More and more research continues to confirm that walkable neighborhoods are better for the environment, the local economy and the health of a neighborhood’s residents. Yet, low income communities of color are often less walkable than others. Walkability is a health equity issue given that walkable neighborhoods have lower rate of chronic disease and given the alarming recent spike in pedestrian deaths in the region. Experts in urban planning, community development and public health are therefore coming together to recognize and promote the importance of walkability.

In Dorchester, Codman Square Neighborhood Development Corporation (CSNDC) in partnership with the Talbot-Norfolk Triangle Neighbors United (TNTNU) was inspired to improve the walkability of their neighborhood from a survey of over a thousand residents in the Talbot-Norfolk area which revealed that residents’ main concerns with the neighborhood included health and environmental sustainability. They were particularly interested in incorporating more green space and opportunities for active transit (biking and walking) in the streets of the neighborhood, along with other environmental sustainability measures. CSNDC and TNTNU, therefore, decided to turn the neighborhood into the “Eco Innovation District,” with funding from the Barr foundation with the goal of promoting transit oriented development in the neighborhood and along the Fairmount Line.

“If you afford someone the opportunity to live in an open space, an open beautiful space, it improves their lives overall” said Tiffany Cogell, a healthy neighborhood champion of the Talbot-Norfolk triangle area. “I believe that low income people are just as deserving of a beautiful place to live as anyone else”

The neighborhood currently faces major safety issues. It is a common cut-through area for drivers who speed through the neighborhood to get to and from downtown Boston. As a result, multiple crashes and a bike death occurred in the area last year. In addition, a major street in the neighborhood, New England avenue, has absolutely no sidewalks. Residents are therefore limited in how they can move around in their neighborhood. As a result, while residents may take a short trip to the corner store by walking or biking, they are unlikely to make longer trips due to lack of walkability in the neighborhood.

“Getting people in the neighborhood out and walking makes them pay attention to the built environment” said Cogell. “People notice when children have to cross an unsafe street to go to school. We have allowed the city to forget our neighborhood by not paying attention.”

To address safety issues, CSNDC has worked with the Boston Transportation Department to designate a slow zone that will include more reduced speed signage, and speed bumps to slow drivers through the neighborhood. CSNDC has also gotten funding from the Boston Public Health Commission to hire residents as Healthy Community Champions, like Cogell. The Healthy Community Champions, mostly mothers from the neighborhood, have conducted a survey of 130 residents about health and mobility. They are now consolidating the findings and using them to inform future work in the neighborhood.

CSNDC also relies on the advocacy and technical assistance of organizations like WalkBoston and Liveable Streets who help them scope out projects and helped advocate on their behalf to the Department of Transportation. As Dave Queeley, Eco-Innovation Fellow at CSNDC has noted,

“it takes a village” to improve a neighborhood and create change.

To help communities around the state understand how to create their own “villages” to boost walkability, WalkBoston and the Mel King Institute teamed up earlier this year to host a workshop on “Promoting Walkability: Creating Safe and Active Neighborhoods.” The workshop, which took place in Codman Square included an overview of the benefits and possible infrastructural improvements to enhance walkability from WalkBoston, and case studies from projects around Boston including the Eco Innovation district along with the following projects:

• Mike Chavez an architect and Enterprise Rose Fellow with the Fairmount CDC Collaborative, spoke about the Collaborative’s efforts to promote affordable housing and smart design in the neighborhoods of Roxbury, Dorchester, Mattapan and Hyde Park.
• Marah Holland, the Health Equity and Wellness Coordinator for Roxbury in Motion and the Madison Park Development Corporation shared stories of community-driven efforts to create Complete Streets in Roxbury that use built environment improvements that improve pedestrian conditions as critical tools to improve social equity, public safety and community health.

While WalkBoston and the Mel King Institute successfully concluded their workshop, the broader conversation on walkability and building more sustainable and equitable communities is by no means over.  

Research has shown a powerful link between  children’s exposure to homelessness and their long term health: children exposed to homelessness are several times more likely to be hospitalized and face more mental and physical health issues later in life than those with stable homes. In order to confront both the health and housing needs for families who are currently homeless or at risk of homelessness, the Boston Foundation piloted its Health Starts at Home initiative with four planning grants this year. Four MACDC members- The Neighborhood Developers, Nuestra Communidad, Urban Edge and Metropolitan Boston Housing Partnerships are involved in three of the projects in coalition with other healthcare and social service organizations. The projects use diverse strategies to link housing to healthcare: Urban Edge and MBHP are working with partners to connect families sheltered in a motel in Waltham to long-term housing and healthcare support while TND and MBHP are creating a referral system through MGH Chelsea so families who come to the hospital in need of social services can be referred to TND’s robust CONNECT program that links families to needed housing, jobs and benefits.

