As health systems work to eliminate inequities in the communities they serve, are we doing all that we can to establish trustworthiness with those communities? What if there is already a lack of trust between provider and patient?
As health systems work to eliminate inequities in the communities they serve, are we doing all that we can to establish trustworthiness with those communities? What if there is already a lack of trust between provider and patient?
Betsy Taylor, Editor of Health Progress and Philip Alberti, Ph.D., Sr. Director of Health Equity Research and Policy and Founding Director of the AAMC Center for Health Justice, join the show to discuss Dr. Alberti's recent article in Health Progress. Dr. Alberti describes why he prefers the term 'vital conditions' to 'social determinants' and offers his insights on how and how not to build and maintain trustworthiness with communities.
Resources
Visit CHA's Community Benefit page for up-to-date resources
Brian Reardon (00:00):
Hello, Betsy Taylor. How are you?
Betsy Taylor (00:02):
Good morning, Brian. I'm doing well. How about you?
Brian Reardon (00:04):
Doing great. How's your new year? Starting off?
Betsy Taylor (00:06):
So far so good. Healthier than ever in 2024.
Brian Reardon (00:10):
There you go. Well, that's what we like to hear. Well, we have a new issue of health progress and as we often do, you and I get a chance to talk about an article that caught our attention. So if you're ready, let's dive into it.
Betsy Taylor (00:23):
Sounds great.
Brian Reardon (00:29):
This is Health Calls, the podcast of the Catholic Health Association. I'm Brian Reardon, your host, and with me is Betsy Taylor. She's the editor of Health Progress, the Journal of the Catholic Health Association. This current issue is about building healthy communities and the topic that we're going to talk about is Building Healthy Communities Requires Trustworthiness. That was the article that was written by our guest, Dr. Philip Alberti. He is the Senior Director of Health Equity Research and Policy and founding director of the A MC Center for Health Justice and AAMC stands for the Association of American Medical Colleges. We're going to bring Dr. Albert in just a moment, but Betsy, let's, as we always do a little context again, this is the winter issue, building healthy communities with community benefit. It really has been kind of a hot topic in not-for-Profit Healthcare. What topics did you and the team at Health Progress feel like you wanted to prioritize in this particular issue? Well,
Betsy Taylor (01:27):
The thinking that went into this issue is, as we all know, CHA's long been a leader in the community benefit space. And so we thought about for people doing this work, what were some of the ways that we could look at the details? What are some of the latest approaches? And so we looked at things like different ways that people are tracking and measuring data and then how is that being used by their healthcare system. We did look a lot at relationship building. So there's an article about not just awarding grants, but working to coach people in communities and listen to their needs and adjust over time. So really not just here's what we're doing in community benefit, but here's how we sort of continuously refine the approach.
Brian Reardon (02:21):
And I think collaboration is so critical. And this article, again, I referenced this just a moment ago, it's called Building Healthy Communities requires trustworthiness and you think, well, trustworthiness would be a pretty key element of any kind of collaborative partnership, but this article actually challenges our readers to a higher standard of community engagement. What made it stand out to you while preparing for the issue?
Betsy Taylor (02:45):
Even from my first conversation with Philip, it was clear that he is really an expert in these areas that he sort of had given a lot of thought and has done a lot of work related to trust is so important in the healthcare relationship and in facilities relationships with their communities. So the fact that he could really talk about how do you build that, none of this is a one and done that you have to really put in the time you have to listen to people and your words, your bond really in these relationships. If you say you're going to do something, make sure you follow up and do the thing you told a community you would do. So just was real interesting to hear from him about sort of really looking closely at trustworthiness and what that means and how you can cultivate it.
Brian Reardon (03:36):
Great. Well, let's bring in Philip now again, Dr. Philip Alberti is Senior Director of Health Equity Research and Policy and founding director of the Association of American Medical College's Center for Health Justice. Philip, thanks for joining us.
Dr. Philip Alberti (03:50):
Thank you so much Brian and Betsy for the invitation to the conversation and the opportunity to write the article for Health Progress. Thrilled to be here.
