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San Diego Embarks On 10-Year Trek Toward Better Health

SAN DIEGO — Bolstered by one of the largest American Recovery and Reinvestment Act grants in the country, the San Diego County Board of Supervisors in July approved a 10-year plan to improve the health of San Diegans.

Taking aim at childhood obesity and preventable deaths resulting from heart and respiratory conditions, diabetes and cancer, the county Health and Human Services Agency will implement policies to help communities improve nutrition, increase physical activity and reduce tobacco use. The $16.1 million dollar federal grant will support this effort.

Although the county’s public health overhaul is in line with the goals of the federal health reform law, plans were well under way here before it was clear that legislation would pass, according to HHSA Director Nick Macchione. Beginning in 2008, HHSA embarked on a two-year evaluation of public, physical and behavioral health to determine how “these three big areas tie together in terms of the total health of people we serve and the community,” Macchione said.  

HHSA currently serves approximately 500,000 people annually through the combination of health and social services programs, making it one of the largest such agencies in the country.

In an effort to establish more cost-effective ways to deliver disease management and prevention, the county’s 10-year plan focuses on four pillars:

  • Prevention;
  • Education;
  • Service delivery; and
  • Culture change.

Prevention and Education: an Interdisciplinary Effort

“Three behaviors — smoking, poor nutrition and a lack of physical activity — lead to four diseases: heart disease and stroke, lung disease, cancer and type 2 diabetes, that contribute to over 50% of fatalities,” explained Dean Sidelinger, referring to the county’s “3-4-50” concept. Sidelinger is the county’s deputy public health officer. Fifty-seven percent of all deaths in San Diego last year were attributable to one of these often preventable diseases.

Efforts are under way to alter the health of residents by changing the environments in which they live and work. In a significant departure from traditional public health practices, San Diego’s health department will work hand-in-hand with other disciplines, such as transportation and land use, as well as with engineers, city and urban planners, and others to create communities that support healthy behavior.

“You have to look at macro-level forces, and the conditions that lead a large proportion of people to not exercise and eat well,” said Anthony Iton, senior vice president of healthy communities at the California Endowment.

That means increasing bike paths, sidewalks and shade trees so people can comfortably walk in their neighborhoods, safe parks and the use of methods to slow down the speed of cars so people don’t feel threatened when crossing streets.

“All of these are health interventions that live in the planning world, the transportation world and in the world of community design,” Iton said.

Analyzing Non-Health Policies Affecting Health  

In addition, Sidelinger said, “Many people live in places where the only food choices are fast food or stores that don’t stock fresh foods.”

To change that, the county will need to evaluate non-health-related policies that have health implications.

“What are the policies that support the distribution of liquor stores or fast food restaurants and can they be changed in a way to emphasize or subsidize access to healthy foods and farmers markets instead of McDonald’s?” Iton asked.

Policy changes are already in the works, according to Macchione and Sidelinger. Four San Diego farmers markets currently accept food stamps to improve recipients’ access to fresh fruits and vegetables. If Assembly Bill 537 by Juan Arambula (I-Fresno) becomes law, all farmers markets throughout the state will be required to accept them in the coming years.

Down the line, the health department will seek to broker new distribution chains so produce can be delivered to local stores faster and, therefore, fresher. The quality of food delivered through HHSA’s senior meals programs and local schools will be improved, and financial incentives will be developed to encourage local retailers to carry healthier foods.  Efforts to work with land use, transportation authorities and other departments that can help change communities for improved long-term health outcomes are rolling out now as well, Macchione said.

Working With Communities

Another departure from business-as-usual for public health is the need to establish relationships with communities and involve them in decision making processes from the start.

“We have 17 different citizen agency advisory boards,” Macchione said. These range from child protection to social services, Medicaid plans and beyond. In addition, the agency reached out to the local chamber of commerce, church leaders, tax payer associations, schools and residents.

“We had a dialogue with all these groups and gathered data from them and then compiled a framework and went back to them for validation,” Macchione said. In all, HHSA held five community forums.

Involving Local Health Care Providers

Creating a system that better supports a long-term relationship between consumers and health care providers is a critical component of this plan’s success. As if that wasn’t challenge enough, officials are concerned that the national health reform law will exacerbate already limited access to health care providers.

“We will get an additional 300,000 to 500,000 new lives coming into the Medicaid system,” Macchione said.

Macchione said HHSA has been working with the local provider community to ensure consumer access to health care providers, including specialists and safety net care. HHSA also hopes to improve and expand upon care management and coordination, create medical homes, and reach out to non-traditional providers, such as housing authorities, in order to reduce the use of emergency departments and provide services that address all aspects of a person’s life.

“If you take a homeless person and give them a one-stop shop for medical care and mental health care needs, but release them to under the bridge, how will they get a continuity of care? So we developed a housing first medical model, bringing in housing partners who have traditionally not been at the table. We looked at our delivery system and asked how we can make a difference,” Macchione said.

The county intends to build on the success of a diabetes-focused initiative — made possible with a federal Medicaid waiver — to improve the coordination of medical services delivery for Medi-Cal beneficiaries. Medical homes and access to nutritionists and counselors who help diabetics maintain their treatment regimens and diets, among other services, led to improvements in health outcomes and lower overall costs, Sidelinger said.

This same model will be expanded to people with mental illnesses and other physical diseases, with efforts to realign resources and better integrate primary and specialty care.

Anticipated Challenges

With a much broader definition of public health at the root of the system’s overhaul, HHSA will undoubtedly face challenges in its quest for an improved public health system over the next 10 years. Among its greatest challenges will be the cultural shift for agency itself in order to carry out its plans.

“Any organization that sets about trying to craft a different strategic direction has to look at its own institutional limitations as a major factor in its ability to be successful,” Iton said.

Macchione is well aware that with approximately 5,400 HHSA employees and more than 16,000 employees throughout the county in 44 different departments, internal educational efforts must be sweeping if they are to successfully change the way public health is perceived and implemented in San Diego.

Of course, one can never discount the importance of money. California is in for some hard years ahead, Macchione said, referring to the state’s epic budget crisis. Aside from the federal ARRA grant, this public health plan’s execution will depend on the creative use of existing funds. “We’ll have to make some hard decisions,” Macchione acknowledged.

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