The planning grant was an important learning opportunity for both the Boston Foundation and the involved organizations to learn how disparate sectors, such as community development and healthcare, could work together to have a collective impact.

“A lot of organizations talked about wanting to work together, but not having the funding or the space to do that” said Pamela Hung, Program Associate in Health at The Boston Foundation.

The planning grants allowed the participating organizations to learn one another’s “language” and learn about one another’s programs and how they could be aligned. From these learnings, the groups created integrated service delivery models and two of the projects started to pilot their models to see what worked and what could be improved. All of the groups also created robust data collection and outcome systems in partnership with Health Resources in Action and the Urban Institute to evaluate the impact of the program on child health.

For the next three years, the projects have been given implementation funding to pilot the programs and evaluate their outcomes. The Boston Foundation hopes that the learnings from these initial pilots will lead to a larger policy change in how healthcare and housing programs are linked.

“Our ultimate goal is that the best practices and models uplifted through Health Starts at Home will lead to  systemic changes in housing and health care funding.” Said Lucy Ellis, Program Associate in Neighborhoods and Housing at The Boston Foundation. 

The United States has the most expensive healthcare system in the world, and yet in terms of actual health outcomes the United States is ranked near the bottom compared to other developed (OECD) countries. Why is this the case? While there are many problems with our healthcare system, one of the major culprits is lack of spending on social services, according to Elizabeth Bradley and Lauren Taylor authors of The American Healthcare Paradox. On average, other developed countries spend $2 on social services for every $1 spent on healthcare. The United States, by contrast, spends only 55 cents on social services for every $1 spent on healthcare. Additionally, the authors found that increased spending on social services was positively correlated with better health outcomes among all the OECD countries (http://academyhealth.org/files/2013/sunday/bradley.pdf).

Thankfully, both health policymakers and healthcare administrators are beginning to embrace that health is ensured not by only pills and procedures but also by access to safe and stable housing, living wage employment opportunities, financial stability and safe neighborhoods.  They are beginning to find ways to redirect their resources in order to address the structural inequities of communities that lead to poor health. Here are three examples:

1.Community Benefits Plans- The Affordable Care Act now requires all non-profit hospitals to conduct community health needs assessments and come up with community health improvement plans to address health needs in surrounding communities. Some hospitals are using those plans creatively to meet community needs. For instance, Dignity health a network of nonprofit hospitals serving California, Arizona and Nevada has created a $100 million loan fund to develop affordable housing, provide job training, assist neighborhood revitalization and build wealth in neighboring communities. However, there are no strict guidelines for the kinds of activities that can be funded by these community benefits plans, and therefore there is wide variation among hospitals.

All Massachusetts nonprofit hospitals publicize their community benefits plans in the Annual Reports section of the Massachusetts attorney general’s website. Community organizations can explore these reports to see what their local hospitals are currently doing and use them to advocate for more creative and impactful programs.

2.Anchor Institution Models- Some hospitals and healthcare systems are realizing that as nonprofit institutions whose missions are to improve health and wellbeing, they have to go above and beyond the IRS community benefits mandate to adequately address the root cause of poor health in their local communities. Kaiser Permanente, the nation’s largest nonprofit integrated health system with operating revenues over $56 billion dollars, is using a concept called “total health” to guide all its non-clinical practices towards promoting health broadly including physical, mental and spiritual well-being, that account for “resilience” factors not traditionally considered by medicine such as people having a sense of purpose, belonging and self-efficacy.  They are intentionally hiring from low income census tracks in their service area, sourcing their food from local farmers, purchasing supplies from woman and minority owned businesses and are also using their investment capital to invest in local housing and economic development. As a leading healthcare system, Kaiser is setting an example for the whole country for how nonprofit hospitals can most effectively and holistically deliver on their mission to promote health and save lives.

3.Accountable Care Organizations-  As a part of Medicaid reforms, some states are authorizing Accountable Care Organizations (ACOs) as new Medicaid delivery systems. ACOs are integrated health delivery organizations that receive a standard payment per member, and then use the combined funding to both pay for healthcare services and coordinate the prevention services for the members. ACOs can keep a share of any money saved, so they are incentivized to invest in creative solutions that improve health and reduce costly treatments.  In Hennepin County, Minnesota, the Hennepin Health ACO found that 30% to 50% of its members were unstably housed or homeless, leading to serious health problems. The ACO worked with local supportive housing providers to pay for room and board in supportive housing units for some of their members. Using savings from the ACO as a result of this program, Hennepin Health was able to invest in social service navigators who help members with housing and other needs.

