Case Study—Community Capacity for Health: Foundation for a System Focused on Health

Abstract

Healthy/healthier people and accessible, quality and sustainable health care: We need both, but how? This case study takes place in Airdrie, Alberta, a Canadian province with Alberta Health Services as the largest single health authority. The community began its journey with the typical request—“we need a hospital”—but later realized what they wanted was to “own their own health, becoming Canada’s healthiest community.” Unique to their journey was the decision to partner with Blue Zones Project®. Airdrie would have been the first demonstration community outside the USA of this integrated methodology to transform community environments and make the healthy choices the easy choices, and in so doing, reduce need for, and cost of, public healthcare services.

This case study offers information, experiences and insights from a five-year journey to develop a community focus for health. Perspectives are provided on strategies to optimize community capacity for health as the foundation for integrated and sustainable systems focused on health.

1 The Challenge Before Us

It is more than 70 years since Tommy Douglas (Premier of the Province of Saskatchewan) championed better health and health care, the genesis of the Canadian Medicare system we have today. Unfortunately, the “RESET Button” imagined by Hon. Dr. Bennett has not been found, at least not within the current construct of the Canada Health Act (CHA) and the provincial healthcare funding structures and legislative frameworks (Fig. 52.1).

Fig. 52.1

Imagine a medicare “RESET Button”

The Lalonde Report, A Perspective on the Health of Canadians (Lalonde 1974), began discussions in Canada to look broadly at health and health care. The Foreword to a Senate Report describes the challenge: “we must change our way of thinking and recognize that good health comes from a variety of factors and influences, 75% of which are not related to the health care delivery system. …we must become proactive and support communities, cities, provinces, territories and a country in producing citizens in good health, physical and mental well-being and productivity” (Keon and Pepin 2009).

The Canadian Medical Association (CMA) continued this dialogue with Town Halls regarding views of Canadians on social determinants of health (those factors outside an individual’s genetics and outside healthcare services that influence the health of populations and as further defined in Fig. 52.5). The CMA’s report with recommendations for inter-sectoral action demonstrated the medical profession’s ethical duty to their patients to work toward a society in which everyone has opportunities to lead a healthy life (CMA 2013).

In a report to the Federal Health Minister, UNLEASHING INNOVATION: Excellent Healthcare for Canada (Naylor 2015), the document’s Foreword underscores the continuing challenge: “Because our mandate was healthcare and that in itself was overwhelming, we did not delve into broad determinants of health or strategies for community-wide health promotion. However, readers will note that our recommendations point strongly towards empowering patients with their own health information, and towards modes of reorganizing healthcare systems to put much greater emphasis on keeping Canadians as healthy as possible, including better integration of healthcare and social services.”

This is the call to action: get at health, and by extension, reduce people’s need for “sick care” and the ever-increasing costs of healthcare services.

This case study provides experiences and insights of Airdrie’s journey to develop community capacity for health. At the end, the authors discuss key elements of a “RESET Button” for an inter-sectoral approach for healthy/healthier individuals with direct correlations to improved system performance and sustainability.

2 Healthy Communities: National and Provincial Contexts

The Ottawa Charter for Health Promotion, co-sponsored with the World Health Organization, describes Health Promotion (HP) as a comprehensive, multi-disciplinary approach (WHO 1986). It encompasses five action strategies (build healthy public policy, create supportive environments for health, strengthen community action for health, develop personal skills for health and re-orient health services), supported by three HP strategies (to enable, mediate and advocate).

Actions related to developing healthy communities in Canada draw from this charter.

• A framework developed by the provinces of British Columbia, New Brunswick, Ontario and Quebec describes five building blocks for a healthy community initiative: community/citizen engagement, multi-sectoral collaboration, political commitment, healthy public policy and asset-based community development (BC Healthy Communities 2011). Their approach identifies action on determinants of health and targets benefits at individual, organization, community and regional/provincial/national levels. Impacting healthcare costs is not a specific focus.

• The Public Health Agency of Canada calls for action by local communities, “to innovate so that the healthy choices are the easy choices” (PHAC 2017, p. 43).

