Building healthy communities.

Sigmond eloquently detailed in his article his vision for the future of American health care. And while the specific details of community care networks may vary by community--as well as the local and national experiences that lead to their creation--Sigmond is exactly correct in his assertion that community coordination of health care services is the solution to what has become a very competitive, complex health industry. Imagine the history of health care in America plotted on a trend chart. You can start the clock running at the emergence of what we consider to be the modern-day hospital. You will later see the advent of today's insurance models, regulatory systems, and government involvement. And at the far right of the graph, you will see the recent flutter of activity as managed care and other new ideas begin to influence the course of health care in our country. Health care's history does not fit on a one-dimensional time line. Its history is one of sharp upward swings (advancements) and long plateaus (the new status quo) as each new program, each new medical or economic revelation pushes the complexity of our health care system up a notch. As the complexity has grown, so have both the demands on our system and our understanding of its capabilities. As Sigmond indicates, we are now at the foothill of another upward thrust in the evolution of American health care. It may be a turbulent climb, but the next plateau holds his vision of a truly community-based, collaborative health care delivery system that, for the first time, will direct resources at the very points at which health is created. Most hospitals and health systems seem to be caught in a rather awkward position as they try to navigate between two very conflicting realities. On the one hand, we seem to be caught up in a "middle game," which is marked by a rapidly growing investment in developing an integrated delivery system (IDS) based on a heavy-competition model. Huge investments are going toward acquisitions of physician practices, development of risk-bearing managed care products, and PHO arrangements with our medical staffs. Concurrently, we are keeping the other eye on the "end game," which is a more collaborative, cooperative approach to developing healthy communities and being more accountable for the health status of a defined population. As we navigate between these two points, it places great stress on organizations, boards, and medical staff leadership to create a vision for the future and develop successful delivery models. The Future Four There are basically four new premises that underpin the movement toward developing healthy communities and new models of care for those we serve. The first premise is that health care cannot be reformed from the top; it can only be reformed at the grassroots, or the bottom part of our health care system. "One size fits all" solutions from Washington, DC, or our state capitols seldom take into account the complexity, diversity, and unique characteristics of our communities. In order to be successful, grassroots models with empowering initiatives at the local community level are the only models that will be sustainable in the future. Unfortunately, these are models with which we have little experience to date. Doctors and acute care hospitals do not create health. Rather, health is created and nurtured (or abused) by our home environment, by our neighborhoods, by the places we spend our time, and by the decisions each of us makes every day for ourselves. Therefore, to succeed in creating greater health and improving the quality of life, we must have greater impact and leverage resources at these crucial points in our communities, families, and neighborhoods that largely determine our health status. Much of the central planning in Washington and the state capitols across the country cannot begin to address health status with the precision of a true grassroots effort, which is many times more responsive to local needs and the interests of people who make local health care decisions on a daily basis. …