Social Determinants and Health Outcomes, National Health Foundation CEO Kelly Bruno on Innovative Strategies that Work

Kelly Bruno

Mark Masselli: This is Conversations on Health Care I’m Mark Masselli.

Margaret Flinter: I’m Margaret Flinter.

Mark Masselli: Well, Margaret in the era of big mergers and acquisitions throughout the
health care industry , it appears another mega merger is in the works . A few months
after CVS announced it was spying the insurance giant Aetna now retail giant Walmart
is moving towards a merger with the insurance carrier Humana. It’s another industry
paring that’s generatin g a lot of buzz.

Margaret Flinter: That does seem to signal an interesting trend of taking the health care
industry into the market places where people interact daily. The CVS Aetna deal if we
think about that one was based on the premise that you can do more to impact health
when the consumer has a direct access to services right in their own neighborhood or
work setting. That could signal shift in how population health might be supported by
frequent interfaces of places like the local pharmacy of which there seems to one on
every corner in American now.

Mark Masselli: Well it does Margaret. You’re absolutely right, these mergers still have
to be approved and it may take quite a while before we see any real shift in the health
care market place. Meanw hile a lot of anticipation from the recently announced
partnership between Amazon and Berkshire Hathaway and JP Morgan and Chase lots
of external forces are at play in the health care industry right now, and it’d be interesting
to see where all this go.

Ma rgaret Flinter: As we know what keeps health cost down over time is the focus on all
of the upstream causes of poor health like poverty insecure housing, poor nutrition.
That’s something that our guest today has focused professional efforts on for decade s.

Mark Masselli: Kelly Bruno is President and CEO of the National Health Foundation
dedicated to launching innovative programs addressing the barriers to health that
affects certain communities and special populations.

Margaret Flinter: Well, Kelly has launch ed some very effective programs that seem to
be having a positive impact, so we’re really looking forward to that conversation.

Mark Masselli: Lori Robertson also checks in. She is the managing editor of
FactCheck.org, but no matter what the topic you can hear all of our shows by going to
chcradio.com or find us on iTunes as well.

Margaret Flinter: If you have comments please email us at [email protected] or find
us on Facebook or Twitter because we love to hear from you. We’ll get to our interview
with Kelly Bruno of the National Health Foundation in just a moment.

Kelly Bruno

Mark Masselli: First, here is our producer Marianne O’Hare with this week’s headline
news.

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Marianne O’Hare: I’m Marianne O’Hare with these health care headlines. He said, he
said a war of words between ousted VA Secretary Dr. David Shulkin in the White
House. The White House claiming that he willingly left leadership of the VA health
system, Shulkin vehemently denies that claim saying that he was fired. The Trump
Administration has been pushing for increased privatization of the VA, but Shulkin was
reluctant to enact a radical privatization of a system that treats nine million American
vets employs 300,000 people and it’s a primary tr aining ground for medical students
and residence across the country.

Kids and depression, it’s a real problem and even bigger problem according to the
American Academy of Pediatrics is that two out of three kids with a diagnosable
condition are never adequ ately screened in the health care setting. They have revised
guidelines for pediatric mental health screenings noting that at age 12 kids should
receive a mandatory screening as part of their routine care. Suicide is a leading cause
of death for teens an d experts feel this would be a great way to prevent tragedies from
happening. Also for more teens to get the treatment interventions they are currently
missing out on.

The opioid overdose crisis is showing no signs of slowing down, in fact the number of
overdose has continues to rise across the country. Now the CDC believes the actual
numbers of overdoses maybe under reported across the country, many medical
examiners n ot including overdose is a cause for such things as cardiac arrest.
Meanwhile, where there’s smoke there may be less fire it seems. Two US studies have
confirmed an interesting trend in states where marijuana use has been legalized, there’s
a discernable drop in opioid prescriptions. According to one study states with medical
marijuana laws showed a 6% drop in opioid prescriptions among the Medicaid
population, and there was another study that looked at Medicare populations, health
care for the nation se niors have found that states with legal marijuana dispensaries
opioid prescriptions went down by 3.7 million doses from the 23 million annual doses
among Medicare recipients.

