Healthy Urbanism

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PLANNING FOR POPULATION HEALTH MANAGEMENT

From the Industrial

Revolution to the subsequent

Urban Sprawl, we have been

on a quest to improve the

quality of our work, play and

educational lives.

We transitioned from cities to suburbs and farms to factories, to factories run by machines. We urbanized, televised, microwaved, motorized and modernized our lives to make living easier, more enjoyable. Easy living with all the amenities that would make our progress-loving forefathers beam with parental pride.

Along the way we created communities where we drive to a playground, drive to work, drive to dine out and drive to exercise. We also created low emission paint, initiated recycling, changed the type of oil our fast food is fried in, decreased infant mortality, nearly eradicated communicable diseases such as tuberculosis, mumps, smallpox and the plague, while increasing our life expectancy. So it’s all good- right?

Not exactly, America- we have a big problem. The results of this modern lifestyle are showing themselves in the upswing of “lifestyle diseases.” Step aside communicable disease, non-communicable diseases are on the rise.1

Heart disease, cancer, chronic lower respiratory disease, accidents, stroke, Alzheimer’s disease and diabetes are the

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1. World Health Organization, “New WHO report : deaths from non communicable diseases on the rise, with developing world hit the hardest” Paul Garwood, viewed February 23, 2016. http://www.who.int/mediacentre/news/releases/2011/ncds_20110427/en/

Out of the land of opportunity, emerges a new opportunity

current top causes of death as reported by the CDC “Leading Causes of Death” Fast Stats.2 The CDC identifies the following behaviors-high blood pressure, tobacco use and exposure to second hand smoke, obesity, physical inactivity, excessive alcohol use, diets low in fruits and vegetables, and diets high in sodium and saturated fat as the primary causes of chronic disease in the United States.3 The lifestyle consequences impact all ages and demographics.

Besides the obvious health concerns, these unhealthy behaviors come at a cost. Increased longevity of life, coupled with an increase in non-communicable diseases means we are living longer, but not necessarily better. The CDC reports that chronic diseases account for 7 of 10 deaths per year. Furthermore the treatment of people with chronic diseases consumes an alarming 86% of our nations health care dollars.4

While the numbers don’t look encouraging and it seems as though we’re all floating toward the proverbial waterfall, there is hope and optimism in the migration towards wellness occurring in our government, communities, healthcare, schools and workplaces. It’s taken us a while to get to this place, and it’s taking us awhile to align our

resources and redirect our focus to a healthier future. The current is shifting and we have an opportunity to write the story of how we improve our quality of life and create a new positive pattern of living well for future generations.

There is a need for reduced barriers to good health and great optimism supporting the proactive approach of a united front when addressing and improving population health. By uniting all sectors of a community, we can create the opportunity to design and reinforce a healthy lifestyle as well as a healthy environment and incorporate it into every day living. This team approach provides the opportunity to help redefine residents’ relationship with their community, their neighbors and the way they live.

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The vision of

H e a l t h y U r b a n i s m is the new opportunity to invest in creating something better.

2. Centers for Disease Control, Fast State, “Leading Causes of Death,” viewed February 23, 2016. http://www.cdc.gov/nchs/fastats/ leading-causes-of-death.htm

3. National Center for Chronic Disease prevention and Health Promotion, “The Four Domains of Chronic Disease Prevention; Common Risk Factors,” viewed February 23, 2016. http://www.cdc.gov/chronicdisease/resources/publications/four-domains.htm

4. National Center for Chronic Disease prevention and Health Promotion, “Chronic Disease and Health Promotion,” viewed February 23, 2016. http://www.cdc.gov/chronicdisease/index.htm

Where is the change to Healthy Urbanism happening?

It’s happening in our

workplaces. Employers faced with rising health care premiums for their employees are stepping up their wellness programs with the intent to off-set medical expenses and keep employees happy and in good working condition. From onsite health evaluations to gym membership discounts to workplaces offering in-house workout facilities and healthy snack options, workplace wellness is on the rise. The benefit, according to a recent report, “Workplace Wellness Programs Can Generate Savings” is that medical costs fall by approximately $3.27 for every dollar spent and absenteeism costs

fall approximately $2.37 for every dollar spent on wellness.5

A recent article in the Greatist.com outlines some of the best corporate wellness programs from large to small companies. Software company Asana in San Francisco, CA offers in–house daily yoga, a nap room, free gym memberships and flexible time off to their 150 employees. Produce from local, sustainable, and organic farms are used to prepare breakfast, lunch and dinner for employees. As if that’s not exciting enough, the company covers 100% of insurance premiums for employees and 50% for family members.6

