Featured Articles: PCMH

Integrating the Social Determinants of Health

Tuesday, January 19, 2016   (0 Comments)
Share |


Cassie Burns, Director of Learning Partners, and Lander Cooney, CEO of Community Health Partners 


Our health and likelihood of dying prematurely are greatly influenced by our education, income, and the neighborhoods where we live.

  • American college graduates can expect to live at least five years longer than Americans who have not completed high school.
  • Poor Americans are three times as likely as their upper middle class peers to suffer from chronic illness.
  • Upper middle class Americans live an average of six years longer than poor Americans.


A statement from the commissiononhealth.org website sums it up: “Income and education are two of the most critical factors for improving health and reducing health disparities.  Until we reduce poverty, particularly child poverty, and improve overall educational attainment and quality, America will not be as healthy as it should be.”                                                                                                                                     

Community Health Partners (CHP) lives this belief.  CHP is a Federally Qualified Community Health Center providing high-quality, affordable medical, dental, behavioral health, pharmacy, and educational services to more than 12,000 clients annually in several rural and frontier counties in southwest Montana.  More than 93% of CHP patients reporting incomes earn less than 200% of the Federal Poverty Level.   One of CHP’s strategies for achieving its mission to enhance community health and well-being is to address the root causes of poor health such as income, education, housing, and access to healthy food.  CHP does this by embedding educational programming into our health centers.  Learning Partners is the educational wing of CHP. CHP provides:

·         Adult Education – Students over the age of 16 can access career exploration, assessments, and instruction in subjects such as basic reading, prepare to take the high school equivalency exam, and get support with college level instruction.

·         Parent As Teachers Home Visiting – A parent is a child’s first and most important teacher.  Home visitors provide parents with research-based child development information so that they can fulfil this very important role.

·         WoRC Component of TANF – Case workers assist people receiving cash assistance with workplace activities and education so that they find a job and support their families.

·         Reach Out and Read – Children receive a free, high-quality children’s book each time they have a medical or dental appointment at CHP.  Parents are also educated about the importance of a daily reading routine.

·         Health Literacy Support – CHP is committed to providing written patient material at a 7th grade reading level.  Learning Partners’ staff edits forms and educational materials using health literacy principles and provides ongoing staff development in health literacy.

·         Community Health Partners has developed trainings that provide the research, practical strategies, and tools needed for health clinics to implement educational support for patients.  Modules include: Social Determinants of Health, Health Literacy, Home Visiting, Parent Education, Adult Education, and Books for Children.

CHP is comprised of five clinics spread over two large counties.  Not all clinics house all of these services.  In the more populated communities, some of these programs are offered through other agencies.  In these areas, we have a robust collaborative relationship and refer patients to the appropriate resource. 


Meet Laura (not her real name):

Laura, a 22 year-old single mother of four, lived with her mother and stepfather in a two-bedroom trailer.  All three generations have come to CHP for medical and dental care.  When Laura enrolled in Temporary Assistance for Needy Families (TANF-WoRC), she was assigned a case manager at Learning Partners. As part of her TANF required 27 hours a week of work-related activities, Laura was able to be a classroom aide in LP’s Adult Education program.  LP staff helped her enroll in the WIOA Youth Employment program which paid her for classroom aide hours.  After a year of hard work, Laura passed her high school equivalency test.  The Parent As Teachers home visitor met weekly with Laura and her mother, offering individualized parenting skills and addressing family well-being.  Laura’s home visitor assisted her mother through the arduous process of becoming a Licenced Childcare Provider so that she could be paid for watching her grandchildren.  With the support of her home visitor, Laura’s oldest child (five years old) was enrolled in the public school special education preschool.  LP staff helped Laura access low-income rent and energy assistance.  Laura also enrolled in group counseling and anger management classes that are offered through CHP.

 After a difficult birth of her fourth child, Laura moved in with the father of her child in another town.  Laura now has many tools that will help her navigate the ups and downs of living.  Laura knows that CHP is here for her and will welcome her any time that she needs support and services.

Community health centers across the country are becoming known for leveraging the social determinants of health to bring value to healthcare.  Health centers are increasingly looked to as experts in the medical neighborhood for managing patients with socially complex lives because we have always taken a whole-person approach when caring for patients. Community Health Partners is happy to help other health centers develop their programming to address root causes of poor health.  We encourage you to help educate your communities about social determinants.  Sponsor a book drive!  Give a speech at your local Rotary Club!  Meet with your local agencies that provide home visiting and adult education!  In this time of payment reform and value-based care, our work and experience to address social determinants of health to improve outcomes and reduce cost has never been more important.

NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.


Membership Software Powered by YourMembership  ::  Legal