• In 1986 in Alberta, the mandate for public health moved from municipalities to health authorities (now Alberta Health Services—AHS). AHS has developed an “Alberta Healthy Communities Approach” with a five-step process (Alberta Healthy Communities Approach). AHS resources include a healthy workplace development tool, practices for comprehensive school health and strategy kits for physical activity, healthy eating, tobacco, alcohol (Alberta Healthy Communities Hub). Implementation has occurred with a variety of focused community initiatives.

Momentum to develop healthy communities is now challenged by financial pressures. A review of AHS states: “the message that these studies create is consistent and clear: Canada’s high rate of spending on health care does not correlate with higher relative performance on key international measures” (Ernst and Young 2019, p. 9). The challenge to AHS is to focus on continuous improvement of health performance while also reducing costs immediately and for the long term.

Strengthening integration of care is necessary to create cost-effective healthcare delivery. These changes will not be sufficient, however, to sustain the system or improve individual and population health, well-being and productivity.

Alberta’s Chronic Disease Prevention Action Plan 2015–2018 (AHS 2016) illustrates the importance of looking to health-related factors and disease prevention in addressing future system sustainability: “Between 2009 and 2011, 58.1% of deaths in Alberta were attributed to cancer, ischemic heart disease, stroke, chronic obstructive pulmonary disease, type II diabetes, and hypertension. Currently, one in three Canadians aged 65–79 have three or more chronic diseases…chronic disease rates are increasing faster among Canadians aged 35–65 years and over, and children currently experience chronic diseases that were previously only seen in adults” (p. 10). … “currently, chronic diseases account for 53% of the total health care costs in Canada” (p. 11).

Many decision makers view financial allocations to health and wellness as additive to the public healthcare system versus a re-allocation. As discussed in the Naylor Report, it is time to widen our thinking and encourage re-allocation of funds currently focused on healthcare services.

This is the context in which this community’s journey for health takes place. As a community, Airdrie chose to focus on improving health and inadvertently may be showing the way to the “RESET Button.” Indeed “Keeping Canadians well, not just patching them up when they get sick” (Bennett 2011).

3 The Journey Begins in Airdrie

Airdrie, Alberta, Canada, is a city of 70,000 in 2019 with 100,000 projected by the early 2030s. It is close to Calgary (25 km to the south). Calgary is one of two major urban centers in the province and is the location of the hospitals serving this community. Publicly funded health care in the community is planned with the Calgary Zone of Alberta Health Services. Local services include primary care, community care, mental health and addiction services, urgent care and emergency services, and continuing care. Airdrie also has a range of social services operated by nonprofit agencies and funded by the city, non-health government ministries and donors. The authors have been part of this journey since the beginning as members of Abrio Health (initially Airdrie & Area Health Benefits Cooperative).

The quotes in Fig. 52.2 launched our journey. For 2016, the question became, “what is a grassroots approach to health?” Consultants were hired with seed funding from the city and private donors. Initial priorities included improving service coordination in the community and improving system performance. Solutions focused on inputs (too many physicians; need for team-based structures) and processes to integrate community-based health and healthcare services across needs-based segments.

Fig. 52.2

Community request 2015

Parallel to this, community leaders came together to form a backbone for community-based work, the Airdrie & Area Health Benefits Cooperative (AAHBC). This organization began to champion a bold community vision, “Own Our Own Health, Becoming Canada’s Healthiest Community” to galvanize community action.

By late 2016, we began to learn the magnitude of the Minister’s challenge. Work in 2017 and beyond has involved community engagement to understand needs and research to identify strategies to develop a healthy community with healthier citizens. The organization was very aware of evidence showing that healthy individuals and communities correlate to reductions in preventable disease and increased financial sustainability of healthcare systems and the RESET Button.

4 Community Plan for Health

The quotes in Fig. 52.3 came from a year-long engagement which informed the first community health plan.

Fig. 52.3

Community input 2018

Leaders of Abrio Health began with a conviction to build on the community’s “can do” attitude and that a sustainable healthcare system could be achieved through community-based changes supporting improvements in both individual and family health. After significant research, Abrio Health recommended the community to investigate Blue Zones Project®.

To learn if the foundations of success were present within the community, Blue Zones Project, representatives came to Airdrie in May 2018 to share methods and results. More than 600 citizens were engaged. Particularly significant to the community’s support and ability to proceed were two factors: First, they would have a comprehensive methodology with evidence and experience in more than 50 locations. Second, the community, through Abrio Health, could act on momentum with a decision to move forward with this organization, cementing local ownership.

