Addressing Social Determinants of Health Through Community Hiring

DARRELL TERRY: Hello everyone, and welcome to our ACHE presentation! I’m Darrell Terry, President and CEO of Newark Beth Israel Medical Center-israel-medical-center/ and Children’s Hospital in New Jersey. We’re one of an 11 hospital system in New Jersey, called RWJ Barnabas Health. I’ve been with Newark Beth Israel for 24 years now, in various roles and I’ve been at the presidency for the last five years. Really happy to be here.

MYRA NORTON: Thanks, Darrell, and I’m Myron Norton. I’m the President at Arena Analytics. A mathematician by training. We’ll be sharing, along with Mr. Terry, some of the work that can be applied to community-based hiring using, actually, mathematics so we’re very excited to be here today. 

AGENDA: Addressing multiple social determinants of Health

DARRELL TERRY: When you look at health outcomes, 80% is impacted by social determinants of health, only 20% is really about the kind of health care that we provide. So I want to talk a lot about how important social determinants are. How important economic opportunity is for the community that we serve.

MYRA NORTON: Thanks Darrell, and then we’ll talk a little bit about, specifically, the HIRE NEWARK program that Darrell and his team have implemented at Newark Beth Israel. And then we’ll talk about how to scale these programs, once you’ve got the proof of concept in place. 

DARRELL TERRY: So, what are social determinants of health? Food security, access to care, housing, mental health, transportation, education, income and jobs, isolation, environment, safety. Community-based hiring addresses most of these social determinants of health.When you look at a workforce, a community that has good jobs, good incomes and safe housing, you’ll find better health outcomes. And so, it’s not enough for us as an institution to just provide episodic care to our patients when they come in. It’s really about looking at, and working with, the community to find out what are their needs. What can we do to make a healthier community? It’s way beyond just providing that sort of emergent type care.In your organizations, which of these issues have you addressed? We have touched upon, at Beth Israel and throughout RWJBarnabas’s system, every single one of these, but some in greater detail than others. Today we’re going to talk a lot about hiring. Hiring has a lot of impact on most of these issues. Community-based hiring can impact just about every single one of these social determinants, except perhaps affordable housing and safe living environments. Arguably, though, if you have stable income, you can live in a better neighborhood or you can make your neighborhood better. So, I would argue that community hiring tagged just about every single one of these social determinants of health. As I said earlier, 80% of an individual’s health is determined by behaviors and socio-environmental conditions, and 20% is about clinical care.  For years, we’ve been concentrating on that 20% without really improving the health outcomes. 

THE PROCESS: Involve the community in the planning

When you’re looking at how you can benefit a community, it’s not about what you think you should do. We should not be paternalistic in our approach. We should really work with our community. Each hospital has a Community Health Needs Assessment, that’s required by the ACA. Working with the community, with leaders in the community, we can find out what the community thinks their needs are. Then we come together to make a plan that works for both the hospital, as well as, more importantly, the community. You make mistakes when you try to build the program based on what you think the community needs. It’s a little, I’d say, arrogant. So it’s really important that we involve the community in creating the plan.

MYRA NORTON: So I’ve got a question for you, because when you talk about co-creating these initiatives, bringing together a diverse group of stakeholders to put together programs like the ones that you have at Newark Beth Israel, are there any shortcuts? Have you tried some shortcuts that didn’t work out? What happens when you don’t co-build programs together with a wide variety of stakeholders in the community?

DARRELL TERRY: I have a great example. We have a greenhouse — which is pretty unique in New Jersey. We have a greenhouse on our campus at Newark Beth Israel. When we created the greenhouse we knew that there was food insecurity in our area. We knew that there was a lack of access to fresh fruits and vegetables, so we understood that we were solving the problem. We went to our neighbors and got variances because it’s literally in a community that this greenhouse sits. They were very supportive of our initiatives. However, we did not involve them in the planning aspects of it. And so there were some policy issues we found out much later. Many people in the very community who were supportive of our efforts were not able to access our Farmers Market. They couldn’t buy our fresh fruits and vegetables because of the form of payment. They had SNAP benefits, and our set-up was not allowed to accept SNAP. And so the very community that were so supportive of our efforts are now excluded from being able to participate in a meaningful way. We went to the policy division of our system, and they actually petitioned the state and local governments to change the policies to enable us to accept SNAP benefits. Then that made a huge difference for the communities that we serve. Certainly an unintended consequence, we just didn’t think of it. That’s why it’s so important to get input —  real input — from the people that you’re trying to impact.

