Working Together in Atlanta, Overcoming the Burden of Inequality

Atlanta Regional Health Improvement Collaborative refers community health workers to FQHC Mercy Care and Grady, a local safety net hospital

The Atlanta Regional Health Improvement Collaborative (ARCHI) seeks to shift the burden of combating racism and other inequities to institutions rather than individuals.

During a recent webinar, ARCHI leaders described how they are working on these issues through community resource centers serving the immediate needs of patients at Grady Health System and Mercy Care Atlanta.

The webinar was sponsored by the National Center for Integrated Health and Social Needs, an initiative of the Camden Coalition of Healthcare Providers in New Jersey.

Catherine Lawler, executive director of ARCHI, said the collaborative involves more than 110 organizations committed to improving health, not only by focusing on the social determinants of health, but also by increasing understanding and knowledge of historical policies and politics. practices and biases that have led to long-standing inequities. “We strive to meet the needs of today in our community, but also do the work of changing systems so that we have a fundamental shift in health outcomes that can last for many future generations,” she said, adding that ARCHI’s work in this area of integrated care is critical to their overall strategy for community health and racial justice.

“Burden Shifting” is an approach to achieving health equity by placing the burden of combating racism and other inequities on institutions rather than on individuals. It includes methods of addressing the “lower” immediate needs of patients with comprehensive health care, an “intermediate” supply of affordable housing, quality jobs and insurance coverage, and “bottom-up” root causes of systemic racism.

According to ARCHI consultant Meredith Schwartz, one of the ways ARCHI has embarked on the concept of burden shifting in Atlanta is through the creation of community resource centers. The organization has worked with its partners to create a network of health systems and providers that seeks to shift the burden of navigation from the patient to the system itself. It’s based on two principles: meeting people where they are and putting them at the center of a system that coordinates their care, she said. “We have two medical sites: Mercy Care, a local FQHC, and Grady, a local hospital of the social safety net,” she said. “The health care providers within these systems identify and work with patients with chronic conditions as well as non-clinical needs that prevent them from meeting their health care goals.”

Community health workers work with patients to identify personal needs and goals and then educate them as they access services online and refer them to partner organizations, while continuing to connect that work to their health. This includes bi-directional data sharing between health systems and agencies, warm-to-hot referrals based on relationships established in the network, mentoring, a clear governance structure and aligned incentives.

“We worked with patients in both health systems during the design phase to determine what social needs were most preventing them from achieving their health care goals,” Schwartz said. “At the top of the list were safe and healthy housing, access to nutritious food and transportation to access needed services. Our partner network comes together as a full group every month. The group attributes its success so far largely to the relationships built in the network. “We also know they want to keep that momentum going. It works for them and their customers, and they’re all still willing to invest time and energy,” she added.