Brian Reardon (03:57):
Yeah, so you write about the importance of trust as we just mentioned in your article. Can you articulate for our listeners what trustworthy trustworthiness, I should say actually looks like between a healthcare provider and a community? Well,
Dr. Philip Alberti (04:10):
I can, and I can't, don't mean to be cagey, but I'll give you two answers so I can tell you what we at the Center for Health Justice at the A MC, what we learned and what we heard through the process of developing our principles of trustworthiness toolkit, and I should say just a little bit about that process, is that it wasn't Philip and the Center putting out what we think are the nuances and flavors of trustworthiness. It really was us in partnership with seven different communities across the country, learning from that local community wisdom to understand what it means for organizations with power and privilege like healthcare organizations to demonstrate their worthy of their community's trust, really flipping that script. And so some of the key behaviors that came up and emerged from those conversations that were common across all the places that we were working were things like respect, taking responsibility, transparency, humility, authenticity, intentionality, et cetera.
(05:08):
And that seems maybe a little bit vague, and I know you wanted a little bit more of an articulation. And I think the beauty of the real, where the rubber hits the road on translating respect and humility and intentionality that rubber hits the road in community contexts. And so a way that a healthcare organization can demonstrate humility in Albuquerque might be similar, but it might be very different than the way that a healthcare organization in Boston is expected to behave per its community and the history and the culture and the customs and the expectations. And I'm happy to say that we're about to learn a whole lot more about what those kind of key behaviors, how you translate those into action. We are going to fund, and we'll announce this in March for community collaborations across the country to actually implement and evaluate our toolkit to understand what are those specific actions that not just healthcare organizations, any organization, public health, a police department, a fire department might take to show they're walking the talk on those 10 principles of trustworthiness. So more soon maybe I'll come back and tell you what we learned in a year and a half or so.
Brian Reardon (06:14):
And on humility, is that a tough one for folks that you work with? Because everybody has strong opinions, have a lot of wisdom and knowledge, and I think is that a difficult one for people to step back and recognize that maybe they don't have all the answers?
Dr. Philip Alberti (06:30):
It is, and it's funny that you point that one out. So our president and CEO, I think that's his favorite one to say in front of rooms filled with physicians and healthcare leaders because the principle itself is you are not the only experts. And this principle of trustworthiness toolkit was born early in the pandemic when we heard a lot of clinical and public health and political experts talking about what community needed when it came to clinical trials or covid prevention. And we didn't hear any community expertise, any community voices to balance that out. And so I think partly it's how we are trained, the scientists and physicians and experts to believe that our knowledge, which is crucial, it is essential to bring to the table, but it's not sufficient. And I think that is a hard lesson for many of us to hear in that it takes health equity at the end of the day is a multi-sector endeavor and it's certainly not a clinical endeavor. And so I think that principle, you really hit the nail on the head on that. That is a tough one to move past sometimes.
Brian Reardon (07:35):
Another distinction you make in your article, you talk about that partnering is actually more important than educating again when it comes to building that trust and that education flows both ways. Can you talk a little bit more about that?
Dr. Philip Alberti (07:48):
Yes. And that really ties into two of the core principles, respect and humility as you just brought up. And as I mentioned, achieving health equity is a multi-sector movement, right? No one owns it. No one sector is responsible and frankly, health inequities are population health dynamics. And that is absolutely not a medical model framework. It's not achievable one-on-one in a clinician's office. It really is in the aggregate for all populations and communities. And so yes, we all can and must learn from each other. And so when the National Academies put out this framework on how you would know if your partnerships, your engagements, your collaborations are effective, one of the domains of measurement is knowledge expanding and not just from the highfalutin experts into the community, but the expansion of knowledge is multi-directional. We all can and must learn from each other. Doctors and public health experts bring data, they bring scientific knowledge that is crucial.
(08:48):
But our community partners and others within the places and spaces we work are bringing expertise around history and customs and key contacts and kind of strategies and tactics for implementation that will be effective locally. And so trust trustworthiness makes that kind of knowledge sticky. And the last thing I would say, at the end of the day, health justice, all of this work is about power. Educating someone using that verb, I'm going to educate you, that implies a very clear power dynamic where you are not looking at your partners as co-equals, you're not looking to co-create. You're not trying to have shared governance or equitable financing in your partnerships. We from on high are going to impart something to you. And that is absolutely one easy way to not demonstrate trustworthiness.
Brian Reardon (09:39):
And you had mentioned earlier that what might work in Albuquerque maybe doesn't work in Boston. So to me in listening to you, it does seem like cultural norms, local traditions, those are some examples I would guess of where healthcare professionals can learn from their community partners.
Dr. Philip Alberti (09:55):
Absolutely. Communities have done this dance before. The past is always present. There is a real thread that can be traced back, not just historical injustices, but all the way up to what's going on today in this moment. And nowhere is that expertise, that wisdom more profound and important than on the ground in local communities. And so for us as healthcare professionals, public health professionals, scientists, to think that we know all of that just because we're educated and statistics and physiology, that doesn't come together so easily. So it really is the partnership isn't just between people, it's between that expertise.