MYRA NORTON: That’s a great point for folks to have in mind who are trying to build these types of community programs for the first time. Talk to us about your guiding principles as you think about putting these programs in place. What do you think is important in terms of how you structure these kinds of programs?

DARRELL TERRY: We always start with the Community Health Needs Assessment and look at what the community is saying that they need. And then we look at the pathology in our community. We look at the metrics around unemployment. We look at metrics around different health outcomes. And then, together with our Patient Family Advisory Council, we come up with plans as to how we can address some of these issues and create a healthier community. It’s continuous iterations. There’s ongoing collaboration and learning, going back, doing things a little differently based on new information. It’s not something that you can just do one time and think that you have a plan, a blueprint. It’s very iterative and it takes a lot of constant feedback from the community that you serve.

MYRA NORTON: And as you’ve stood up a number of programs, did you find, for some, you have to create new roles inside of your organization? Or carve out, or create, a new set of responsibilities for existing employees to oversee this kind of work?

DARRELL TERRY: Absolutely. For example, how many hospitals have a farmer on their payroll? I literally hire a farmer for my greenhouse. In addition to that, there are several adjustments that we need to make in people’s role based on the needs of our community. You never really quite understand what the needs are, until you get into the program or planning phase of it, and then you back your way into what’s required to accomplish the plan. If you tried to plan it all yourself, you would never be creative enough to think about all the possible needs of the community.

MYRA NORTON: That’s such an important point, I think, because that means you as a leader in your organization have to be nimble, in a way, right? You’ve got to set on this journey with the expectation that it’s going to be continuously iterating.

DARRELL TERRY: Absolutely nimble, and being able to switch on a dime. We experienced this throughout the hiring program. We couldn’t have ever thought of some of the issues that we found we needed to address in order to make sure that our participants were successful.

Community-Based Hiring

MYRA NORTON: You guys have a long history of prioritizing hiring from the community and really focusing on that. Partnering with local community organizations, religious organizations, connecting with local job training programs… this is nothing new for you all. But the program that you’ve put in place to really take this to the next level, I think, is really innovative. How did you think about more deliberately putting an actual program in place — called HIRE NEWARK — to focus on scaling that prioritization of community hires.

DARRELL TERRY: We have for years wanted to make an impact and have our workforce representative of the community that we serve. However, there was a group of people who were really difficult to employ. Either they had long breaks from the workforce because of, maybe childbearing, maybe they never had been in the workforce for significant periods of time. This was not a re-entry type program, it was more about people who are chronically unemployed for a variety of reasons.  We wanted to try to figure out a way to get them into the workforce. There has NOT been a lot of concentration on that type of community. And so we created this program. It was at the Mayor’s request – Mayor Baraka is an unbelievable leader and someone who really cares about the community that he represents. He asked for us to come up with an idea, a plan. And he called it, Centers of Hope. We created the HIRE NEWARK program with his leadership and his team. The plan was to take community members, the requirement being they had to live in Newark and be unemployed for up to five years. The plan was workforce training. As you can see, the little kid, and the mom’s lap. There are so many barriers to folks getting a job, particularly if they have not been in the workforce for a period of time. It’s childcare issues, it’s transportation, it’s mental health, it’s clothing, it’s professional attire. We encountered so many different things that we could have never anticipated, until we delved into it. People have all kinds of issues — there was domestic violence, for example. So, if you’re not really committed to it — it’s hard work. It is really hard work and your hands will not be clean during this process. If you want everything to be perfect and hope folks to abide by all the rules and do everything right, then this is probably not the right program. This is a program where you really have to learn on the fly, be very nimble, and really care about each and every individual that participates. Because every story was slightly different, every circumstance was slightly different. And you have to take that into account. This is not for the faint of heart. It was a tough project. I will say, it was also so rewarding. There was a mom who had five boys. All of them were under the age of seven when she came into our program, so she was out of the workforce for a number of years because she was having babies. She had five boys. Since she came on board, she has become a cook for us. She has created her own business opportunity. She got married. They bought a house, and she had a sixth child, who’s a girl. She’s done amazing things for us here, and we were able to do a lot for her. There’s a bunch of success stories, just like that. So it is hard work. It’s challenging, but it’s very rewarding, too. When you look at the graduation rate, 99%. Either we hire the employee or one of our community partners hires. This was not just about Newark Beth Israel. We had about 13 or 14 other organizations that we worked very closely with to place the successful graduates. The graduation was phenomenal. The parents would come to the graduation, they’d bring the kids to it. It was a really exciting time for the organization. Our board chairman came to the graduation. Each graduation. It was a full commitment to the community that we serve. I’m very proud of this program.

