Approaches to Improving Community Health: The Six-Box Framework

Across the nation, hospitals and health systems are searching for new ways to reduce costs, enhance quality of care, and improve health outcomes (the “triple aim”). As we seek to better understand and enhance the role of health institutions in community investment, we’ve been exploring the wide range of population and community health initiatives currently underway.

A well-established body of research illustrates the connections between the social, economic, and physical environments in which people live, work, and age and how long and how well they live. Increasingly, health institutions are both moving outside the walls of their facilities and going beyond traditional clinical practice, taking a more expansive view of their role in promoting health.

Based on our observations, there appear to be six different types of approaches that health institutions are using to improve health outcomes. We organize these approaches based on whether or not the intervention is clinically oriented and the breadth of the target population (patients, at-risk individuals who are likely to become patients, and the larger community).

The Six-Box Framework: Health Institution Actions to Improve Health Outcomes

Six Box Framework

For example, Box 1 – clinical interventions impacting patients – includes the kinds of activities a hospital would undertake in their facilities or in other health care settings to improve health outcomes for their existing patients. For instance, a hospital could reorganize care delivery or make electronic health records available throughout the health service network to reduce the likelihood of duplicative tests. A hospital with many Spanish-speaking patients might hire additional Spanish-speaking staff to ensure better communication.

Instead of waiting for patients to arrive at the doors of a hospital, health institutions could engage with individuals who are likely to seek health services by sending doctors to homeless shelters or paying for nurses or community health workers to visit expectant mothers. Such activities would fall in Box 2. At a larger scale, health institutions might open clinics in schools, thereby expanding access to health care to an entire population.  This would fit in Box 3.

Health institutions may improve health outcomes by screening for and addressing patients’ social needs, for example by providing transit passes to medical appointments or referring patients to social service agencies that provide assistance with food, job training, housing and other supports. Activities like these, which are intended to impact patients but are not themselves clinical, would fall into Box 4.

Boxes 5 and 6 take health institutions further “upstream” to intervene directly in the determinants of poor health.  For example, rather than simply treating children with asthma who repeatedly require the services of the hospital emergency department, some health institutions have begun to organize or participate in programs that remediate poor housing conditions such as mold. By identifying the “hot spots” with high concentrations of asthma patients, health institutions can cost-effectively reduce unnecessary hospital visits and improve the quality of life for children and their parents. Programs like these benefit the specific individuals who participate, and thus would be classified as Box 5 interventions. In Box 6, health institutions can improve wellness for entire communities by working on policies and programs that reduce particulate emissions, eliminate food deserts or improve water quality. Here, we would find support for developing a new K-8 charter school, or sponsorship of workforce training programs in the community.

Health institutions may work in multiple boxes at the same time, and may emphasize different activities depending upon their institutional imperatives and the needs of the communities they serve. We have observed that health institutions often expand their activities from a single box to multiple areas as their understanding of patient and community needs grows. For example, asking patients about their non-medical needs or tracking emergency visits by patient zip code can reveal patterns in the community and motivate clinicians, payers, and others to deepen investments in the determinants of health.

Whether an institution starts by intervening in obesity, hunger, poor housing, or unemployment, exposure to the complexities of life for low-income people can encourage health institutions to tackle multiple social determinants. Also, as health institutions engage with the community, they may discover potential partners – social service agencies, nonprofits, foundations, banks and others – who they can collaborate with to leverage collective expertise, financial resources, and other assets in new ways.

At CCI, we are particularly interested in what it will take to get health institutions to increase their investments in the types of activities featured in boxes 5 and 6.  We believe that health institutions have much to contribute (i.e. knowledge, financial resources, land, etc.)—and much to gain—by participating in the community investment system and improving the environments that so powerfully shape health outcomes. Understanding how innovative health institutions develop their population and community health initiatives and how their thinking shifts over time is critical to illuminating the path for more institutions to adopt a community investment approach.

We are about to launch a new initiative, Accelerating Investments for Healthy Communities, to help leading health institutions accelerate and deepen their investments in community health and wellbeing.  We look forward to sharing what we learn about how hospitals and health systems can maximize their contribution to improving health by leveraging strategies, tools, and resources across each of the six boxes.

Transforming investment in communities

The Center for Community Investment at the Lincoln Institute of Land Policy is supported by the Robert Wood Johnson Foundation, The Kresge Foundation, the John D. and Catherine T. MacArthur Foundation, and the Surdna Foundation.

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