The state of racial health inequities is a national crisis that many communities have recognized must be addressed. The big question is typically, how? It is a long-standing injustice in many marginalized communities throughout the U.S. At a macro-level, healthcare access challenges often combine with unmet social needs to produce inequitable outcomes.
On Chicago’s South Side, a community with some of the worst health disparities in the U.S., a coalition of providers came together to transform health outcomes. The South Side Healthy Community Organization (SSHCO), a group that consists of five safety net hospitals, six federally qualified health centers, and two health systems, is engaging community stakeholders and leading a transformation that combines innovative care models, new technology, public sector partnership, and a highly engaged community.
Local Solutions Are Needed for the National Crisis
Because healthcare is local, responding to individual communities requires an understanding of the local planning environment. Local solutions to health disparities that can impact social determinants of health must focus on the unique regional planning context to shape financing, policy, and the activation of community stakeholders.
“The national issues related to inequities and health disparities are pervasive on the South Side of Chicago,” said Brenda Battle, Senior Vice President, Community Health Transformation and Chief Diversity, Equity, and Inclusion Officer at UChicago Medicine. “The South Side was once a very vibrant area, but now we have one of the worst life expectancy gaps in the country.”
After working with The Chartis Group to develop a proposal for state funding, supported by community engagement, SSHCO was awarded funding in July 2021. Their solution focused on the reversal of longstanding health disparities, reduced costs, and improved economic sustainability.
Trust: The Pervasive Element of Collaboration Among Multiple Partners
From grassroots efforts to organizational leaders, SSHCO has developed effective ways to collaborate, communicate, and compromise to stand this transformational new model of care up on its feet.
“What’s transformational about this model?” Dr. Barrett Hatches, President and CEO, Chicago Family Health Center, said. “We have hospitals, systems, federally qualified health centers, all working together on the South Side of Chicago. [That] is transformational by itself. …To come together and work together on an issue as important and broad as this issue of health equity is absolutely amazing, [but] it came with its natural challenges.”
One of those challenges is cultivating trust at every level of the coalition. For example, to ask for community input, “you better be willing to listen … and implement what they’re saying,” Dr. Hatches said.
The Healthy Community model brings 4 distinct roles into alignment: the primary care role, the behavioral care role, the specialty care role, and—critically—the care coordination role. This last role is played by both community health workers and nurse care coordinators. It is essential to supporting chronic disease management and helping patients address key unmet social needs.
“Our community health workers are typically community pillars and staples of the community themselves,” said Dr. Airica Steed, Executive Vice President and Chief Operating Officer, Sinai Chicago.
Turning from community engagement to organizational leadership, Dr. Hatches expressed how the care model changed their workstyle. Leadership from each organization had to grow to trust one another and work through challenges, he said. “The one thing that kept us focused was that we were there for the same purpose—and that is to provide better access to good quality healthcare to everybody on the South Side of Chicago.”
Connecting a Community Continuum of Care with New Technology
Another key challenge for the coalition is the development of a connected care platform that will require them to think differently about how we use our technology platforms.
A critical aspect for the success of this model is partnering with a coalition of various community-based organizations. SSHCO identified the top social determinants of health and now seeks to connect with focused community-based organizations that can help to address a particular set of needs.
For example, housing insecurity, transportation gaps, and food insecurity are core challenges, Dr. Steed noted. “We’re looking for community-based organizations that have an expertise in really driving strategic solutions to addressing [those] challenges. … Our goal is to work directly with community organizations that are a part of the neighborhoods that we’re serving.”
The connected care platform will also include specialty add-on components, connecting with niche vendors to identify community-based organizations would allow for referrals within our connected care platform.
With limited resources, a focus has been placed on strategically leveraging data. “A key component of how we’re looking at the connected care platform is the power of not only traditional data analytics but also the power of predictive analytics. We’re thinking about this short term and long term,” Russ Hinz, Vice President of Strategic Partnerships at Advocate Aurora Health, added.
Optimism and Opportunity for the South Side Community and Its Providers
Collaboration, partnership, purposefully designed technology, and community engagement are the pillars of community healthcare transformation for this coalition. Though evolving, the SSHCO is already making great strides toward increasing the number of care providers within the community, seamlessly transitioning data sharing across a connected care technology platform, and addressing unmet needs related to preventive care, care coordination, chronic disease, behavioral health, care coordination, and social determinants of health.