Clarification of Policy Ideas Listed in Survey

Question 1:How can we enhance infant/early-childhood outcomes?

1. Integrating parental health education into pregnancy classes
 As the Forsyth County Infant Mortality Task Force has previously stated, “working to help women be healthy over their entire lifespan is the best way to save babies’ lives and improve the health of our community.” To that end, we recommend a continued focus on the mother in order to best enhance infant and early childhood outcomes. However, current measures in place are insufficient.  It is recommended that parental health education initiatives be integrated into pregnancy classes. In this way Forsyth County can better look to the future and help to improve the health of the child by implementing pregnancy workshops that educate on topics like breastfeeding, staying in school, postpartum depression, and healthy food preparation techniques. The best way to improve the health of the child is by first improving the health of the mother.

2. Tax incentives for fully paid parental leave
Currently, the lack of fully paid parental leave is the norm rather than the exception. Infants and those in early childhood cannot experience the most ideal outcomes if their mothers (or fathers) are not there to take care of them. With an increasing trend of rising income inequality both nationally and here in Winston-Salem, businesses should be granted a modest tax incentive for offering parental leave beyond the required time periods. The City of San Francisco recently implemented such measures and initial signs are positive. Tax incentives not only bring mothers home to their children, but they also increase the likelihood that those same mothers will return to work and earn higher wages; such an outcome is advantageous for businesses and families alike.

3. “Starter Kit” box for mothers leaving hospital after birth
Prenatal education for mothers and fathers must be revamped, and it is proposed that every mother receive a box with basic and necessary supplies after she leaves the hospital. This “starter kit” has been in place for over 75 years in Finland, and many consider it to be the reason why the country has one of the world’s lowest infant mortality rates. Contents of the box would include bodysuits, a sleeping bag, outdoor gear, bathing products for the baby, as well as diapers, bedding and a small mattress. The box, while primarily fostering an enhanced relationship between doctors and mothers, also has the effect of uniting all new mothers, including those from different generations. Mothers can feel like they have a tighter nucleus and a better support system with the box. A cash grant could be offered to those who do not wish to have the box for whatever reason.

4. Early intervention programs for non-English speakers and those with special needs
Early intervention programs to aid those who are non-English speakers are lacking. There should be ample access to pregnancy classes for those who do not speak English, as it is frequently the case that these are the people who need the classes the most. These programs should be separate so as to unite those from similar backgrounds and allow them to feel comfortable with the process with those around them to whom they are similar. These classes could also serve other mothers with additional special needs.

5. Offer free Women, Infants and Children (WIC) Program to all mothers leaving hospital
The Women, Infants and Children Program (WIC), a special supplemental nutrition program, should be offered to all mothers who leave the hospital. Since the program is more targeted at those from lower income backgrounds, mothers are sometimes reluctant to ask about it or inquire about help. If all women are informed, awareness will be increased, and all who feel they are good candidates for the program can find out if they are. Mothers should be given information about how to apply to the program, where to seek clarification on eligibility requirements, and be told that the program is free.

6. Program to clarify misconceptions about vaccines
A campaign should be initiated to clarify misconceptions about vaccines. New research has shown that mothers do not realize the importance of vaccines and some even view them as harmful. The first step is to initiate the campaign, which could be independent or incorporated into existing pregnancy classes. The ultimate aim would be to make vaccines mandatory.

Question 2: How might we expand access to reliable and affordable health care, including mental health care?

1. Community Garden to increase access to healthy food
A community garden can serve as a place where people can go to trade (gardening) skills for food. This could be a relatively low cost program but could provide a substantial upside by giving access to free healthy food. Community gardens already exist in Winston-Salem, some funded by nonprofit organizations. A potential barrier to this could be that some low-income people might lack the knowledge or resources to prepare this food to eat. If the land could be donated and a limited number of tools bought to be shared across all of the gardens, costs could be significantly restricted and the only recurring costs would be the soil and the plants which would range in price depending on the size of the garden. Additionally community cooking classes could be offered. This could provide a relatively cheap solution to facilitating access to healthy food, an essential component of good health.

2. Halfway House Rehabilitation Option post-surgery
Provide qualified people with the option of staying in a halfway house after coming out of surgery. Oftentimes people get a surgery that helps them out only to return to their inadequate living situations during the recovery phase. This can sometimes lead to infection, longer recovery, and generally negative impacts on their health. Basic halfway houses can run between $100 and $300 per person per month which is cheap compared with the cost incurred in a person being readmitted to the hospital due to inadequate care post-release after surgery.

3. Re-route public transit in Forsyth County
Riding the bus in Forsyth County can be inefficient in terms of reaching places necessary to maintain good health. From some locations (often food deserts) it may take 1-2 hours to get to a supermarket or health clinic. Sometimes people have to walk or get a ride for miles to the bus nearest their house, store, or clinic. Focusing on re-routing bus lines so that more buses travel between low-income areas, supermarkets, and health clinics would reduce the inefficiency. If buses were easier to ride, people would be more likely to take them to buy healthy food and see a doctor.

