Silos are for Farms. HealthSpark Foundation’s Integrated Approach to Improving the Health for Montgomery County
The following article appears in the Spring 2016 edition of the Philadelphia Social Innovations Journal.
By Tamela Luce and Russell Johnson
Improving health can’t be done in silos.
We at HealthSpark Foundation have long recognized there are many factors that contribute to one’s health. Where you live, what you eat, what you do for a living and how much you earn – these all contribute to your health. Unfortunately, we are seeing this play out in the water crisis in Flint, Michigan. It will be years before we understand the long-term effects of exposure to the high levels of lead in the water, especially on the children of Flint. The complexity and interwoven nature of these factors can make the notion of improving health more daunting: complex problems necessitate complex solutions.
What’s more, our foundation simply does not have enough funds or resources to address all of these areas for every resident in Montgomery County.
So how CAN we make a difference? Of course we support a number of efforts that might be considered more in line with a health funder: behavioral health, oral health, long-term care. In Maslow’s Hierarchy of Needs, meeting one’s basic physiological needs for food and shelter are essential before progressing to higher stages of growth. A person who is hungry and living on the street will certainly have a more difficult time attaining and maintaining employment or securing benefits to support financial stability unless they can get something to eat and a safe, clean and healthy place to stay.
HealthSpark works to improve health outcomes in Montgomery County influenced by housing and food, two basic “social determinants of health.” We convene stakeholders, provide technical assistance, commission research and inform policymakers. In short, we use a population health framework to help us understand what influences health outcomes in the county as a whole, and then craft our work around what we have learned.
HealthSpark – A Brief History
In our fourteen-year history, HealthSpark Foundation (formerly North Penn Community Health Foundation) has always worked to support healthier lives for vulnerable and at-risk populations in our community. Yet we realized early on that achieving good health outcomes meant more than access to healthcare, and it’s affected by much more than periodic exams, tests and medications.
Building on our early efforts to learn about the barriers to accessing healthcare, we launched several initiatives beginning in 2006 with other foundation partners: the BoomerANG project, that examined opportunities to help older adults remain active and engaged in their communities; An Independent Assessment of the Health, Human Services, Cultural and Educational Needs of Montgomery County; and the WISE SNAC initiative that partnered with three school districts to reduce the incidence of childhood obesity. These initiatives were designed to engage the community in building a shared understanding of population health and specific opportunities to improve the health and well-being of the community, especially vulnerable, at-risk residents. Each initiative underscored the importance of understanding the underlying system structure and what it was producing or hindering in terms of outcomes and cost.
The 2006 needs assessment ultimately contributed to the creation of a public/private partnership called Your Way Home. This partnership is transforming the county’s housing system for those experiencing homelessness, targeting the most vulnerable to offer a person-centered set of services to rapidly re-house these individuals.
A year earlier marked the start of our foundation’s significant involvement in food and nutrition, a journey that has continued to evolve over the last decade, resulting in the creation of the MontCo Anti-Hunger Network and a countywide approach to improving the emergency food system.
Early Work in Housing
The needs assessment identified some troubling issues with the county’s housing and homelessness system. Even then, Montgomery County was an expensive place to live. Median housing values in 2004 were $230,491. Forty-one percent of renters were spending more than 30% of their income on housing. For those experiencing homelessness, affordable housing was scarce. Getting into the shelter system was confusing and difficult, often requiring an individual or family to make daily calls to nearly a dozen different agencies to determine if shelter was available. Luck factored heavily into whether someone was able to secure temporary shelter. Worse, the way the system operated was that those with the greatest challenges and barriers to overcoming their homelessness were the least likely to be served because of their substantial challenges and barriers. Transitional housing programs functioned as “housing readiness programs” designed to help prepare a homeless individual/family for successful, long-term housing stability. However, one could spend two years or more in transitional housing, at a sizable cost to the system. With dwindling public support for social services, and a bottlenecked system that inhibited timely access to services, this model was unsustainable, in addition to being inefficient and not terribly effectual.
After the publication of the needs assessment, some homeless system leaders began discussing these challenges. As detailed in a previous Philadelphia Social Innovations Journal article, our foundation soon began convening groups of stakeholders to discuss the challenges and identify possible solutions. Along the way, an external consultant was hired to research best practices, provide backbone administrative support, keep discussions going and progress moving forward. We funded several pilot projects including a centralized intake and referral system and a strengths-based service engagement model to explore what could work in Montgomery County and to learn what supports were needed to assure long-term success. In general, those two projects succeeded and were expanded, tweaked by the learnings gleaned from the pilots and influenced by an emerging understanding of nationally recognized best practices and evidence-based service delivery models.