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5. Health Affairs,”Workplace Wellness Programs Can Generate Savings,” Katherine Baicker, David Cutler and Zirui Song, viewed February 25, 2016. http://content.healthaffairs.org/content/29/2/304.full

6 Greatist.com, “ The 44 Healthiest Companies to Work for In America,” Abigail Thorpe, October 27, 2015. http://greatist.com/health/healthiest-companies

It’s happening in our

schools.

One notable public example happened in the fall of 2009, when TV personality and chef, Jamie Oliver set out on a mission to change the way an entire city ate. Filmed in Huntington, WV the show, “Jamie Oliver’s Food Revolution,” was centered mainly around the school cafeteria and improving their menu options. The cast and crew spent five months in the town, named the fattest city in America in 2008 by The Associated Press. They consulted with cafeteria workers, coached kids on healthy eating and opened a community kitchen serving healthy meals- all united with the goal of changing the residents’ unhealthy

relationship with food. Oliver is fighting for food education for every child with his movement, “Food Revolution Day.”

Elementary schools are a microcosm of society. The model of walking to classes, playing outdoors for recess, and eating healthy creates a culture of well being that can be carried through to the communities and homes of students.

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7. Food Revolution Day website, viewed February 23, 2016. http://www.foodrevolutionday.com

“My wish is to create a strong sustainable

movement to e d u c a t e every child about food,

inspire families to cook again and e m p o w e r people everywhere to

fight obesity.”7

-Jamie Oliver from his website food revolutionday.com

It’s happening in our healthcare. Thinking of healthcare as a proactive partner in your total well being and not as a reaction to a set of symptoms, changes the mindset of the patient. Medically integrated fitness facilities offering professional medical advice with the extension of trained physical fitness instructors all in one location working synergistically together offers a convenient and proactive approach to health and well being.

MC Fitness & Health is the first of its kind medically integrated fitness facility with an emergency room. Located in Delaware County Ohio, the emergency room is the second one in the rapidly growing county. Designed to promote a proactive approach to health and

wellness, the 130,000 square foot facility includes women’s health, imaging, lab services, physician offices, occupational and physical health rehab services, cardiac rehabilitation, community health and cardiovascular imaging. Also available is a 25-meter, 8 lane lap pool, exercise pool, warm water therapy pool, state-of-the art cardio, workout studios and a healthy foods snack bar. 8 The facility is aimed at making it easier to be healthy.

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8. Columbus Business First, “MC Fitness & Health opens with fitness Center and stand alone ER,” Carrie Goose, January 19, 2016. http://www.bizjournals.com/columbus/blog/2016/01/photos-mc-fitness-health-opens-with-fitness-center.html

This True Integration project combines the

expertise of Ohlson Lavoie Collaborative and

Davis Wince, Ltd. to provide long term health and wellness in this, growing community. More than

just a building, MC Fitness was designed to encourage engagement between the patient and

the health care provider.

It’s happening in our

communities. Non-profit organizations like the Walkable and Livable Communities Institute “helps create healthy, connected communities that support active living and that advance opportunities for all people through walkable and bikeable streets, livable cities and better built communities.”9

The progressive and visionary planned community of Nexton in Summerville, S.C. is setting the standard for healthy living. The 4,500 acre mixed-use community includes homes, office, retail and medical in a tight-knit community designed to improve and enrich the lives of its residents. Approximately 2,000 acres will remain green space or wetlands. According to the community website they “offer miles of trails and pristine roadways for walking and biking.” Integrated within the community is a state-of-the-art medical campus that will support independent practitioners while promoting collaboration through clinical integration of medical, health and wellness services. The community of Nexton creates a new standard for healthy

and wellness living.10 Communities like Nexton bring health services to the heart of the community, raising both awareness of opportunity and convenience of healthcare services.