One study author suggest it starting to be considered as a nonlethal alternative to the
highly addicted opioids which lead to roughly 90 deaths per day. Hefei Wen co - author
of the Medicaid study and research with the University of Kentucky College of Public
Health said that marijuana is one of the potential non - opioid alternatives tha t can relief
pain at a relatively lower risk of addiction and virtually no risk of overdose. I’m Marianne
O’Hare with these health care headlines.

Kelly Bruno

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Mark Masselli: We’re speaking today with Kelly Bruno President and CEO of the
National Health Found ation a Los Angeles based nonprofit entity dedicated to closing
gaps in the health care system by creating programs that address the social
determinants that lead to poor health. Previously Ms. Bruno served as Chief Operating
Officer and Vice President of Programs at the foundation overseeing numerous
innovative initiatives. Prior to joining NHF Ms. Bruno was Vice President of
ONEgeneration which supports intergenerational shared site programming for child and
senior daycare participants Ms. Bruno served several nonprofit organization such as
Tierra Del Sol Foundation, Santa Clarita Valley Youth Project and the Santa Clarita
Valley Domestic Violence Center. She earned her BA in social work at Azusa Pacific
University , her MSW at Cal State Long Beach. Kel ly welcome to Conversations on
Health Care.

Kelly Bruno: Thank you for having me.

Mark Masselli: Our producer saw you at South by Southwest Conference in Austin,
Texas and it was one of the largest gatherings in the world for the intersection of arts
and ideas and health care has become a prominent topic at this annual event. Your
panel address the challenge many of us in health care are grappling with how to make
health equity a reality for everyone and it’s a core foundation principle for the National
Health Foundation. I’m wondering if you could share with our listeners what kinds of
partnerships are required and how do you make such an impact on initiatives?

Kelly Bruno : National Health Foundation has recognized as have many health care
providers th at health care has simply changed over the course of the last few years.
80% of what makes an individual healthy are those social determinants of health,
education, access to healthy food and water, built environments, housing are some
examples of those. The health disparity that we see in under - resourced communities
are because of those social determinants of health. In order to address this we need to
look at the root causes of the problems of health, and address those things then and not
after we alre ady see the problem has occurred.

I like to tell a story about a woman that was in south Los Angeles and we can call her
Kate, and she wakes up one morning and recognizes or feels thirsty, and know that
that’s not typical. She takes a bus down to her loca l hospital and the doctor tells her
that she has pre - diabetes and that he recommends to her that she eat more fruits and
vegetables and did some exercise. She leaves the hospital and she goes home and on
her way home she passes 13 McDonald’s, five Taco Be lls and In - N - Out Burger at a Pan
Express. Needless to say in a few weeks her symptoms have not subsided, and so she
goes back to the doctor, he too is concerned and what he does is he suggest and puts

Kelly Bruno

her into an education program to teach her how to eat better. Kate is fully aware of
what a carrot is and how good it taste, but she does not have access to that carrot on
that path that I just described that was her way home.

As a society until we change the path that Kate is walking on or going home one, w e
cannot possibly expect her to be healthy. That is what National Health Foundation does
is we’re working to change the path that Kate walks on and that is what health equity
looks like for us. The partners that are needed for this are tremendous in hosp itals,
clinics, businesses, other nonprofit organizations, but what’s most important and the
most important partner are the residence that live in that community, and often times we
feel that that’s who’s left out.

Margaret Flinter: We also focus very muc h in our work on tackling these upstream
issues of social determinants of health as a crucial strategy to improving health
outcomes. I wonder if you could talk a little bit about one of the initiatives that you’ve
spearheaded which dives a level deeper in to trying to close these gaps. I know you’ve
been engaged in the Path way Recuperative Care initiative which recognizes that if
somebody is in the hospital and then is discharged not to a comfortable warm
supportive bedroom with people to take care of them and but instead are discharged to
the street. Tell us about how you’re supplying bed space for healing and recuperation
for homeless patients who are being reduced from the hospital, what are you finding?