Concurrent with the decision to move forward with the program, two changes took place to strengthen the environment for collective impact.

First, a new name was developed for AAHBC to move away from a focus on the organization to focus on a “movement” within the community: Abrio Health (Brio meaning “Great things are happening here, in Airdrie).

Second, the updated Community Health Plan (Abrio Health 2019) recommitted to the vision with a more complete description of the desired future:

• Vision: Own Our Own Health, Becoming Canada’s Healthiest Community.

• Mission: A healthy community culture where health = physical + mental + psychosocial health, where we connect health and healthcare efforts, where social determinants of health matter, and where individuals can own their own health.

• Outcomes and Shared Benefits: Community engagement, well-being, health outcomes, efficiency and resource utilization, economic benefits.

The Community Health Plan had four interconnected strategies:

• Connecting the Dots for Health, with Blue Zones Project as the framework for driving multi-sector impact on health determinants with measurable correlations to reductions in need for healthcare services

• Meeting Needs in New Ways for innovations to connect, reconfigure and enhance community health and social services and healthcare services

• Digitally Connecting and Engaging Individuals and Our Community

• Supporting Our Community Plan with partnerships and vehicles for community leadership.

This Community Health Plan continues to guide our work, with annual updates to the community. Momentum is building as indicated in support for this plan, Fig. 52.4.

Fig. 52.4

Community aspiration, health plan 2019

5 Aspirations Advanced by Blue Zones Project

Blue Zones Project is a community-led health improvement framework designed to make healthy choices easier by permanently improving our living environments. Established in 2010, Blue Zones Project is based on research by Dan Buettner, a National Geographic Fellow who identified five cultures of the world—or blue zones—with the highest concentration of people living to 100 years or older. Blue Zones Project incorporates Buettner's findings and works with cities to implement policies and programs that will move a community toward optimal health and well-being. The community was impressed by changes to improve health status and reduce healthcare costs across communities in the USA (some examples, Blue Zones Project 2016, 2018; Weiss 2018; Sears et al. 2013).

The program has four integrated components:

• 1. An evidence-based methodology. Blue Zones Power 9® principles promote healthy behaviors through simplicity and connections to what matters for healthy living, addressing stakeholder expectations to learn what matters for health. As illustrated in Table 52.1, Power 9 principles align with modifiable factors for chronic disease prevention.

  Table 52.1 Alignment of Blue Zones Power 9 principles with risk factors for chronic disease

• 2. An all-in approach to community engagement to transform a community’s environment for health (one’s life radius), delivering on the community desire for broad community engagement. The methodology integrates evidence-based expectations that support environmental changes across three areas: policies, including built environments, food and food systems, alcohol and tobacco policies, and smoke-free environments; places including faith-based organizations, schools, worksites, grocery stores and restaurants; and people, with strategies to engage individuals about their health, including the personal pledge, and for interpersonal connections and to create momentum with a broad range of community and civic organizations, like Purpose Workshops and Moais®.

  As illustrated in Table 52.2, addressing policy, places and people also aligns with modifiable factors for chronic disease prevention.

  Table 52.2 Alignment of Blue Zones Project’s policy, places, people interventions with risk factors for chronic disease

  Following a Foundation Phase where the community is assessed for strengths, challenges and opportunities, a blueprint is developed in conjunction with community leaders using well-being indicators (denominators for change). This blueprint is the roadmap for change that guides transformation activities for multiple years. Defined methodologies (certification tools and improvement targets) for each area galvanize shared accountability toward the goal of becoming a Certified Blue Zones Community®. Specific time frames drive a sense of urgency and facilitate milestone completion.

  This approach drives multi-sector engagement and empowers informal connections and “networks for health.” These are keys to such health issues as mental well-being, loneliness and social isolation for persons living with challenges or for informal caregivers and aging adults. This multi-sector framework also means that what adults experience at work, in the community, and the grocery store aligns with what their children would experience in a school.