Brian Reardon (10:37):
Really important insight. Another thing I liked about your article, you make the distinction, you write about the familiar language of addressing social determinants and then what you call creating vital conditions. And that again, kind of piqued my interest. So what are the difference between those two? Can you go a little deeper and explain addressing social determinants versus creating vital conditions?
Dr. Philip Alberti (11:00):
And just for full transparency, the vital conditions is a framework that was produced by not by me. I did not have a hand in it by the Rethink health folks and the Ripple Foundation. And so here's the main distinction for me, social determinants a first and foremost, they're not determinant. Just because a community has inhumane or unstable housing or not a lot of affordable housing doesn't mean that every single person in that community is kind of destined towards a life of ill health or health inequity. So it's not determinant. I don't love the lack of precision in that word. Secondly, I think the verb addressing is really vague. What does it mean? What does it mean for a healthcare system to address all of these other factors, all of these other crucial building blocks for health in our community? Is it healthcare's job to address housing?
(11:55):
Does that mean make a referral to housing? Does that mean build affordable housing? Does that mean have apartments on their hospital campus? What does that mean? And is it that right size role? And so what vital conditions does for me is first and foremost, it's goal focused. So instead of saying we're going to address, we're going to address housing instead. Vital conditions say all communities need humane housing to thrive. It's a basic fundamental building block. Similarly, healthcare is addressing transportation, but really what every community needs is reliable transportation. It needs potable water, arable soil, breathable, air freedom from violence, freedom from racism and discrimination. These are kind of the low bar of what any community, no matter what its composition needs to be able to thrive. So it really appeals to me for two reasons. One, as I said, it's goal focused. It tells us exactly what we are working towards.
(12:53):
We're not working for everyone to be millionaires and billionaires living in mansions. We are working towards a future state where everyone can just have those basic building blocks. The second thing, those goals, humane housing, reliable transportation, meaningful work, lifelong education, those goals are universal and inclusive. And so for me, particularly in these divisive times, we can have conversations in any community about whether or not their neighborhood, their community, their county, their state, has those basic vital conditions. And then you can open up new veins of inquiry, even if it's really selfish, I want these things only for my community. Well, why don't you have them? What are the roadblocks? What's standing in the way of your community, your people having humane housing, likely there's some policy roadblocks there, maybe some political roadblocks. So it opens up this conversation about health justice, which is at the end of the day, a policy focused movement to really create new organizational, local, state, federal policies that create health opportunity for all of our communities.
(14:02):
That fair and just opportunity to attain your highest level of health, that is that goal of health equity. And so when a community has those basic vital conditions, then all of a sudden we're in a state where health equity, that equal opportunity is possible. So for me, vital conditions, goal oriented, super inclusive, can talk about it anywhere in any part of the country, even where a lot of these conversations are literally prohibited. And it's resonating with some of the work at the federal level, which is important just for alignment purposes. So all kinds of reasons that our center was an early adopter of the vital conditions framework.
Brian Reardon (14:38):
And you gave a list of things that healthcare providers, it may not be so to speak, their lane to drive in, but they can have influence. And your article also talks about the evidence to policy imperative, I think is being a main focus. If a healthcare provider is partnering with others in a community, lending their voice and advocacy is critically important. So can you talk a little bit more about what it means to have an evidence to policy imperative as being sort of an underpinning of advocacy efforts?
Dr. Philip Alberti (15:12):
Absolutely. And so I'll start by defining health justice more formally. So we say that it starts with one foot in community wisdom in multi-sector partnership. And it's that engagement that we co-develop the kind of evidence that we can embed in policies. So that's kind of our health, the way we think about health justice. And yes, it can be for individual clinicians. I think there's a lot of evidence that individual clinicians have outsized voices at all advocacy tables, local, state, federal, organizational. But it's also about how our organizations as organizations advocate at those same levels. And so while there might be, and certainly there is incredible patient benefit, for example, in a healthcare organization saying, we are going to make sure that every patient that crosses our threshold has a referral to affordable housing or local community-based organization focused on housing stability. That's important for those patients, and it's important for those patients health and healthcare outcomes as well as the patient's family.
