. We do this by working at the intersection of medicine and public health and bringing to this work a philosophy and practice based heavily on data and analytics, integrated care models, care coordination and community engagement — tools that work to improve the underlying conditions and circumstances that affect people’s health. We have learned that medical care that diagnoses and treats only the presenting clinical condition — offering prenatal care with no ancillary supports, or diabetes management with no assistance with meal preparation or access to fresh produce — won’t, by itself, improve health or health outcomes or really make the kind of difference we seek for the patients we serve. An atomized approach to healthcare doesn’t work well for most patients. People, covered by public and private insurance alike, are subject to the same diagnostic and illness-oriented care that underattends to conditions like early onset mental health issues, substance misuse, and environmental conditions like lead paint in pipes. Prevention and early intervention are largely missing from healthcare for all Americans, and not well paid for even when they are present. Mental health benefits are extremely limited. The list goes on.Perhaps the key to improving health outcomes in America isn’t more devices or high-tech startups, but rather a healthcare system that embraces a public health vision. With new care models, we will have the capacity to see the larger picture and provide services and supports that connect cause and effect. The public health field – you, its newly minted graduates – have much to contribute to this vision.