Five Pioneer Accountable Care Organizations were set up in Massachusetts in 2012-13, and four of five were able to use the model to cut spending.  Learn more about states that have supported social services through their ACOs in this report.

4. Determination of Need Community Health Initiative- Here in Massachusetts, any hospital expanding their services, undergoing extensive capital expenditure or starting a large solicitation process must undergo a Determination of Need process (DoN) process through the state in order to prevent excessive spending on healthcare. Approved projects must allocate at least 5% of the funds to “provision of primary and preventive health care services necessary for underserved populations in the project’s service area” through the Community Health Initiative. As a part of their CHI, Brigham and Women’s hospital (BWH) has released an RFP for 10 Health Equity grants of $20,000 to $100,000 to promote community psychological health and wellbeing, strengthening employment and job skills opportunity as well as addressing health inequity issues with a racial equity lens. Through these grants, BWH is setting an innovative standard for how hospitals can use community health funds from a DoN process.

All of these hospital and healthcare organizations rely heavily on partnerships with community organizations to identify needs and support investments in the housing, workforce development, local businesses and local neighborhoods. Community organizations in Massachusetts have the opportunity to identify and reach out to the community engagement coordinator at their local hospital to find out how they can better partner to improve health and wellbeing in communities.

A few years ago, a fire caused by a tenant at Urban Edge Housing Corporation displaced over twenty families. Residents had to be evacuated and the organization had to deal with the fallout of the incident. With the complexities of relocating shocked residents, including staff members, Katie Provencher, Deputy Director of Urban Edge and former Director of Community Engagement, realized that they needed to develop robust written policies and procedures as an organization to address traumatic events.

“We realized that each of us were building up a skillset, confronting shooting incidents and fires, so we started putting together policies and procedures.” Said Provencher

Developing a trauma response plan as an organization is not just about each individual incident, but about helping communities heal from a long history of disinvestment and oppression. Unfortunately, violence and trauma occur at higher rates in poorer communities of color. Compounded with the trauma and stress of intergenerational poverty and racism, trauma in low-income communities of color is a significant public health issue linked to poor physical and mental health outcomes. Responding to trauma and facilitating healing in communities is an important way for CDCs and other community leaders to boost community resiliency and improve mental and physical health.

Background

With 1,400 units of housing, things can and do happen at Urban Edge, a CDC serving the neighborhoods of Roxbury and Jamaica Plain in Boston. Fires, shootings and accidents have all occurred during the organization’s 40 year history. Thankfully, Urban Edge is mindful of the need for strong support to survivors of trauma. Even though Urban Edge outsourced property management several years ago, they chose to keep resident services within the organization, so that they could maintain a strong connection with their community.

Urban Edge’s policies and procedures around addressing trauma include three parts: addressing residents’ needs, addressing the self-care needs of staff (who will have their own emotional reaction to such incidents), and leveraging external resources to respond to the emerging needs of the community. 

Implementing A Response Plan and Working with Partners

A few years ago, the shocking death of one of Urban Edge’s youth shook the community.

“Within the first few hours of the incident, we went door to door to see how affected they [residents] were,” said Robert Torres, Director of Community Engagement. “We looked for physical signs of distress, sometimes people were crying and sometimes the event was a trigger for something else in their life.”

Torres and his team referred affected residents to Courtney Gray, the Director of Trauma Services at the Boston Public Health Commission (BPHC). Courtney’s team of trained trauma counselors helped the residents cope with the physical and emotional stress they felt following the incident. 

Working with BPHC is now standard practice for Urban Edge.  Given that each incident is different, Urban Edge also works with community members to address their specific needs. When a young adult was caught in the cross-fire of a shooting incident and died, the staff helped his family apply for funeral assistance and made an appointment with the Louis D. Brown Peace Institute, which provides support to the survivors of homicide victims.

Preventing and Responding to Incidents

Ideally, violence and accidents would not happen.  That is why Urban Edge engages in significant efforts to reduce violence, strengthen community ties, ensure solid property management, and otherwise promote prevention. In a large community, there will come a time when CDCs and other community leaders need to respond to a tragic event, whether it is violence, fire or even a natural disaster. Given that incidents will occur, the robust and detailed policies that the organization has developed along with their network of outside partners enables Urban Edge to be ready to respond appropriately and professionally when the time comes.

By combining both prevention and a robust response plan, Urban Edge is using a trauma informed approach to help communities heal – emotionally, physically and socially.

Katie and Robert are teaching a workshop on Responding to Trauma: Facilitating Healing in Community on February 10th to help organizations develop their own policies and practices around traumatic incidents. SIGN UP TODAY.