4. Affordable Busing.
The current bus system is already very cheap. However, for some people it is still unaffordable. Making busing free for qualified individuals or for everybody would entice people to use the buses to bring them to places they need to go to be in good health. This would not cut into profits significantly if at all because the people who can’t afford it don’t use the buses as of now anyway. Higher costs incurred due to increased numbers using the buses could be covered by government subsidies. Re-routed bus lines would reduce inefficiency and increase the effectiveness of affordable busing.

5. Pay health care providers for quality not quantity of services
This would be a significant undertaking but would generally focus on rewarding primary care providers for the quality rather than quantity of their services. This could either be done by re-structuring salaries or by giving bonuses to doctors/clinics that do a good job of keeping their patients in good health. Doctors are usually paid according to the number of patients they see and this system would have to be re-imagined to implement this policy idea.

6. Subsidize food stamps to be twice as valuable for payment for healthy food
This suggestion, relatively simple to implement, could have major benefits. Healthy food is generally more expensive than junk food so this idea bring the relative costs into alignment and encourage people to use their food stamps to purchase healthy food. Costs would be incurred by the food stores as they would essentially be selling their more expensive products at a discounted price so there would need to be some form of government subsidy for this plan to be feasible.

7. Monetize preventative care.
This is similar to rewarding quality of care over quantity of care by rewarding health care providers for successfully preventing chronic diseases and similar ailments. This can be done by giving outright bonuses for successful preventative care or by cutting payments to doctors/clinics and offering the opportunity to make the income cuts back and then some by way of bonuses. It is difficult to project estimated costs of this broad plan, which needs a great deal of refinement for it to materialize.

8. Focus on early school and childcare center health education
Devoting a small amount of time towards developing healthy habits in young children can pay off exponentially in the future. Allocating 15-30 minutes per day, say before lunch or recess could hold young children’s interest and attention. Costs would be low as it would not require more schooling or paying teachers more money for this to be implemented.

Question 3: How best to shift providers and patients alike to a focus on preventive care, e.g., treating chronic diseases before they become life-threatening?

1. Medicaid expansion in North Carolina, including extending continuous eligibility for children.
Increasing health insurance is the most fundamental way to increase access to healthcare. Medicaid eligibility expansion to 138% of the federal poverty line would extend coverage to between 375,000 and 500,000 North Carolinians, and many thousands of Winston-Salem residents, to be sure. The Affordable Care Act guarantees federal coverage of 100% of the costs of expanding Medicaid until 2020, and then will cover 90% of the costs after 2020. The city council should pass resolutions calling on the state legislature to draft and pass Medicaid expansion legislation.

2. City Emergency Medical Fund for grants to pay for medical bills.
Create a city emergency medical fund to which people can apply for grants to pay for their medical bills. This policy recommendation stems from stakeholders’ stories of Winston-Salem residents being unwilling to pursue care in acute health crises for fear of being asked for insurance information. The city can evaluate what are the most common health crises that go unattended, and create a fund whose eligibility is restricted to target those health outcomes among low income residents below a certain income threshold. This safety net program could mirror Columbia University’s Special Health Fund, a “discretionary fund to defray costs for time-sensitive and important health-related services.” This fund allocates $750 per health condition for two requests a year.

3. Educate about and expand telemedicine opportunities
Teach about and expand telemedicine opportunities for those with smartphones, especially with an eye towards behavioral health. Telemedicine is the “use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status” (American Telemedicine Association). Telemedicine expands access by allowing low cost, no transportation consultations with healthcare professionals through phone or video call, or text message. Wake Forest Baptist Health utilizes a Patient Portal called myWakeHealth that allows patients to view their medical information, link their family’s records, manage appointments, email your care team directly, request medication refills, and receive text message reminders for appointments. Expanding this type of platform across healthcare providers (from clinics to hospitals) would serve to expand telemedicine access while also increasing care coordination. Other examples of telemedicine include nurses calling patients twice a month to improve adherence to medical plans, and some studies have found this to be a cost-neutral but effective form of care (Peikes et al. 2009)

4. Provide childcare for medical appointments
Provide childcare for doctor appointments, since children aren’t allowed in some waiting rooms. Many healthcare facilities do not provide childcare for their patients, making parents disinclined to seek healthcare for themselves and their dependents. Wake Forest Baptist Health has a Children’s Choice Learning Center, but this program serves as a formal preschool program, not as a situational program for individual appointments. There are a plethora of examples of these kinds of programs, including North Pointe’s “Fit N Fun” childcare program. The city could mandate childcare facilities for providers of a certain size or provide tax incentives for practices that do provide childcare.

5. Increase quality of care/range of services at clinics
Increase level of care at clinics, not just their number. People need more than just a checkup. The city should work to develop and broaden the range of services provided by community clinics, rather than simply increasing the number of clinics. This policy recommendation stems from the proliferation of healthcare providers that service our community, making it difficult for patients to get a full range of care without significant time and transportation commitments. This recommendation dovetails the policy recommendation below.