• 3. Measurement for individual, organizational, community and system learning: Blue Zones Project measurement methodology will bring meaning to targeted outcomes in the Community Health Plan. Their Simulation Model to project future impact on healthcare utilization and costs was of major interest. Representatives shared possibilities for impact in this community based on their rich data set of outcomes across 50 communities and health indicators and healthcare utilization by Airdrie residents. Their model projected reduced healthcare service utilization, improved productivity in local workplaces and enhanced regional economic development totaling over $100 M (CDN) annually, as early as seven years after implementation.

• 4. Implementation through community-based leadership. Each community has a steering committee of local leaders and sector work groups that are responsible to lead implementation of the blueprint for their respective areas and monitor success toward the goals of becoming a certified community.

These possibilities, combined with the systematized process for Airdrie residents to own their health improvement, were compelling for the community, and the overwhelming consensus was to proceed. Abrio Health has entered into a contractual agreement for Blue Zones Project® by Sharecare.

6 Blue Zones Project Airdrie Implementation

Blue Zones Project Airdrie was announced June 2019. “Own our Own Health, Becoming Canada’s Healthiest Community” becomes tangible: “Becoming Canada’s First Certified Blue Zones Project Community.”

Airdrie would be the first implementation of this comprehensive health improvement initiative in the context of a single-payer, publicly funded healthcare system. Airdrie is recognized as an innovation project and contemplates three collaborators: The City of Airdrie for its municipal leadership, local policies and responsibilities related to the built environment; Alberta Health Services (AHS) for its healthy community policies and expertise and information regarding healthcare outcomes and costing; and Alberta Blue Cross (a nonprofit wellness organization and health insurance provider) as the measurement partner and healthy workplace thought leader.

This innovation project will deliver:

• A Canadianized adaptation of pledges, policy menus and reporting language integrated into certification materials

• A measurement methodology adaptation for Canada, with all data collected remaining within Canada and applicable to Canadian healthcare systems and

• A demonstration in Airdrie for the benefit of this community, with learning for potential application of this methodology beyond this community.

Implementation began on September 2019. The Foundation Phase (typically 8–10 months) involved hiring and training a local team, adapting materials, developing local leadership groups, and engaging citizens and organizations to identify priorities for action.

The first phase ends with a community blueprint for action. A community-wide launch will mobilize implementation, the largest community engagement in this city’s history. The Transformation Phase of community-led action follows (approximately two years) with progress measurement guiding and nudging action. This ends with an assessment regarding completion of blueprint requirements for certification. Planning for sustainability will be ongoing through implementation.

The local team will build on work in Airdrie to engage citizens in understanding implications of Social Determinants of Health (SDOH). In 2018, the city, in collaboration with Abrio Heath and their proposal to the Federal Government’s national Smart Cities competition, began to socialize a framework for SDOHs, HealthSmart Airdrie (Airdrie 2018). Figure 52.5 |provides a description of the eight SDOHs included in HealthSmart Airdrie. During the Transformation Phase, the team will examine linkages between these elements as one input into Blue Zones Project Airdrie. They will also document community assets (formal and informal) to populate an inventory of resources, organized by categories reflecting HealthSmart Airdrie. This will support action to enhance community capacity for health.

Fig. 52.5

HealthSmart Airdrie imapcts blue zones project Airdrie

Measuring population well-being occurs through a community-wide survey, unique to, and comparable with, the program implemented in 50 other communities. This includes elements shown to have the greatest impact on well-being: purpose, social, financial, community and physical. This assesses impact of change initiatives, resulting in a Community Well-Being Index (CWI) score. Recent work by Sharecare with Boston University continues to support the use of the CWI to monitor community progress and the social determinants of health.

Airdrie’s initiative is funded by partners (funding from the city; in-kind by Alberta Blue Cross), community granting bodies and private donors who believe in the importance of developing healthy communities as the base for a sustainable healthcare system.

As of November 2020, physical distancing measures related to the COVID-19 pandemic and shifts in priorities of local businesses have made it impossible to continue with Blue Zones Projects Airdrie.

However, the first four months of learning and input through Blue Zones Project Airdrie had an impact as illustrated by comments in Fig. 52.6: Learning has been significant and will guide future community work

Fig. 52.6

Community engagement and momentum 2020

7 Abrio Health Experiential Insights

Our first insight: Challenges of implementing a grassroots approach for community health have been many, and we know there will be more.

