J Clin Pathways. 2016;2(1):19-22
An interview with Erin Hagan, MBA, PhD, Evidence for Action, San Francisco, CA
Evidence for Action, is a national program of the Robert Wood Johnson Foundation (RWJF) that supports the Foundation’s commitment to building a Culture of Health in the United States.
It is an investigator-initiated research program designed to support high-impact action-oriented research to assess population health and health care outcomes and set priorities for future study. Launched on June 1, the organization was founded on the expectation of helping to bridge the gap between areas of research that exist outside of traditional health care but have an impact on the health of individuals and communities. The program aims to provide individuals, organizations, communities, policymakers, and researchers with the empirical evidence needed to address the key determinants of health encompassed in the “Culture of Health Action Framework” (Figure 1). This framework includes four “Action Areas:” making health a shared value; fostering cross-sector collaboration to improve well being; creating healthier, more equitable communities; and strengthening integration of health services and systems. 
The organization will be awarding approximately $2.2 million dollars annually for grants of periods up to 30 months and anticipate funding opportunities to be open for the next 3 years. These grants will support creative, rigorous research on the impact of innovative programs, policies and partnerships on health and wellbeing, and on novel approaches to measuring health determinants and outcomes. This initiative drives Evidence for Action’s greater mission, which is to integrate health into all aspects of society and to encourage cross-sector partnership and collaboration. For this purpose, all researchers with innovative approaches towards fostering a Culture of Health are encouraged to apply; this includes applicants representing a wide range of fields and disciplines both within and without the health sector.
Erin Hagan, MBA, PhD, serves as the deputy director for their Evidence for Action initiative alongside health experts Nancy Adler, PhD, Director of the Center for Health and Community at the University of California, San Francisco (San Francisco, CA) and David Valhov, PhD, FAAN, Dean of the UCSF School of Nursing, Laura Gottlieb, MD, MPH, Assistant Professor of Family and Community Medicine, UCSF, and Maria Glymour, Associate Professor in the Department of Epidemiology and Biostatistics, UCSF. Hagan has authored numerous publications on initiatives to improve public health, including joint reports on supplying greater access to healthy foods and strategies for preventing chronic illnesses. JCP discusses with Hagan her concerns regarding the current structure of our health care industry, what her organization hopes to accomplish in funding its wide range of unique studies, and how clinical pathways play a part in what the future of health care looks like for communities around the country.
Tell us more about Evidence for Action and what it hopes to accomplish?
The RWJF has launched a broad new vision of building a Culture of Health in the United States; Evidence for Action is one of their means of finding the root causes and the possible solutions to different problems in population health and health care. We are particularly looking at creative collaboration and at topics that maybe we haven’t thought about traditionally in the health sector before. What I think is exciting about our program is that the foundation’s grant making strategy is very much evidence-based, but it is also looking to fund areas that have not yet been studied and to take some risks. We don’t know yet if those strategies are promising or if they’re really linked to health outcomes, but we get to help build that evidence base. One of the areas I think we’re especially interested in is funding work that explores and proves or disproves some of our more closely held beliefs. I think there are areas where we believe that certain actions lead to improved health, but we don’t actually have the empirical evidence to say that definitively. Take the focus on multi-sector collaboration for example – this is something we even encourage through our program. The assumption that partnerships are needed to achieve key outcomes and/or are more effective in doing so is intuitively appealing, but there is limited empirical evidence on whether partnerships actually do lead to improved population health outcomes in a cost-effective manner. We’re also trying to fund work outside of the health sector that looks at how health is being affected by initiatives that aren’t designed to affect health. Examples of these initiatives include community development activities, asset building strategies, job placement programs, housing (re)development, transportation planning, or criminal justice reforms. These initiatives are generally designed to have specific social or economic benefits, and we expect they also wind up affecting health outcomes. The goal of integrating health considerations into these other sectors feeds back into our beliefs about the need for multi-sector collaboration, but we also know there are challenges associated with complex partnerships. In the context of limited resources and competing priorities it is not enough to know whether partnerships are beneficial, but also whether they are cost effective.
You are also interested in looking at the different socio-economic conditions that affect the provision of health care and discrepancies in patient access.
Absolutely, we are certainly interested in determining the different determinants of health. We want to focus on looking at the whole spectrum of health outcomes. And then really how decision-making upstream of health care—regarding where housing is developed or where transportation is available, for example—are impacting people’s health outcomes. The RWJF has an action framework, that includes four action areas, and those areas form the foundation’s thinking about grant making, guiding our own focus towards inquiry. Those areas aim to make health a shared value, foster effective cross-sector collaborations, create more healthy and equitable communities, and strengthen integration of health systems and services. We hope better understanding how those areas interact with each other can lead to healthier, more equitable outcomes for the whole population.
What are some of the different areas you would be interested in funding?
On the health care side, we’re interested in more systems-based research. For example, initiatives to look at patient-centered care, collaborative care organizations, the implementation of the Affordable Care Act. There are also really interesting questions about how electronic health records can be linked with other data sources to improve outcomes and how collaboration between public health, community health, and health care providers can be fostered. Another great question of particular interest to Journal of Clinical Pathways is how wrap-around services and other social services can be integrated into clinical pathways to improve their effectiveness. So there are a variety of interesting questions that need to be answered.
How do you think those concepts can influence how we’re helping patients?
