Excerpted From: Jessica Mantel and Jasmine Singh, Why a Sustainable Public Health System Needs Community-based Integrated Health Teams, 6 Belmont Health Law Journal 75 (Spring, 2022) (102 Footnotes) (Full Document)


Mantel SinghAt the outset of the COVID-19 pandemic, expressions of solidarity by politicians, celebrities, and Facebook posters were seemingly everywhere, encapsulated in the catchphrase “We're all in this together.” But while all of us have been affected by COVID-19, its impact has been anything but equal. In particular, existing inequities in income, employment, safe housing, transportation, and, most crucially, in health care have contributed to socioeconomically disadvantaged groups experiencing higher rates of COVID-19 infections, hospitalizations, and death.

Given the link between these pre-existing inequities and COVID-19 healthdisparities, the pandemic has revealed the necessity of building a more sustainable public health system that better meets the needs of economically and socially marginalized populations. This Article describes one approach for doing so-- leveraging the skills and resources of community-based integrated health teams (CIHTs) to support public health emergency responses that coordinate medical, behavioral health, and social services.

CIHTs are multi-disciplinary teams that help provide or coordinate medical, behavioral health, and social services for socioeconomically disadvantaged individuals with complex healthcare needs. In recognition that these patients often have chronic health conditions that are further complicated by social, financial, and behavioral health needs, CIHTs take a holistic view of an individuals' health and address the full continuum of patient's health-related needs. Specifically, they offer these patients intensive case management services and coordinate care across the health care, public health, and social services sectors. While the composition of each CIHT's team varies, they may include physicians, nurses, nurse practitioners, behavioral health specialists, community health workers (CHWs), and social workers.

One of us (Prof. Mantel) previously conducted a literature review of published articles and blog postings discussing how CIHTs can repurpose their resources to help communities meet the health needs of economically and socially marginalized populations during a public health emergency. This research found that CIHTs are well-positioned to quickly and effectively respond to the challenges that disadvantaged groups face during a public health crisis, both on an individual level and community level. As summarized in a previously published article reporting the findings of this research, during a public health crisis, CIHTs can conduct outreach to high-risk individuals and educate them about their health risks, provide individuals with material resources and emotional support, and connect them to health care providers and available community resources. CIHTs also can support system-level interventions designed to meet a community's needs during a public emergency, such as public health education campaigns and coordinated, cross-sector initiatives.

This Article builds upon this prior research by describing specific examples of how CIHTs have supported their community's COVID-19 public health response that were shared with the authors during qualitative interviews with CIHTs. To determine whether and how CIHTs support local public health emergency response efforts, we interviewed team members from different CIHTs about their COVID-related efforts. Although the responses during the interviews did not confirm every type of COVID-related activity by CIHTs described in the literature, the CIHTs participating in our study have supported COVID-19 response efforts in a variety of ways. Specifically, the CIHTs we interviewed provided assistance to high-risk individuals and supported system-level interventions.

This Article proceeds in three parts. Part I describes the research study we conducted, including who we interviewed, descriptions of the types of CIHTs we included, and the topics about which we inquired. Part II describes how CIHTs can provide assistance to individual patients during a public health crisis. Part III is the system-level counterpart of Part II and describes how CIHTs can leverage their capabilities to support public health interventions targeting specific populations. Part IV concludes by confirming that CIHTs can quickly and effectively respond to the complex challenges facing disadvantaged populations during a public health crisis, and that allocating public health funds in support of CIHTs would support a more sustainable and effective U.S. public health system.

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Long before the COVID-19 pandemic hit America's shores, there was ample evidence that a person's socioeconomic status affects their health. Economically and socially disadvantaged populations face more barriers to affordable, high quality care than other populations, as well as live, work and play in conditions that often adversely impact their health. The COVID-19 virus has only heightened these healthinequities, with disadvantaged groups disproportionately experiencing the pandemic's negative effects. A public health system that neglects these economic and social differences across different populations risks repeating the failures of the COVID-19 pandemic, with the next public health crisis only further deepening existing healthdisparities. A sustainable public health system therefore must have the capacity to address the complex, multifaceted needs of disadvantaged populations during public health emergencies. With their proficiency in coordinating a broad range of health and social services at both the individual and population level, CIHTs can provide invaluable assistance to these efforts.

The published literature highlights various ways in which CIHTs can leverage their expertise and resources to support the needs of economically and socially disadvantaged populations during a public health emergency. Specifically, during a public health crisis CIHTs can utilize their data collection and analytics capability to identify high-risk individuals, conduct outreach to and connect with available resources individuals adversely impacted by the public health crisis, ensure that individuals' medical and mental health needs are met, and support coordinated, cross-sector responses to the crisis. The CIHTs that participated in our qualitative study confirmed that, during the COVID-19 pandemic, they supported their local public health efforts in these various ways.

In addition to the important role CIHTs can play during a public health crisis, research has shown that during ordinary times CIHTs can both improve the health of economically and socially disadvantaged individuals and lower health care spending. All of the CIHTs participating in our study similarly reported success on either health outcome and efficiency metrics such as reducing emergency room visits, or offered anecdotes of how they were increasing patients' overall wellness or social circumstances. Yet despite their promise for reducing health care inequities and spending, the CIHT model has not been widely adopted. One obstacle to CIHTs is the substantial up-front costs required to start a CIHT, as well as uncertainty about securing sustainable financing remain. Our interviewees similarly commented that funding remains an ongoing challenge for their CIHTs and hinders their success.

The COVID-19 pandemic has highlighted that importance of investing in CIHTs as part of building a sustainable public health system that can quickly and effectively respond to the complex challenges facing disadvantaged populations during a public health crisis. Investing in CIHTs also provides the added benefit of strengthening ongoing efforts to reduce healthinequities. As policymakers consider how to best spend future public health dollars, allocating a portion of this funding to the expansion of CIHTs across the country would support a more sustainable and effective U.S. public health system.

Professor of Law and George Butler Research Professor, Co-Director Health Law & Policy Institute, University of Houston Law Center; B.A. University of Pennsylvania; J.D. and M.P.P. University of Michigan.

J.D. Candidate, University of Houston Law Center; B.A. University of Houston; B.S. Baylor University.