Commentary

Patrick Flood: Healthy communities built with investment, coordination

Editor’s note: This commentary is by Patrick Flood, the former commissioner of the Department of Mental Health, the Department of Disabilities, Aging and Independent Living and former deputy secretary of the Agency of Human Services. He recently retired from Northern Counties Health Care.

What do rising costs in health care, education and mental health have in common? They seem intractable, and no matter what we do, the costs just continue to rise. In desperation, we look to ideas like accountable care organizations, which will only increase administrative costs, or putting a cap on teachers’ health care benefits. These steps will not succeed. The reason they won’t is that we are looking for the solution in the wrong places. It is time to recognize and address the underlying causes. Fortunately, science now points to the major causes and the solutions.

Research and studies have demonstrated without a doubt that if we really want to lower health care costs, education costs and most of our costs for human services as well, we must start addressing two things: the so-called “non-medical determinants of health” such as poverty and homelessness, and childhood trauma. Both have been shown to be prime drivers of health care costs later in life. The study of adverse childhood events by the Kaiser Permanente Foundation, conducted over a multi-year period that included nearly 20,000 people, showed an incredible correlation between adverse childhood events and not only mental illness and drug addiction, but physical conditions such as heart disease and lung disease. Research also shows that up to 69 percent of mental health, 61 percent of incarceration, and 78 percent of IV drug problems are attributable to adverse childhood events. We also know a significant part of the increase in education funding is for special education costs related to student behavior problems, also related to adverse childhood events.

Briefly, adverse childhood events and other trauma include such experiences as child abuse and neglect, losing a parent, having someone in the family incarcerated, and domestic violence. Trauma can also result from homelessness, hunger and poverty. We can all understand how such events could have a negative impact on children.

Thanks to the research, we know now the enormous impact adverse childhood events can have on our mental and physical health as adults. Many medical, social services and legislative leaders are very aware of this study and there is common agreement in Vermont that this is extremely important. Legislative committees are discussing bills to further address trauma in Vermont.

The key is, what are we doing about it? The answer is, so far, not nearly enough.

We can, over time, rebalance our systems and costs if we use the knowledge we now have about the impacts of trauma to reinvest in effective community services.

 

We will never get health care, education and other social costs under control until we address the impact of adverse childhood events and trauma. What we must do is not a mystery. We must be willing to refocus our attention and redesign our helping systems. Across Vermont, there are some successful efforts already underway.

The good news is that if we focus on addressing trauma, we can both help people who suffer today, and do a much better job of preventing costs in the future. We can provide more effective care now and start reducing costs, while steadily developing a healthier society year after year which will reduce health costs

So why is that not happening? A large part of the problem is that our current systems, including health care, human services and education, do not work well together. Those systems do a poor job of communicating and working together in an integrated way. They are also structured in rigid ways that prevent treatment and services that actually get to the root of a person or family’s underlying problems. The solution does not require large investments. What is needed most is to recognize the impact of trauma and redesign our services through that lens. We need services that treat the whole person and family. Our systems must stop operating in silos. Schools and service providers need flexibility in how services are delivered and how existing dollars are spent. Those communities that are already working together in new, trauma-informed ways need to be empowered to make the changes they are eager to make.

For example, in St. Johnsbury, the hospital, mental health agency and Community Action partnered to develop and operate a warming shelter. The hospital, the FQHC and the mental health agency pooled funds to add a caseworker in the emergency room. The hospital has funded a social worker in the local elementary school. A local group has been meeting for years to integrate their efforts to address the opiate crisis. This is an example of a community that is willing to break down the old model, and even without new money, use existing funds differently to get better results.

Yes, there will need to be investments in mental health services, and there need to be small investments in flexible funding so that community teams can solve problems like lack of food or homelessness in a timely way. But those investments can start out very modest. More importantly, the communities know of ways to use existing funding more effectively if the state will give them the flexibility to do so. So far, that flexibility is in short supply. Then, as the community has success with more and more persons and families, savings can be shared with the state and the community. The community will reinvest its portion in other services to get even more positive results.

It is well established by now that health care systems in Europe obtain better outcomes at a lower cost than in the U.S. It is well understood that is because European nations spend more on social services and prevention and correspondingly less on expensive medical care. Our systems are the reverse. We can, over time, rebalance our systems and costs if we use the knowledge we now have about the impacts of trauma to reinvest in effective community services. We can begin that rebalancing with very small investments, but with flexibility and integration. Over time, funding will continue to shift from expensive medical care to more prevention.

Spending more on new ACOs, or simply capping expenses, will not solve the problems we face. The existing education, health care and social service systems must stop operating in silos, recognize the crucial impact of trauma and begin working together at the community level to addressing the needs of families in a holistic and collaborative way. That is the only way we will ever successfully address trauma and begin building healthier communities and reducing health and education costs. The knowledge we need it right before us. All we need is the courage to change.

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  • Robert Appel

    Kudos to Patrick for his vision and his continued engagement. I agree with him 100% that we both as a state government and as smaller communities need to take a more integrated approach to achieving better outcomes. However, the conversation regarding “silo busting” goes back at least 25 years in my experience. The bureaucracy is structured to support the status quo rather than promote better lives for Vermonters. I can only hope that I live long enough to see the necessary shifts.

  • Beverly Frost

    It is great to have such a good assessment of solutions to our societal problems. I totally agree with what is said and we need to do even more. I have had quite a lot of contact with the homeless, nearly homeless mentally ill and those with autism. One common thread is t h e need for supported housing. Many I have met just are unable to manage a single occupancy apartment alone and their own attempts to find a suitable roommate can be disastrous. They may also need money doled out as needed rather than one monthly lump sum, close medication management and other help to keep them on track. Such help is hard to come by and then only if you fit the right silo. Two or three compatible individuals might do much better in supporting each other. The current system seems intent on putting everyone in their own solo apartment even when it is clear the individual is totally incapable of this level of self care and never will be able to cope without assistance. We need both group living homes and supported apartments and need to separate the criminally dangerous homeless from the rest of the homeless population.

  • Scott Johnson

    Childhood Sets the Stage for Everything: Thank you Patrick for highlighting that, early childhood experiences, both positive and negative, have a tremendous impact on future violence, victimization, lifelong health and opportunity. As such, early experiences are an important public health issue.

    What can be done about preventing ACEs? The wide‐ranging health and social consequences underscore the importance of preventing ACEs before they happen. Safe,stable, and nurturing relationships and environments can have a positive impact on a broad range of health problems and on the development of skills that will help children reach their full potential and be resilient.

    The Lamoille Family Center is one of fifteen Parent Child Centers (PCCs) in Vermont that use the Strengthening Families Framework and have a two‐generation approach to both mitigate and help prevent ACEs. The Centers for Disease Control recommends strategies for preventing ACEs, which resonate with the 8 core services that PCCs offer or that we refer to for support, including: home visiting to pregnant women and newborns, parent training programs, social supports for parents, parent support programs for teens and teen pregnancy prevention programs, high quality child care, income support for lower income families, intimate partner violence
    prevention, and mental health and substance abuse treatment.

    It takes all of us to build flourishing communities that support the healthy and resilient development of our children; let’s not wait to invest health care dollars in preventing adverse childhood experiences!