(16:17):
But that might not be making a dent and the lack of affordable housing across a community. So what is the role of a healthcare organization that has that outsized voice of individual clinicians? Not every clinician needs to be a social justice advocate, but for those that are self-selected in that role, what does it mean to lend your voice not only in support of advocating for your patient to have access to humane housing, but to advocate to lobby for the kinds of local policies that create more opportunity for humane housing across the board. And so I think that really is where health justice sits kind of takes it out of the clinic, even though of course we want all of our patients to have the most health opportunity and healthcare opportunity possible. It's really this population health dynamic and leveraging the resources, the voices, the reputations of physicians, yes, but healthcare organizations even more centrally and partnering across sectors to advocate for those vital conditions for health.
Brian Reardon (17:17):
And I think it bears repeating. I like what you say, the process of grounding one foot in community wisdom and multi-sector partnerships and the other in an evidence to policy imperative is at the core of how to operationalize health justice. So I think that that phrase in your article really resonated. Before I bring Betsy back in, just my last question would be, you've provided a lot of really good perspective on what healthcare providers can do to, again, build trustworthiness. What would be your, I guess, caution of what not to do to erode trust in a community?
Dr. Philip Alberti (17:51):
Well, first and foremost, don't behave in ways that run counter to those 10 principles of trustworthiness. I guess that's the easiest answer. But I think, and again, it comes back to not assuming that you know what you should and shouldn't be doing to take that moment to do the tough work of bread breaking, of listening, of spending time to really understand that first principle of trustworthiness, that community is already educated. That's why it doesn't trust you. So if you want to rebuild trust or create trust in new because it never existed, you need to really spend some time and understand what does taking responsibility look like for your community? What actions would produce restorative justice, the recognition of past and current harms, the repairing of those harms, and then transforming to a different state, what actions for your community will repair? And there's that Boston-Albuquerque difference, right? What's the future state that we want to transform into? Only a local community has the power to decide that for themselves. And so what not to do is to make any assumptions and to take that time to really understand what that local truth is, and that's the way that you forged that path forward.
Brian Reardon (19:11):
Yeah, I'm being very intentional in doing it. Betsy, you've been listening to the conversation. You've worked with Philip on the article, your takeaways or other comments you have.
Betsy Taylor (19:20):
One thing that strikes me out of the conversation is that the trustworthiness, you also have to trust the people you're working with in the communities. It's not just about you demonstrating trust. It's about trusting that. If I just think about in these situations, you may have a lot of type A people who are used to being leaders who are used to, here's how we fix problems. We want to do this quickly. And I think it's really interesting to think about slowing down a little bit and really trusting that a community does know what it needs, that someone may not have the same degree as you, but they live in a neighborhood and they know, hopefully they're the person who lives next door and they know what happened 10 years ago. And so just, it sounds kind of elementary, but taking the time to really listen to people and to listen to what they inherently know about themselves and their community and their needs, I think is a really important part of this process.
Brian Reardon (20:23):
Philip, you agree?
Dr. Philip Alberti (20:24):
A hundred percent. There is a long arc to health equity, and there's a long arc to demonstrating trustworthiness. I think there are no quick fixes. There are no easy answers. It comes back to, particularly for healthcare organizations, is the internal house in order in a way to really sustain that kind of commitment, right? Whose job is it? Who's incentivized to do it? Who builds relationships and maintains them when there's no ask, there's no research ask, there's no education ask. It's relationship building for relationship building's sake. And that's not easy. That's not always top of mind, but I think Betsy had it exactly right.
Brian Reardon (21:03):
Great insights. Again, your article, building Healthy Communities requires trustworthiness. It's in the current issue of health Progress. Again, Dr. Philip Alberti, senior Director of Health Equity Research and Policy, and founding director of the Association of American Medical Colleges Center for Health Justice. Thanks again for contributing to Health Progress and for being our guest on this episode.
Dr. Philip Alberti (21:26):
Thank you so much, Brian.
Betsy Taylor (21:27):
Thanks, Philip. Good talking with you.
Dr. Philip Alberti (21:29):
You too, Betsy.
Brian Reardon (21:30):
For Betsy Taylor, editor of Health Progress. I'm your host, Brian Reardon, and this has been another episode of Health Calls, the podcast of the Catholic Health Association of the United States. You can listen and download health calls from all of your favorite podcast streaming services, and of course, you can also find it on our website chausa.org. And when you do find it on the website, there will be a link to the article that we were just discussing. As always, health Calls is produced by Josh Matejka and engineered by Brian Hartmann at Clayton Studios. Thanks for listening.