Kelly Bruno: Yes, National Health Foundation has been involved with Pathway
Recuperative Care since 2007 and you framed the concern beautifully. Homeless
individuals or those experiencing homelessness being discharged from their hospital
and simply had no safe appropriate place with which to discharge them, so those
individuals go back to the street which is the worst possible place to recuperate. Then
of course end up right back into the emergency room. Pathway Recuperative Care has
utilized local motels to provide that home, so hospitals are able to discharge their
individuals experiencing homelessness to us. We accommodate them within hours of
their discharge, they come right to us and we provide that home, we provide medical
oversight, a safe appropriate place with which to recuperate. We help th em with their
medicines, and then we connect them hopefully on the backend of some sort of
housing.

We’ve seen tremendous outcomes, we partner currently with 60 hospitals and we’ve
estimated that we’ve saved the hospital community or avoided cost of over 3 5 million
dollars since 2010. The goals of our program are really quite simple, we are hoping that
we can advance every individual’s housing plan when they’re with us, so they are closer
to housing when they’re with us than they were when they got there. They’re better
able to handle their own health and their own medicines, and that finally that they are
better connected to the community. Los Angeles has the largest homeless population

Kelly Bruno

and it really has a concerted effort right now to connect every sing le provider so that we
can collectively work on ending homelessness for as many people as possible. Our
program is a piece of that continuum and we play a role in that [inaudible 00:11:38 ] for
many people.

Mark Masselli: We’re speaking today with Kelly Bruno President and CEO of the
National Health Foundation a nonprofit entity dedicated to developing programs that
address the upstream social determinants that lead to poor health. Kelly let’s drill down
a little further i nto the idea of food is health and access to food remains a real challenge
for many Americans with about one in five children lacking proper access to food some
point during the year. Federal government is considering a shift in the SNAP Program
which pro vides food assistance to some 45 million vulnerable Americans. They’re
talking about sending blue apron like boxes of government provisions in place of the
current system which provides financial assistance for SNAP recipients and your
organization has co me out strongly against that, how did we do better?

Kelly Bruno: There’s been a research that’s been done that shows that every five
dollars in SNAP funding actually provides nine dollars in economic development for
those communities with which it serves. This blue apron type of a solution really takes
that out of the equation, the cultural sensitivity we feel would be lost with this somebody
else making the choices of the food. The education portion is also missing, SNAP here
is also accompany wi th SNAP - Ed which is the educational piece that goes with the
SNAP benefit. Really when I look at how we can do better, we really need to focus a
little bit more on making sure that those people that are intended to received the SNAP
benefit are actually r eceiving the benefit.

There are huge populations, the elderly population in particular that are simply eligible
for this benefit that are not signing up and focusing more so on the barriers that exist as
to why this populations aren’t signing up for the be nefit in the first place is really where
we felt we should be focusing out time. Not worrying about the individual that signed up
for SNAP it shouldn’t be, but more so concerned about that person that isn’t signed up
that should be.

Margaret Flinter: Wel l, Kelly you’ve also gained national attention for another program
that you’ve helped developed known as intergenerational shared site programming that
brings children in daycare centers and senior and adult daycare facilities together under
one roof. I k now you’ve collaborated with institutions such as Penn State and Virginia
Tech researching the effectiveness of these programs. Tell us about this work that you
began while at ONEgeneration and is this idea actually gaining momentum across the
country?