We have moved from planning by the organization and bringing plans to the community to being community driven (from/with/by the community). At the same time, individuals and organizations are busy with their own work; potential collaborative projects have been perceived as getting in the way of their own priorities or mandates. This is changing with time as the community’s aspirations and opportunities become clearer, but requires consistent engagement, shared learning, striving for mutual value and time to build /rebuild relationships and trust.

Our second insight: Organizational theory about aligning structure–process–outcomes applies, but with differences.

Community aspirations are needed to inform structure, with frameworks and supports for community work. Together, they guide processes for engagement and change. The resulting cycle for healthy community development is illustrated in Fig. 52.7.

Fig. 52.7

AbrioHealth, healthy communities development cycle

• 1. Community Aspirations for Health. Discussion over four years created focus, increasing trust and community readiness for change.

  • The vision, “Own Our Own Health, Becoming Canada’s Healthiest Community,” mobilized initial action and the desire to be Canada’s first Certified Blue Zones Project Community.

  • The mission is informing our language and work.

  • Outcomes informed the choice of Blue Zones Project, with its ability to bring meaning to shared benefits.

• 2. Framework and Supports for a Community Focus on Health. Airdrie, like many communities, did not have infrastructure for community-wide action related to health. Today, this includes:

  • A community-based organization as a catalyst and support for activities toward the vision. Abrio Health provides strategic engagement and advocacy, ability to create contracts and partnerships for community development, and capacity for fund development for community-focused initiatives.

  • A Community Health Plan to create momentum, linking community initiatives across four strategies. It is a point of interface for all community initiatives and creates shared understanding, a key component for collective impact. Critical to this plan was stewardship for development by the Partnership Committee, with continued oversight by the Health Leaders Council (committees of community and health leaders).

  • A capacity to be data driven and technology-enabled to inform planning and accountability and to optimize digital tools for individual and community health in collaboration with partners.

• 3. Processes for Engagement and Change. As described in Table 52.3, processes align with the five principles in Alberta’s Healthy Communities Approach (Alberta Healthy Communities). Blue Zones Project’s approach aligns with each principle, a factor in selecting the project as a partner.

  Table 52.3 Alberta’s healthy communities approach: alignment with processes underway in Airdrie

Resources included the local Blue Zones Project team and a small staff for Abrio Health (CEO, Operations Director, Chief Technology Officer and consulting resources for areas such as fund development) plus Abrio Health Board volunteers and community members on committees. Abrio Health had initiated contact with academic partners to provide external perspectives to Blue Zones Project Airdrie implementation and learning for our journey.

Our third insight: Developing a system to measure results is multifaceted.

• 1. Implementing targeted outcomes in the Community Health Plan to measure progress and impact requires measures that come from the community. Development work benefited from partnerships with ABC and AHS enabling access to and use of data, resources and tools allowing for scalability and spread across Alberta. Initiatives included:

  • Digitizing engagement tools

  • Developing mechanisms to collect and share well-being and health risk/outcome data with individuals in the community and aggregate these data for community learning and monitoring

  • Aggregating relevant secondary data related to health outcomes and healthcare utilization

  • Refining and enhancing community simulation models to project longer-term impacts on healthcare costs and economic gain.

• 2. The community is also learning that the dynamics of engagement and change to become a healthy community require the need to think about, prepare for and capture immediate, near-term and long-term gains.

  • Immediate benefits include community learning about local organizations, citizen perspectives about needs and new ways of thinking about health and configuring health and healthcare services. Creating safe places for input and learning, such as Blue Zones Project Airdrie engagement to date mobilize change.

  • Near-term (3–5 years) gains come through tangible actions based on the blueprint for change and other developments that are occurring through the Community Health Plan.

    At the end of three years, the intent was that this community will have demonstrated a comprehensive process to mobilize a healthier community. Engagement indicators would show increasing participation of individuals and organizations for health and new policies for healthy environments; the Community Well-being Index would show change and allow comparisons with other Blue Zones Project communities; and there would begin to be movement in key health outcome measures. These results would inform community eligibility for Blue Zones Project Community Certification and planning for ongoing sustainability.

  • Longer-term gains (5–10 years and beyond) bring focus to the final two outcomes, efficiency and resource utilization and economic benefits. These would come from the foundations for change established and sustained from the first 3+ years. The Simulation Model has the capacity to project impact for healthcare savings, business productivity and local and regional economic growth (and to update initial projections noted at the end of Section 5).