Early Work in Food and Nutrition
In 2005, our foundation awarded a grant to The Food Trust to convene and facilitate the Nutrition Coalition, a collaboration of food pantries in the North Penn and Indian Valley areas of Montgomery County. Many of the dozen or so pantries in the area did not know each other; it was not uncommon for pantries to run parallel food drives and to serve some of the same consumers. The goals were to foster communication and collaboration among pantries, increase access to fresh produce for clients and design a sustainable infrastructure informed by best practices in the industry. Pantries soon began sharing excess inventory and coordinating fresh produce drives for the benefit of all. Manna on Main Street in Lansdale worked with Lehigh Valley Dairy to secure regular milk donations and built a process to redistribute what it could not use to other Coalition members. In 2011, Philabundance assumed the role of facilitator and the Nutrition Coalition continues to meet several times a year.
Also in 2005, our foundation partnered with the Health Promotion Council to reduce childhood obesity in three school districts in Montgomery County through the Wellness Initiative for the School Environment: Smart Nutrition and Activity Collaborative (WISE SNAC®). Using an evidence-based tool developed by the Centers for Disease Control and Prevention, the initiative sought to promote collaboration among schools and community partners, reinforce healthy messages, and provide professional development and capacity building opportunities for school personnel, families and organizations. After eight years and roughly $1 million in grant support provided by our foundation, WISE SNAC successfully reduced the obesity rate – as measured by body mass index (BMI) – by 2%. Each district also eliminated many high-fat, high-sugar, high- caloric foods from their menus, substituting healthier food options chosen by parent councils, students and school district food services personnel. While no longer funded by our foundation, the WISE SNAC initiative continues to influence healthy eating and promote physical activity in these districts.
Cultivating Communities Campaign was launched by our foundation a year later to enhance year-round access for low-income individuals and families to fresh, locally grown and nutritious foods. A collaboration of four organizations – Health Promotion Council (lead), The Food Trust, Penn State Extension and the Montgomery County Health Department – came together to develop or expand up to 24 gardens in the greater North Penn region. Gardens were paired with an entity, such as a food pantry or communal meal program, that could use more fresh produce. Though the program has ended, many of the gardens continue to supply produce to their original food safety net partners.
Progressing to Systems Change
Our foundation underwent another evolution in 2012 when we formally embraced a systems change approach, conveying to current and potential partners our desire to create long-term, sustainable changes to systems serving the neediest in Montgomery County.
Another key change was that we expanded our service community to encompass all of Montgomery County. Previously, our foundation concentrated the majority of our work in three school districts. Foundation board and staff recognized that to be successful in changing systems within the safety net, we must scale our work.
This new chapter for our foundation ultimately precipitated a name change. Feedback from communities where we had little or no historical connections highlighted that our name was a confusing message and brand. The community simply could not understand why the North Penn Community Health Foundation (emphasis added) was working in their community. Our new name and brand – HealthSpark Foundation – eliminates the geographic moniker and more appropriately states our commitment to investing in healthy communities by seeding good ideas. Further, the removal of the term “Community Foundation” eliminated the misperception that we solicit grants and raise money.
Evolving Work in Housing
During the deepest parts of the Worldwide Recession (2008-2010), housing providers continued to meet periodically, alongside county and foundation officials. Significant research into various models that could reframe the traditional Continuum of Care to a more relevant and responsive system in our community characterized the majority of discussions.
Two opportunities began to emerge: the federally sponsored Homelessness Prevention Rapid Re-Housing Program (HPRP) offered financial assistance to test out new service and system models; and Housing First, a model introduced in New York City that helps individuals find housing first, then provides only the supportive services necessary for the client to remain stably housed. Without lengthy stays in programs operated in the ”old system,” the Housing First approach promised more clients could be served at the same or lower cost.