Kelly Bruno

Ke lly Bruno: Our society was build on being intergenerational. If you look back you’ll
see that there were multiple generations in each house, they had a grandmother and a
mother. You didn’t have to force that intergenerational interaction, it was already there.
What we found though is that there are benefits to that engagement that our children
today simply don’t have. We actually did do research on our intergenerational program
when I was at ONEgeneration with Virginia Tech, and what we were able to sh ow is that
the children who attended our program for at least two years showed higher levels of
empathy than children who attended a non - intergenerational program. It’s not
necessarily on what the children’s think about the older generations, it’s what th ey don’t
think. It’s because they had interactions with what they call the neighbors from birth,
and so they don’t have those stereotypes that have already been developed, they had
their own experiences, and those experience has shaped their ideals and th eir empathy
improves because of it.

Mark Masselli: Kelly the upstream movement has gained momentum under the
Affordable Care Act and the expansion of Medicaid has allowed states to become more
innovative and responsive to the needs of the underserved popu lation. We’re seeing
continued efforts to undermine parts of the low both in Washington and in states around
the country with a number states requesting work requirement for Medicaid recipients.
I’m wondering if you could talk about the role of Medicaid expansion in the ACA have
played in closing health equity gaps and what policies you’re advocating for?

Kelly Bruno: ACAs had a tremendous impact on health equity and ensuring that more
people Medicaid in particular received coverage. Before that, if you are between the
ages of 25 and 64 there were very few programs that you would be eligible for, that is
no longer the case. You can see that change ripple through the community, and
hospitals I think are probably one of the most noticeable places whereas any nonprofit
hospital has a community benefit requirement that they have to spend dollars within the
community for those less fortunate or food programs that need our help. Before the
ACA the vast majority of those dollars were spent on ensuring or provi ding care for
those that didn’t have coverage. Well now that’s not the case, now they have coverage,
so you have nonprofit hospitals that have a tremendous larger amount of money to
spend on the community than they’ve ever had before, and together you’ll see a lot of
hospitals making great stride and ensuring that those dollars are spent on upstream
solutions. I think keeping our eye on hospitals right now is where we should be
spending some time because there is a lot of momentum on the part of the hospi tals to
be a part of that solution.

Margaret Flinter: Well, Kelly I maybe just ask you for your thoughts on what you’re
doing to address one more which is literacy and specifically health literacy. Maybe
share some of the success from these pilots and we ’d love to give you a chance to just
tell us a little bit more about the National Health Foundation what were its origins and

Kelly Bruno

where do the support come from if you’d like to take a moment to educate our listeners
about that as well.

Kelly Bruno: We really believe that health is local, and that addressing these issues and
these barriers at the local level is really the best way to address them. A percentage of
our program is a significant percentage are within high schools and deal with teenagers,
and we a llow them to identify the health barriers that exist within their high school
community and then come up with their own solutions to addressing them. Some of the
outcomes and the things that they’ve come up with have been pretty remarkable one of
which wa s that they determines that drinking fountains in their high school were less
than stellar. They raised the money necessary to put a Brita Hydration Station in their
high school. They redesigned the cafeteria but did that so that they can increase the
nu mber of students that were able to get through the line in the short amount of time
that they had for lunch, I believe they increase it by over 25%.

They also came up with a brilliant strategy called the Share Table which allows students
that get free brea kfast in the morning who may have some nonperishable items fruits,
vegetables or things like that to put those items on a table in each classroom in the
morning so that throughout the day students can grab from that table a healthy snack.
All student led all reducing barriers and all really improving health outcomes for their
community. It’s kind of that perspective that NHS looks from is really involving the
community and identifying those solutions. A National Health Foundation its mission is
to improv e the health of under - resourced communities by taking action on the social
determinants of health and we have been in existence for almost 50 years, and we are
a multi stream funded, but a lot of our funding comes from individual donations, private
foundat ions, minimal amount of government funding as well.

Mark Masselli: We’re speaking today with Kelly Bruno President and CEO of the
National Health Foundation dedicated to developing programs to address the upstream
social determinants that lead to poor hea lth. You can learn more about their work by
going to National Health Foundation.org or follow them on Twitter @National Health
Foundation. Kelly thank you so much for your work and for joining us today on
Conversations on Health Care.

Kelly Bruno: Thank you so much for the opportunity.