When we’re talking about our Action Framework, and in particular the Action Area of integrating systems and services, our hope would be that there’s better integration across all the places where people are accessing health care as well as integration with other systems and services that are impacting health outcomes. We’re early in our progress towards this, but that would be a really successful shift in the culture of health. Regarding the socio-economic determinants, recognizing and integrating the consideration of those determinants in the way that we make decisions across not just in health care, but also from all areas in society, would also be an important shift. I was recently at an Institute of Medicine (IOM) meeting and we spoke quite a bit about how care was being incentivized and reimbursed, and I think that’s a critical piece and a significant culture shift in the US. If the IRS could recognize investments from private hospitals in housing improvements in their communities as part of their community benefit requirement for the Affordable Care Act, or if Medicaid would reimburse hospitals for doing work in improving housing standards, that would be a huge culture shift. Some of these investments targeted at addressing social and economic determinants of health and connecting people to wrap-around services on the front end of care could show significant improvements in population health outcomes, particularly for low income people and people of color, who are experiencing the worst health outcomes right now.
Do you see clinical pathways as one of the methods for enhancing healthcare?
I think that clinical pathways may be a way to move the country towards better health overall. However, that is only if those social determinants are being incorporated into the pathways and people are being connected to other services that aren’t necessarily considered explicitly health care in those clinical pathways. The pathway must be broader than just what medical services are being provided by a clinician in a hospital. This is most relevant to people who don’t have immediate access to social services and need that assistance; but for all people, there needs to be an increased recognition of the fact that so much of our life experience is impacting our health. I think people are starting to realize that health isn’t just about people’s personal choices and behaviors, but that it really is a function of where you live, you’re environmental exposures, your social and economic status. In the evolution of our health system, I hope that there will be a much broader consideration for the impact of external determinants of health on people’s health outcomes.
One of the things we’ve discussed extensively internally and with experts in the field is the need for better short- and intermediate-term health measures that can indicate progress toward long-term changes in disease outcomes. A really great example of this is tobacco use. We now have enough research that we can confidently say, if you decrease tobacco consumption, you will improve health outcomes. That wasn’t always the case; it took us decades to build the evidence in order to confidently make that claim. So we’d like to be able to build upon those indicators of progress in other places and accumulate evidence to support them—for example, to demonstrate if increased civic engagement such as voter turnout or volunteer engagement leads to improved health outcomes.
Of course, initially, this is a 30-month grant cycle, and so we’re likely not going to see long-term results or outcomes in 30 months, but we think we can start to demonstrate some progress.
Do you see clinical pathways as a means of achieving Evidence for Action’s targeted objective, such as by addressing financial toxicity and the economic burdens of treatment to patients and their families?
Absolutely. Including those sorts of considerations in a clinical pathway, I believe, would make such a pathway more successful for not only patients, but really providers as well. The idea of testing that approach is something we might be interested in funding, because right now I don’t think that we have great evidence and we haven’t tested those ideas. Evidence for Action could certainly play a role in funding research to better understand how financial toxicity impacts health outcomes and determine whether clinical pathways are a successful model for addressing financial toxicity.
What has the response been so far?
It’s incredibly exciting. In just the 3 months since we’ve launch our program, we’ve already received over 170 letters of intent, and the proposals cover all facets of health: HIV, smoking cessation, consideration of redevelopment of housing, and linking electronic health records, to name a few. There have been some incredibly innovative ideas in the proposals we’ve received. One of the strengths of the program is that we haven’t limited the field by posing questions. We’ve become investigator-initiated so that researchers can tell us what they think are the most important questions to answer in order to move the needle on improving health outcomes in the country.
What have been the barriers that have prevented this kind of research from being done in the past?
I think part of the problem, as I mentioned earlier, is that we don’t have strong measures for some of the constructs that we think are associated with health, much less measures that link those constructs to long-term health outcomes. For example, we believe social cohesion improves health outcomes, but we don’t have very good instruments to measure social cohesion, much less strong metrics that connect social cohesion to health. I also think funding streams have been siloed and, to some extent, the focus of the research is narrowly defined by the funders, whether they be a government funder or a private foundation. Often those sorts of organizations or entities are in a position to have a good understanding of the data and the issues on a macro level, but I think you miss out on some innovation when you pose specific questions to researchers rather than having them develop their own questions. So that’s one exciting thing about this program: we are allowing people to really be creative in their thinking.
Otherwise, I think the biggest challenge is how long it takes to accumulate the evidence to support these connections. In fact, the fact that our focus is so broad could be a shortcoming. The question is: can we build a significant enough evidence base in one particular area because we’re accepting proposals on so many different topics? We will continue to learn as we develop the program, and it may be that 3 years from now we will be more focused on the particular topics that we think are the most promising or are at a tipping point for developing a robust evidence base or a strong connection between interim and long-term health outcomes. But for now, we really are most interested in getting creative and innovative ideas from people.
Are researchers viewing Evidence for Action as a place where these proposals that normally wouldn’t get funding can receive support?
Yes! We’ve actually said that. And we’ve tried to tell people that, if you’ve had trouble getting funding in the traditional health sector, we might be able to fund you. We don’t have nearly as strict requirements as somewhere like the NIH. We are open to a wide variety of methodologies, including those that, in the domestic health sector, haven’t been as well embraced. For example, economic modeling as it relates to health is one of those areas the domestic health field has been slow to embrace, whereas these modeling approaches are used extensively and are well respected in the field of economics. We are encouraging people to think how they can apply methods from outside the health sector to solving health-related problems.
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The Full Evidence for Action Team