As referenced earlier, our foundation funded a pilot program in 2011 to test the efficacy and cost-effectiveness of a Housing First approach. Fifteen clients were served during the pilot, and at the end of six months only one client had opted out. Seven clients were no longer at risk of losing their housing within two months of initial contact, and the remaining seven clients secured permanent housing before the pilot closed. Services provided to maintain housing were based on the client’s individual needs and were relatively minimal: utility assistance, payment of back rent, payment of security deposit for new rental, negotiation of lease payments with the landlord, job placement assistance, transportation to job interviews and computer training. Under HPRP, the average cost to stably house a client was around $5,500. The average spent per client in the pilot, however, was just under $3,100 – a 44 percent reduction! Service innovation was beginning to excite rather than scare the provider community.
Though a small sample, the success of the pilot affirmed that the Housing First model held promise. To see a countywide implementation of Housing First, we arranged for a three-day multi-stakeholder site visit to Alameda County, California, in early 2012. Alameda County launched its Housing First model – EveryOne Home – in 2007. Structural, organizational, programmatic and service opportunities that could be adopted in Montgomery County were noted.
Learnings in hand, the team began to develop its blueprint for Housing First in Montgomery County.
Evolving Work in Food
Expanding our foundation’s footprint to serve the entire county meant we needed to understand both the extent of food insecurity in Montgomery County as well as the policies and programs available to those in need.
In 2012, we engaged Mariana Chilton, PhD, MPH, from the Center for Hunger-Free Communities at Drexel University’s Dornsife School of Public Health to conduct research into the issues and challenges food-insecure families face in our county. Dr. Chilton and her team surveyed food pantry clients and those who serve them, and accessed publicly available data sources to produce A Preliminary Analysis for Ending Hunger in Montgomery County. The report confirmed many beliefs about hunger in the county:
- Hunger exists throughout the county, concentrated in the urban centers of Norristown and Pottstown, and in very rural areas;
- Food insecurity is masked by the county’s significant wealth;
- The county’s emergency food providers need to be networked to support better communication, foster collaboration and develop a sense of community
Though difficult to actually quantify exact numbers for the county given existing sources, the report did identify a food insecurity rate of about 15% for families with children. Dr. Chilton and her team stressed the importance of public benefit programs like SNAP (Supplemental Nutrition Assistance Program) in lifting people out of poverty, a key population health strategy.
Following the release of Dr. Chilton’s report, we commissioned The Food Trust to research and publish a report on what programs comprise the emergency food safety net, how those programs work together (or don’t) and offer recommendations for the state and county governments, philanthropy and individual providers. The Hunger and Food Safety Net System described the flow of public dollars related to emergency food and other safety net programs supported by the state and county, and how the county compared to others in Southeastern Pennsylvania.
Armed with this knowledge, we hired a consultant to engage local food safety net providers in additional on-the-ground research, conducting focus groups to inform investment opportunities. Late in 2013, our foundation offered planning grants of up to $5,000 for organizations to work on a self-defined, food-related issue in their community. Planning grantees had approximately four months to convene a diverse set of stakeholders to further articulate a focus for their efforts and develop potential solutions. At the end of the period, all were invited to apply for an implementation grant of up to $50,000, with the potential to renew at the same level or higher for two additional years. We learned an important lesson: you can’t rush great ideas to fruition.
From nearly a dozen applicants, only two implementation grants were awarded in 2014. One grant went to Manna on Main Street, which has been working to improve child food security in the North Penn area of the county through a multi-prong approach that includes increased access to fresh produce, nutrition education, the introduction of a summer feeding program and improving the financial security of clients.
We awarded the second grant to Philabundance to provide facilitation and backbone administrative support for what eventually has become the MontCo Anti-Hunger Network. (A full description of the initiative was described in a September 2015 article in the Philadelphia Social Innovations Journal.) At first glance, this program does not fall into the original intent of the grants, as it is a countywide effort to improve how food is being sourced and distributed through the emergency food system. However, this initiative is thoroughly a system change effort and is working to build the network of providers that Dr. Chilton originally advocated.
Beyond the Grants
The role of our foundation to effect change continues to include endeavors that support the direct work of our grantee partners. Hosting meetings, commissioning reports, providing technical assistance, helping inform policy makers, and serving as “thought leaders” in the community and region all contribute to the work and support our doctrine of systems change. As a staff of four, our foundation has only so much bandwidth. Accordingly, we actively seek to collaborate and partner with others. Our board encourages the staff to nurture and support public/private partnerships, learning collaboratives and other strategies that can help leverage a shared vision into actionable countywide initiatives, a key element necessary for population health work.