Our final insight: Determining the value of this initiative is based on a philosophy of action learning through a journey of change.

• The Blue Zones Project Airdrie team would monitor process-related feedback for ongoing improvement and learning for other communities.

• The Community Steering Committee would monitor progress and outcomes related to the blueprint, with the initial targets for policy, places and people interventions, to become a Blue Zones Project Certified Community (as outlined above).

• Abrio Health, through the Health Leaders Council, would monitor opportunities to integrate and support Blue Zones Project principles in other development initiatives, broadening impact and enhancing sustainability of community transformation objectives.

• The community recognized that making fundamental and sustaining change to shift environments and practices for health is a long-term journey. This project was designed to show changes in Airdrie at the end of the Transformation Phase. The hypothesis was that comparisons with US experiences would demonstrate likelihood for ongoing, positive change and guide future investment to sustain and deepen changes.

• Finally, development of an analytic simulation model would show the correlation between community health activities and policy changes with optimized healthcare system utilization, improved health outcomes and ultimately decreased healthcare system costs. This would have been key to showing the validity and value of the Blue Zones Project approach in a publicly funded health care system.

8 Perspectives: Healthy Citizens, Sustainable and High Performing Systems—We Can Have Both WHEN….

The authors posit that the RESET Button for a system focused on health and wished for in the introduction to this chapter is beyond a single “button,” but rather a “RESET DIAL.”

Based on this community’s experiences, the authors suggest that there are five functions on the RESET DIAL which are interrelated and need to move strategically and concurrently for desired impact. This DIAL embodies inter-sectoral actions as envisioned in the reports of the late 2000s and aspirations and actions for health system reform underway in pockets across this country.

This multi-function RESET DIAL is illustrated in Fig. 52.8.

Fig. 52.8

REST DIAL for healthy individuals and sustainable healthcare

Function 1, developing community capacity for health, is seen as a foundation for our desired future. Functions 2 and 3 reconfigure and integrate community-based supports and healthcare services for improved results. “White zone functions” underpin individual, organizational and system capacity for health: Function 4 optimizes digital tools across all initiatives, and Function 5 aligns federal and provincial expectations and funding for health.

Three factors are important if community capacity for health is to become a foundation for systems focused on health:

• 1. Placing a priority on funding evidence-based and measurable health promotion and disease prevention initiatives. In so doing, incentives (with funding) need to be provided for community-based initiatives that enhance capacity for health. The impacts of mobilizing action related to community capacity for health, and thereby impacting health care use and costs, are too important to be left to ad hoc demonstration initiatives supported by ad hoc funding.

Based on outcome data from Blue Zones Project’s implementations and system-impact algorithms, it is possible for increased expenditures impacting health determinants to create opportunities for future re-allocation of resources currently in the system, not additive to the increasing costs associated with healthcare provision.

The demonstration initiative in this case study is one example of a comprehensive approach to transforming a community environment for health and moving toward an integrated health and healthcare system with improved performance.

• 2. Implementing “loose, tight” system governance and working relationships. “Loose relationships” encourage community engagement and ownership; “tight relationships” may be more appropriate for horizontal and vertical integration of care services.

Success in this case study has been this community’s ability to develop a vision for health, organize for that and implement a major health improvement initiative. At the same time, the community sees itself contributing to the aspirations of this province and a healthcare system for “healthy Albertans in a healthy Alberta.”

This experience aligns with work of the Tamarack Institute regarding the concept of “loose/tight working relationships,” with loose relationships most helpful with high leverage opportunities for change (Cabaj and Weaver 2016).

• 3. Aligning cross-ministry policies that influence individual and community capacity for health.

An analysis of policy implications from local perspectives would have been undertaken concurrently with Blue Zones Project Airdrie.

Support and collaboration of the City of Airdrie, Alberta Health Services and Alberta Blue Cross for Blue Zones Project Airdrie have been key to community gains and learning for other communities. Abrio Health looks forward to continuing this journey with service transformation initiatives (Functions 2, 3 and 4) which leverage unique opportunities in this community.

SO—can there be a future with integrated systems focused on health and where we have both healthy/healthier individuals and improved health system performance? YES, WHEN all functions on the RESET DIAL work together for health.