August 12, 2020

NEWS and New Pubs!


All upstream SDOH work all over the country is largely about improving health and life equity. In our experiences and observations, no community has done a better and more comprehensive job of focusing on racial equity than the District of Columbia CAPGI coalition, as led by the Jane Bancroft Robinson Foundation. Our May 19th webinar highlighting their extraordinary contributions to the evolving field of health and social equity work can be heard here. We strongly encourage all students and practitioners of health equity work to listen if you were not able to catch the May 19th event. The next four paragraphs provide essential background.

The Jane Bancroft Robinson Foundation (JBRF) was founded in 2011, through the integration of Sibley Memorial Hospital with Johns Hopkins Medical System. JBRF, grounded in the legacy of the United Methodist Church and Sibley Memorial Hospital, strives to reduce the disparities in health and livelihood that disproportionately hinder Black Women who live east of the Anacostia River in Washington, D.C. The Foundation’s philanthropic approach champions community change, built from the ground up.  JBRF engages with community members and non-profit partners to identify both their most pressing needs and a genuine path for growth and improvement. This partnership strategy produces mutual satisfaction, substantial stakeholder buy-in and tangible results.

Launched in 2019, the Black Women Thriving East of the River (BWTEotR) Initiative, funded by the Jane Bancroft Robinson Foundation, partnered with Black women living in Wards 7 & 8 and the community-based organizations (CBOs) that serve them to collaboratively design a series of strategies to change inequitable cancer and health-related career outcomes. By convening the most impacted individuals into issue-specific workgroups on Patient Navigation and Workforce Development, resulting “road maps” were created to address the root causes of these issues and implement equity-focused solutions in the prioritized community.

The mission of BWTEotR is to reduce cancer mortality and create health-related career opportunities for Black women in Wards 7 & 8 by transforming the culture of racially unjust and inequitable systems. We see a city where black women thrive in Wards 7 & 8 because they have access to racially equitable opportunities and resources that lead to optimal health.

Planned CAPGI Intervention

Today, the most impacted populations are frequently the objects, rather than the architects, of policies, programs and solutions. In Washington D.C., Black residents experience cancer at a 54% higher rate than white residents, and mortality rates for Black residents are a staggering 90% higher than white residents. The BWTEotR Initiative recognizes that those closest to a situation can best identify their needs. When it comes to cancer patient navigation, all too often there is a one-size-fits-all approach. With this initiative, BWTEoR is developing enhanced cancer patient navigation services that are informed by the viewpoints of those most intimately affected, specifically Black women living East of the Anacostia River in Washington DC. This navigation approach goes beyond the typical assistance for appointment setting and transportation. It looks at the social determinants of health, chronic disease factors, distress and environmental challenges to ensure effective deployment of navigation resources. A standardized assessment tool, developed based on existing research and validated by Black women East of the River, will indicate the level of navigation support, or tier, needed by each patient to optimize their cancer journey and improve outcomes. Through this pilot, the assessment tool and resulting recommendations will be evaluated to ensure that no one slips through the cracks and navigation supports meet all the relevant needs for Black women East of the River. By layering the CAPGI funding model into this intervention, BWTEotR intends to:

  • Strengthen the overall case for a coordinated cancer navigation system in Washington DC,
  • Promote the idea that sustainable funding for cancer navigation is an important step toward addressing health inequities and providing racially just services that improve the health outcomes and quality of life for Black women living East of the River, and
  • Champion the BWTEotR approach as a strategy for building community change from the ground up.

Citation: Price, Rebecca Anhang, Janice C. Blanchard, Racine Harris, Teague Ruder, and Carole Roan Gresenz, Monitoring Cancer Outcomes Across the Continuum: Data Synthesis and Analysis for the District of Columbia. Santa Monica, CA: RAND Corporation, 2012.

Recent notable webinars: The Cleveland United Way-led application of CAPGI for medically tailored meals for socially isolated older adults with certain chronic conditions was highlighted in our webinar on September 24th (link to 60 minute recording here , slides available here ). We were proud to have co-creator Lauren Taylor open the webinar with a CAPGI 101 that she does so well, hear opening contextual remarks from United Way President Augie Napoli, a bit of how Cleveland United Way led and organized the CAPGI conversation and collaboration from Health Director Jenn Kons, and then the unique but aligned perspectives from panelists Karen Cook, Director of Health Families and Thriving Communities, MetroHealth System, Dr. Dale Block, Market CMO for Ohio CareSource, and Dr. Srinivas Merugu, CMO and VP for Population Health of UnitedHealthCare Community Plan of Ohio.

The essential roles of Trusted Brokers were highlighted on November 3 (listen to fascinating recording here ). Exemplar Trusted Brokers from Cleveland, Albany, Waco, Anne Arundel County, Maryland, DC, Kansas City, and Virginia discussed they learned and taught us. We know their insights will be useful to all who may be considering similar collaborative journeys.

Our final webinar in this series will be in early 2022 and will shine a spotlight on the DC team, led by the Jane Bancroft Robinson Foundation, which has implemented a comprehensive approach to SDOH intervention design with authentic community engagement through a racial equity lens that is truly unique in our experience.

Some other recent public events featured CAPGI and friends.

On April 13, 2022 RWJF’s Systems for Action program highlighted CAPGI in their webinar featuring Lauren Taylor and Len Nichols (link to recording and slides HERE).

On October 28, 2021 Len Nichols was interviewed for the podcast “Wonks at Work”, which is a creation of Craig Wilson (Director of Health Policy) and Joe Thompson, MD (Founding CEO) of the Arkansas Center for Health Improvement. The conversation turned into a succinct introduction to SDOH and CAPGI all at once. Listen here.

On September 15, 2021 Mathematica Policy Research organized an event entitled “The Vital Role of Health Care Payers in Addressing Social Determinants of Health to Advance Equity” which also featured Len Nichols talking about CAPGI on a panel of equity and SDOH experts.

In late May 2021 the National Academy of Medicine held a series of workshops on Financing that Rewards Better Health and Well-Being, which featured a number of pioneers around the country, including CAPGI co-founder Len Nichols. More details on the Academy’s work can be found here.

On October 27, 2020, the New Hampshire Business Acumen Initiative’s virtual event The Payoff of Investing in Social Determinants of Health: A Sustainable Financing Approach That Improves Outcomes featured presentations by CAPGI co-creator Len Nichols (Urban Institute) and Cleveland’s Trusted Broker, Ben Miladin (United Way of Greater Cleveland). Ben’s presentation is particularly interesting, as he explains how Cleveland moved so quickly and effectively toward implementing CAPGI to provide Medically Tailored Meals to socially isolated older adults with certain chronic conditions. Visit the NH Business Acumen Initiative webpage (link above) to learn more about how they are leading creativity in health and social policy in the Granite State.

And then on October 28, after a series of fascinating panel discussions featuring local leaders from health care, social service, and politics, all organized by the Alliance for Better Health, a unique IPA and information technology backbone for social service organizations in Albany, Troy, and Schenectady, NY, Len Nichols gave a keynote describing CAPGI and how it might help the upstate New Yorkers CONVERGE on collaborative SDOH solutions. The American Journal of Managed Care covered the event and captured the highlights adroitly.

We are quite happy to announce the publication of the Health Affairs Blog post on August 13, 2020. This post describes our Feasibility Study, the lessons we learned, and the status of CAPGI implementation plans in our ten participating communities, including the recent news that the Cleveland coalition voted on July 29th to do medically tailored meals by January 1, 2021.