DARRELL TERRY: Then we had to scale the program. We started off very small. I think the first class might have had about 30 participants and we scaled it up to 120 in 2016… Real impact.Here’s another story, Shamika. I see her every day. She is a wonderful representative of Newark Beth Israel. She can now provide for her family, they moved and the children can play safely outdoors. She can get them what they need. She’s a very personable young lady who we helped through every aspect of social, mental, whatever her challenges were, we worked with them. It was not a one size fits all program. By no means. It was very individualized care that we had to provide for each of the participants in the hiring workflow.

MYRA NORTON: It makes me think of the conversation at the beginning of this session around how community hiring touches all of those different components of the social determinants of health. It touches them at the macro level but it touches individuals at each of those levels. Because you guys had to surround each person with whatever supports they needed to be successful. If a fellow CEO of another health system came to you and said, I want to do something like this, where should I start? Do you have any advice for them to get something like this off the ground?

DARRELL TERRY:  Yes. The advice that I would have is you really need to be committed to doing it. That’s the first thing. Because you will learn things about your community, and participants, that you probably don’t want to know. But, in order for it to be successful, you need to know. 

• Put together a team.

• Include other employer partners.

• Get your local government involved. That would probably vary but still, it would be important.

• Identifying the right candidates for this would be important.

• It’s not inexpensive either. It costs a significant amount of money. What we did was, we took our big fundraising event — called Partners in Progress that we have each year — and we took the proceeds and committed it to this program because it’s so individualized, it makes it much more expensive.

• You would need a leader, an owner of the project.

The person who owned it here — she’s now the Director of Diversity and Inclusion. She’s someone who is from this community and totally committed to making the community where she lives better. She gave her cellphone number to the participants; they would call her up at 5 o’clock in the morning, they would call her up at midnight. She would deal with issues that she would never have ever dreamed that she would have to deal with. But that kind of commitment is required if you’re really going to make a difference in these folks’ lives. And so I think that’s a critical component — having the right leader who owns this program. And you, as a CEO, would need to understand that you’re entering into something that is very different. Your hands will not stay clean throughout this process, and you just have to be committed to it.

MYRA NORTON: You have to be personally committed to it, not, not just organizationally, for sure. And I just wanted to share with everyone you know some of the organizations that were involved in this partnership and you can see it’s a diverse set of employers: public, private, you name it.

DARRELL TERRY: This was a really important piece. That part of it wasn’t as successful as we had hoped. The worst thing that we could have done was — after five weeks of these community members giving us the very best that they have to offer — to not have a job for them. Something that I insisted upon from the first class of the program, is that everybody has a job when they graduate. I wanted everyone, when they went up to get their certificate, to tell us where they will be working next week or next month. In that first year we were struggling. Different employer partners were not able to hire for whatever reason. Then we’d lose credibility as an organization. And we’d further frustrate people who have already had many challenges in their lives. That’s not something we wanted to do. So anytime that there were issues, and our employment partners were not able to support the hire, we would find employment for them within our healthcare system.

MYRA NORTON: This speaks to what you said, the number one thing is your level of commitment and dedication to this. So — to the extent you can, recognizing you don’t know till you’re in it — it’s really important to enroll partners that have that same level of commitment. At a high level, what was the philosophy behind how you determined what that five-week training program should do? How did you think about what the specific teaching and curriculum should be?

DARRELL TERRY: We wanted people to understand our mission at Newark Beth Israel. We wanted people who are like-minded in trying to create a healthier community, trying to take care of our patients in the best way possible. So there was some of that, but really it was more about job skills: interacting with a supervisor, getting to work on time, interview process… the basics that most people take for granted and think of as elementary, but it was really important for us to start at the very beginning. And then we learned about all the obstacles to those things that we thought were a given, like getting to work one time. There are public transportation issues, challenges that created significant obstacles to people being successful. When we talked about the professional attire and the interview process — there were people who did not have what they needed to present themselves in a professional way. We helped with all of that. We made sure that they had every single thing that they needed to be successful. And a lot of it was learning as we went along, because we could not have predicted some of the things that we found out as we started to implement this program.We hired consultants from the community that we serve. People who spoke the same language.  We actually brought back graduates to speak to new classes. It was a lot of meeting people where they were, as opposed to where we thought that they should be.