6. Behaviorists in clinics to see patients alongside medical providers.
The city’s clinics should place behaviorists in consultations alongside medical providers, and employ incentives to encourage private providers to do the same. Some private, non-profit clinics in Winston-Salem already have this program in place. Rather than simply encouraging patients to seek mental healthcare, this policy intervention ensures that patients receive holistic care and that their mental health needs are addressed every time they go to the clinic. This policy would remove stigma by creating integrated care, from which patients can be referred to other mental health care providers.

7. Increase care coordination/information sharing between healthcare providers
Increase care coordination by giving permission to healthcare providers to share information with each other, pop up shops, and school systems about patients. Care coordination refers to the communication and collaboration between various healthcare providers. The primary technology used for increasing care coordination is Certified Electronic Health Record (EHR) technology, but many clinics lack to funding or infrastructure to be able to maintain EHRs. City funds to develop Certified EHR systems across all the city’s healthcare providers would increase care coordination among providers. This policy recommendation also entails a strengthening of transitional care programs, an initiative which would allow in-patient and out-patient services to share relevant health information without as many bureaucratic barriers.

8. Community Care Center in Magnet Schools
One option discussed is the placement of a community care center in one, or a few, of the magnet schools in the Winston-Salem/Forsyth County area. Magnet schools are public schools with specialized courses and are able to draw students from across the normal school boundaries defined by authorities. The Winston-Salem area offers 20 different magnet schools for grades K-12. One that might be of particular interest to us, is Brunson Elementary which focuses specifically on science, technology, engineering, and math courses. This school already educates their students in the sciences, and by placing a community care center here, we would be creating a community hub for healthcare. Community care centers often offer toddler and after-school care at low prices. They also would be able to provide healthy and nutritious meals and snacks for the children. In addition to the beneficial services provided at community care centers, placing one in or near an elementary school will reduce transportation costs and time.

9. Mobile Care Clinics.
Introduce mobile care clinics offering mental health care, therapy, and reproductive health care. Winston-Salem State University has a program similar to what we are proposing. They call their mobile clinic RAMS Know H.O.W Mobile Unit and they offer preventive health services to East Winston residents. The mobile clinic is run by faculty, staff, and student volunteers from the School of Health and Sciences. These services are invaluable to members of the East Winston community and should be expanded. Many mobile clinics in other communities are run by doctors and nurses and can offer many more services such as immunizations and sick visits. As of now, the RAMS Know H.O.W Mobile Unit offers blood pressure measurements, BMI measurements, glucose and cholesterol screenings, health education, and medical referrals.

10. Expanding Pro-bono medical care
As of now, Wake Forest Baptist Medical offers pro-bono care through their Delivering Equal Access to Care (DEAC) Clinic. This is a student-run and a physician staffed free clinic that provides services such as blood work, free medications on-site, social services, mental health and STI screening, and community wellness and prevention education. It runs on Wednesday evenings from 6pm-9pm at the community care center. This type of work needs to be increased by, for example, expanding the time and days that the clinic is open. Referring to the above suggestion, they might consider making their clinic mobile in order to increase residents’ access to the services. However, these medical students should not limit their work only to this clinic, and may want to consider outside services they can provide to members of the Winston community whom are in need of cheaper and more accessible healthcare.

11. Educating Advisors on health/wellness care
Research needs to focus on where different sectors of the Forsyth County community go to receive healthcare information. Healthcare advisors might include doctors, guidance counselors and trusted volunteers. Once data is obtained, these advisors should be educated on distributing appropriate information relating to health/wellness care and how to expand their care teams to include informal providers of such information.

12. Overcome stigma related to mental health issues
It is important to converse with young men about masculinity and as it relates to a mental health care barrier. Many men can be too proud to admit that they struggle with mental disorders. However, 1 in every 4 adults in the United States will experience a mental health problem in a given year, and on average, 87 men each day take their life by suicide in the United States. One idea for combatting this problem is creating videos from mental healthcare providers themselves, which would allow people to ‘meet’ that professional virtually before even going to the clinic and make them feel more comfortable in the professional’s presence. Another option for making clients feel more comfortable is to connect them with ethno-racially similar providers. Finally, these meetings could be set up through a broader ‘chronic disease study’ so that men would be more inclined to participate.

13. Improve access and frequency of bus transportation
Many of the people with poor access to healthcare often work late shifts at their various jobs. They rely on the public bus system, which can be extremely inefficient. As of now, most of the bus routes end at 11:55pm, but some end even earlier, such as at 11:30pm. The buses generally start running again at 6:15am. They do not run on Sundays. While expanding these times may seem unrelated to expanding healthcare (since most clinics would not be opened past midnight), it would allow people to go to the clinics during the day/evening, while still working the night shift. In addition, it can be unsafe to walk around Winston-Salem past midnight, and having access to late-night transportation would reduce the incidence of crimes and accidents.

14. Facilitate parents’ transportation to attend students’ psychiatric care at school
Some schools offer trauma-based care and/or psychiatric care for their students, important and necessary services. It can be of added benefit for parents also to attend these sessions. It is suggested that a program be introduced that coordinates transportation for parents to attend school for their children’s psychiatric care. This could be done in a variety of ways including the use of school buses for parents’ transportation. Alternatively, the program could involve volunteer drivers transporting parents to and from their children’s appointment.