Current Work in Housing
Your Way Home Montgomery County (YWH), the public-private partnership working to solve homelessness in the county, launched in January 2014. County residents experiencing homelessness or who are at risk of becoming homeless, can now contact one toll-free number through which an intake and assessment is conducted. Callers are connected to appropriate services based on their needs and circumstances; some are referred to shelters with open beds and some receive counseling. Housing stability coaches and Housing Locators work directly with clients at one of three Housing Resource Centers. Clients are assisted in developing a personalized housing stability plan and securing affordable, stable housing in the community of their own choosing.
Since its launch just over two years ago, the impact of the YWH initiative has been remarkable:
- Transformational public/private partnership with seven county agencies; eight philanthropic funders; and nearly 20 direct-service provider partners
- Unified housing crisis response system
- Number of people diverted from emergency shelter went from zero in 2013 to 428 in 2015
- Percentage of people exiting shelter directly to permanent housing rose from 31% in 2013 to 46% in 2015
- Coordinated and leveraged public/private funding yielding $12 million.
Understandably, additional improvements and system refinements still need to be made. Systems transformation requires time and patience. Additional efforts are needed to address the critical shortage of affordable housing units, wait times for services must be reduced or eliminated, a trauma-informed agenda should be integrated across the entire system, employment readiness efforts that started earlier this year ought to be enhanced and more. While we continue to work on these opportunities, the county’s housing and homelessness system does not look the same as it did in 2006 when the needs assessment first identified service issues. And that is a good thing.
Current Work in Food
Similarly, the county’s emergency food system has changed.
Manna on Main Street’s efforts to transform child food insecurity have led to the creation of a very successful summer feeding program for the North Penn School District. An average of 2,000 children were fed last summer at 32 community sites within the district. The introduction of a van last year helped to increase the scale of the program’s impact. In early March, we hosted a meeting with key stakeholders who will replicate this program in another district in the county.
The MontCo Anti-Hunger Network continues its work to develop a food distribution hub-and- spoke model that will support the logistics of managing large scale donations resulting in a more equitable distribution of food among the county’s roughly 50 food pantries. It is building the network of pantries through a variety of strategies that include an annual conference, monthly newsletters and a professionally facilitated peer learning circle.
And in the spring of 2015, our foundation launched a new capacity building program for food pantries to address their operational challenges and infrastructure needs. Grants have supported the introduction of technology, the transition to a choice model that provides a more dignified experience for clients, board and staff training and strategic planning for a number of the county’s pantries.
HealthSpark Foundation’s Future
Along our journey, we have learned much about collaboration and partnering and how these efforts are necessary to improve systems. We realize and willingly share that this is really hard work. Relationship building is essential and takes a lot of time and patience. And with any relationship, discord and conflict can and does occur and occasionally feelings get hurt. Change comes slowly and incrementally and not always in a linear fashion. Still we persevere, knowing that compromise and the collective wisdom of our partners will yield the best and most lasting solutions. Ultimately, the work is amazingly rewarding.
Over the next year, our foundation will explore how to further integrate and align our health, housing and food work. Those who are homeless may already visit a food pantry. Pantry clients might be in danger of losing their homes or living situation. Poor health and lack of access to clinical care, health literacy and supports can and does undermine the best intentions of our work and that of our partners. We will continue to seek high quality, high-impact, cost-effective solutions that integrate comprehensive approaches to helping vulnerable people live with dignity and success in Montgomery County.
Access to good sources of reliable data is another example of how our foundation is thinking about “next steps.” We are exploring whether an existing shared database used by our housing providers could also be used by food pantries and what benefits or challenges that could bring. Another possible investment is helping smaller, mostly volunteer-run food pantries that record client data on index cards to computerize their operations. A fully-integrated housing and pantry data system may be years away, but interest is growing on the emergency food side and frankly investors (foundations, government and individual donors) want solutions that are cost-effective and eliminate duplication and redundancy of efforts.
We also hope to build upon the mutual interests of our philanthropic colleagues and the leadership at Philanthropy Network Greater Philadelphia. We are interested in identifying a few funding partner models that can be applied to our future work without having to reinvent or rediscover the same models or entertain using a model that is not well designed to achieve lasting value. This effort is fully consistent with a population health approach to the overall well-being of our community.
How can a small foundation have a big impact on health? We at HealthSpark Foundation believe we can by thinking about health more broadly. We bring together diverse stakeholders to work on the social determinants of health and encourage them to think creatively about solutions. No one can do this work effectively alone.
Silos are best left on the farm.
(See article for full list of references.)