MYRA NORTON: Please tell us where this stands now, what are you guys focusing on now?

DARRELL TERRY: We’re focusing on post-hire. It’s not enough to get someone in. It’s not enough that they start off at an entry level job that’s maybe part-time, maybe per diem. We really wanted to create career opportunities for the graduates. They’re past the baseline, they’re past the basics, and we wanted to create a ladder for them so that they can have the ability to apply for, and get, jobs that are more career-oriented, less entry-level, and more advanced so that we can offer real economic opportunity for the participants.If we’re really trying to impact the health of the communities that we serve, then we need to help people have economic opportunity. If they don’t know where their next meal is coming from, they don’t know how they’re going to pay rent, then they’re not going to get that colonoscopy that we recommend, they’re not going to get that mammogram that could determine whether you find something early that’s treatable and curable or whether you find something very late that has much more adverse outcomes. It’s not realistic to think that people are going to focus on those things that are clearly associated with better health outcomes, if they can’t put food on the table. It’s really important that we have people working jobs at a livable wage that they’re proud of, that their families are proud of, and then they’re able to address some of those other social determinants that we talked about earlier for themselves, as a result of their own economic stability.

SCALING COMMUNITY HIRING: Leveraging Machine Learning Technology

MYRA NORTON: Let’s spend a few minutes talking about how to scale these types of programs using tech. What Darrell has just shared with us the details of the human aspects, of how you surround people with the resources and support that they need to be successful. At Newark Beth Israel they’ve already started scaling this program year over year, touching more folks and impacting more lives. The thing that’s really exciting is, we now live in a world where the technology exists so that we can scale this type of hiring. One of the biggest challenges, as Darrell mentioned is, how do you identify the right folks to be in these programs? Traditional hiring approaches and traditional hiring technology doesn’t work here because these are folks who are chronically unemployed, who’ve been out of the workforce for a while. And so the beauty of a program like Hire Newark is you’ve created a data footprint that shows you the wide variety of folks who can be successful and take advantage of these programs. And so, this is where technology can help to then take this to the next level. How do you identify the right folks to bring in these programs and do that at a larger scale? As Darrell shared, it’s very time and labor intensive when you first start. It has to be that way because you need to understand all the nuances. Then, as you start to develop learnings about the categories of support that are needed, and you start to see waves of candidates move through this process and become employed and be successful, you can then start to apply technology to actually identify larger pools. We all know — and I’m sure Darrell would agree with this — this is just the tip of the iceberg in terms of folks in Newark — and other places like Baltimore where I am — who could and should be benefiting from programs like this. So the idea here is to basically build algorithms that can go and identify folks who have been out of the workforce so they’re not showing up on anyone’s radar, who can be successful in programs like this. I’ll just give you a quick thumbnail of how do you do this, and what does that actually mean. I’m not going to go into too much detail on math. Essentially, what you’re able to do is take data from a wide variety of sources. Everything that Darrell walked you through today — all of those activities, what’s happening in the community, the unemployment rate in the community, the local job market, the housing situation, all of those components create a data context that helps you start to understand the dynamics in terms of what predicts whether someone will be successful in a particular job at a particular location. You also incorporate the data reflecting what Darrell talked about in terms of the barriers to success that need to be removed, the components that could be contributing to someone’s ability to be successful or not, the barriers to success that are being removed. All of this comes together to create a data footprint that allows us to build a set of models that can identify more people in the community who can benefit from this kind of program.And this is really just technology doing what Darrell and his team have done for the last several years. started with a small program learned, literally, day by day, year over year, do more of this, do less of this… technology just does that at scale. So every person that you bring into the program, every person who gets hired at Newark Beth Israel, how they succeed and how they perform continually feeds that big data footprint. And you can continue to identify these non-traditional sources of talent and build the program at scale. The one thing that I want to emphasize here is that when you’re leveraging technology (predictive analytics), in a program like this, people exist in the hiring system. What you’ve heard Darrell talk about is, he and his team have really architected a system that supports the people, not only that they bring in through Hire Newark, but every person that comes into Beth Israel. It’s supporting their success throughout this lifecycle. Identifying the right folks is not enough. When you bring them on board, you then got to support them, help them be successful. Then as they succeed, their success begets future success. They become the models for the people that come in behind them. They progress in their career, not only being role models for their families and their communities, but for other employees inside of the organization. So it’s really a virtuous cycle and it is important that we don’t look at any of these pieces in isolation. Technology can be an incredible force multiplier but it only works in the context of understanding the human dynamics that are happening on the ground. A couple of must-haves if you’re looking at how to leverage these types of technologies: predictive analytics AI, machine learning… If you’re saying we want to apply these kinds of technologies to scale our community hiring programs, or hiring programs in general, I think there are 3 really important components that you have to ask yourself: 