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Mark Masselli: At Conversations on Health C are, we want our audience to be truly in
the know when it comes to the facts about health care reform and policy, Lori Robertson
is an award - winning journalist and Managi ng Editor of FactCheck.org, a non - partisan,
nonprofit consumer advocate for voters that aim to reduce the level of deception in U.S.
politics. Lori, what have you got for us this week?

Kelly Bruno

Lori Robertson: The number of people collecting benefits under the Sup plemental
Nutrition Assistance Program formally called food stamps has been declining since
fiscal year 2014. Consistent with that trend average monthly enrollment decreased by
about two million from fiscal year 2016 to fiscal year 2017, that happened par tly on
th
President Donald Trump’s watch. Trump took office on January 20 2017 while the
st
2017 fiscal year started on October 1 2016. About four months a third of that fiscal
year were during Barack Obama’s presidency, but some [inaudible 00:20:52 ] have
attributed the entire drop in enrollment last fiscal year to Trump’s policy. On Fox and
th
Friends on March 17 Rachel Campos - Duffy said, quote, “Two million Americans are off
of food stamps.” Claiming this was the opposite of what happened in the Obama
Adm inistration and that the number was now coming down in one year. The number
has been declining for several years. The statement turned into a meme that has been
circulating on Facebook where many of our readers saw it and asked us about it.

Let’s take a look at the numbers. The number of people enrolled in SNAP initially
increased during the Obama Administration, a consequence of the deep recession that
begin in 2007 according to a report by the nonpartisan congressional budget office.
Those on food sta mps reached a peak average monthly enrollment of 47.6 million in
fiscal year 2013, but then SNAP enrollment decreased as the economy recovered and
poverty on unemployment rates went down. Enrollment was down to 42.7 million in
January 2017 when Obama left office. That decline has continued under Trump, the
rate of the decrease however is slower. That’s my fact check for this week, I’m Lori
Robertson Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from t he country’s
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you ’d like checked, email us at
CHCradio.com we ’ ll have FactCheck.org’s, Lori Robertson check it out for you, here on
Conversations on Healthcare.

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Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Childhood obesity has reached
epidemic proportions in this country and it’s reaching into the most vulnerable
populations toddlers and preschoolers. The trend was particularly disturbing to
Louisiana State University Behavioral and Community Health Professor Dr. Malinda
Southern who said the numbers of obese children in Louisiana preschool is particularly
distressing.

Dr. Malinda Southern: On average across the United States 15% of children zero to
five years are obese or overweight, and as a minority populations it’s actually one third

Kelly Bruno

so it’s much greater. In Louisia na it’s actually in that population greater as well, and
then as they approach adolescence their risk for developing type two diabetes and high
cholesterol and high blood pressure also increases.

Mark Masselli: Dr. Southern discover that a majority of the children in head start
programs across the state are spending much more time in sedentary activities, 90% of
the time. They devised a program that brought dietitians into series of head start
daycare centers and created opportuniti es for the children to increase their movement
every day. Using accelerometer s they were able to get accurate assessments of
increased movement among the children.

Dr. Malinda Southern: That measured how long they were being physically active and
how har d or how intense, and about 80% of the time the zero to five year old were
sitting or lying, they were not being physically active. What we found was that only in
the intervention centers that we see an increase in physical activity. It was in 22
increas e in total physical activity, and what was even more amazing was a 50%
increase in the vigorous activity that we really want those preschoolers to engage in.

Mark Masselli: The study was published in the journal Childhood Obesity a low cost
intervention t hat has the potential to have significant impact on one of the underlying
causes leading to childhood obesity which is sedentary lifestyle, now that’s a bright
idea.

Margaret Flinter: This is Conversations on Health Care I’m Margaret Flinter.

Mark Massell i: I’m Mark Masselli, peace and health.

Conversations on Health C are broadcast from WESU at Wesleyan University,
streaming live at www.wesufm.org and brought to you by the Community Health Center.