1. You’ve got to have a diverse set of data. If you are using the same old data sources that organizations have used for years, decades, when they look at what makes someone “successful” in a job, you’re going to miss this opportunity to tap into and grow a new source of talent here and to really impact your community. So, you need folks inside your organization who understand how to access diverse data sources so that you’re not inadvertently you’re not having any unintended consequences there. 

2. The second piece goes into the way machine learning works. You have to make sure that there is a consistent feedback loop. Just like in the human example and the program that Darrell and his team built in those early days, where it’s human beings learning: okay, we’ve had this set of folks come through the program, this has happened, now we know we need to do this thing differently next time. You have to have that same learning process embedded in the technology that you build or use, because things are changing on the ground quickly and your learning is going to be happening quickly so you cannot leverage static predictive algorithms. The algorithms have to be dynamic. 

3. And then the third one, which I think is probably the most important, you have to have a clear way to eliminate bias in both the data sources that you’re using, and in the way you’re building and deploying models. Technology is very powerful. And it can be used for good. It can also be used to reinforce bias that exists. We’re fortunate that we live in a world today where technological advancements have gotten us to a place where we can effectively mitigate bias in technology, but you have to be sure you’re doing it. Just because it is possible doesn’t mean that it’s being done. And I think that is really critical. Especially for a community-based hiring program like this where, again, you are tapping into a vast talent pool that doesn’t necessarily “look” like what your traditional talent pool has looked like, but can and will, as Darrell has shared, really be incredibly additive to your organization. This isn’t just good for the community, it’s good for your organization.

If you’re thinking about how to apply tech to your community hiring initiative, there has to be a combination between technology and human wisdom. The human wisdom is what enables you to build the foundation, and the structure of a program that is going to deliver the outcomes you’re looking for. Technology can help you scale that, but, if you apply technology without human wisdom, you’re likely going to end up in a place you don’t want to be. So you need to first implement your program with supports, involving stakeholders, incorporating the takeaways that Darrell has already shared. Then you infuse technology to scale the program. Darrell, a few last words on how you would recommend setting community hires up for success? Once they graduate from the program, after they’ve been hired and are now on the job?

DARRELL TERRY: It was important for us to make sure that people had unconventional resources to help deal with whatever issues they will have. Just because they’ve graduated the five-week program, they’ve gotten the job, does not mean that all of the issues that led to their initial situation are resolved. By no means are they resolved. So we have mentors throughout the medical center who they can reach out to if they are having challenges. It wasn’t enough to get them hired, we had to be committed to their success. And so having venues, where they can reach out to people to help them navigate the work environment, was something that was critically important.

MYRA NORTON: Thank you. We’re at the end of our time and we just want to leave you with a few questions to think about as you go back to your organization and consider how to implement these kinds of programs. 

• First, which social determinants of health have your health system worked to address, and what was the impact of those efforts? 

• Are there pieces that you’ve learned here today that you might take back to help magnify the impact of those efforts or even stand up some new ones? 

• What community organization partnerships has your health system been involved in? And what was the impact of these efforts? 

• Based on our conversation today, are there a wider range of organizations that you might think about connecting with to really tackle some of these community challenges? 

• What would be needed to go beyond entry-level, community-based hiring? To really scale career pathways for your organization and for the communities that you serve? 

We hope these questions give you a few things to think about, and, hopefully, some of what we’ve shared today inspires you to build these kinds of programs in your own communities. Don’t hesitate to reach out to Darrell or myself if you want to know more. Thank you.