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Studies show that

communities designed to support

an active lifestyle can prevent 50% of heart disease, stroke and site-specific cancers - and

more than 90% of type 2 diabetes. 11

9. Walkable and Livable Communities Institute website, viewed February 23, 2016. http://www.walklive.org

10. Charleston Regional Business Journal, “Nexton Development Team Looks Ahead,” Liz Segrist, January 8, 2014. http://www.charlestonbusiness.com/news/50044-nexton-development-team-looks-ahead

11. “Intersections Health and the Built Environment,” Urban Land Institute, pp. 29-30 http://uli.org/wp-content/uploads/ULI-Documents/Intersections-Health-and-the-Built-Environment.pdf

This True Integration project combines the expertise

of Ohlson Lavoie Collaborative and Davis Wince,

Ltd. to help grow the vision of an ideal, livable, walkable, bikeable community with a healthcare

system at the core. Currently in the second phase, our team is helping create a community that

promotes and reinforce the ideals of healthy living.

It’s happening in our

government.

The passing of the Affordable Care Act in 2010 set forth the most significant regulatory overhaul of the U.S. Healthcare system in fifty years, since the passing of Medicare and Medicaid in 1965.12 For all of the nuisances of the ACA that cause concern, there is also cause to celebrate the underlying theme of the movement- to proactively attend to your health, no excuses. No denial of coverage for pre-existing conditions, no cost preventative screenings when using a doctor within your health insurance network, guaranteed coverage to any child with a past or current health condition, your children can stay on your health plan until they are 26.12

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This proactive approach

to healthcare

encompasses a

commitment to be

accountable for your

own health and well

being. The new model

of health and wellness is

a team approach with

the patient as the lead.

12. Humana.com, “What is Healthcare reform?” https://www.humana.com/health-care-reform/affordable-care-act

How can we move Healthy Urbanism forward?

Creating a united front. The momentum for creating a better built and health focused environment has been building for decades across different sectors. What we’ve seen in the past several decades is a desire to make a change in the way we live our lives. It’s happening on many fronts with great strides and to varying degrees of success. Now, it’s time to elevate and unify the effort.

In 2009, thought leaders in the built environment community gathered to unite and develop strategies for awareness about the impact of community design on health, lives and healthcare dollars.13

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13. Centers for Disease Control and Prevention, “Healthy Community Design Expert Workshop Report,” September 21-22, 2009. http://www.cdc.gov/healthyplaces/publications/CDCExpertWorkshopReport_FINAL.pdf

Dr. Andrew Dannenberg, Associate Director for Science, Division of Emergency and Environment Health Service, National Center for Environmental Health at the CDC is also the lead for the CDC’s Healthy Community Design Initiative. Not only does he have quite possibly one of the longest titles in the group of experts that shaped the report, but he has a genuine and passionate interest in the subject and the ability to view the community as a whole equal to the sum of its parts. He

recognizes the reality that d i f f e r e n t s e c t o r s m u s t u n i t e , that this is not simply a segmented issue left to

be solved separately. He is quoted in the report, “Who are the people we need to reach? Most of them are outside the health field. We’re talking about politicians, people working in transportation, in housing, and in other areas that are not primarily health areas. But, in fact, anyone working in those areas is impacting public health, and so as health people ourselves, we need to convey the message to people in these other fields that actually they’re all part of the public health realm.”13

The idea of working as a team to improve community health is echoed by Alan Berger. Berger, a professor of landscape architecture and urban design at MIT’s School of Architecture and Planning is the principal author on a research report examining how cities affect our health and possible remedies for improving communities for better health. In an interview with Peter Dizikes from the MIT News Office, Berger summarizes the evolution of how we became disconnected, and a look to the future of planning. “The whole profession of city planning evolved out of solving sanitation problems during the late 19th and early 20th centuries. The public health field then went toward disease management, and city planning went in another direction, and they never came back together. We’re trying to get public health officials, designers, planners, and engineers in the same room to talk and come up with better solutions, and we want them all to be thinking across disciplinary boundaries.”14 What the strategy lacks is a leader.

In 2000, the U.S. Department of Health and Human Services released its report, “Healthy People 2010, Understanding and Improving Health.” The research and subsequent report was created to achieve two goals: increase quality and years of healthy life and eliminate

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13. Centers for Disease Control and Prevention, “Healthy Community Design Expert Workshop Report,” September 21-22, 2009. http://www.cdc.gov/healthyplaces/publications/CDCExpertWorkshopReport_FINAL.pdf

14. MMIT News, : “3 Questions: Alan Berger on cities and health, “ Peter Dizikes, November 21, 2013.

health disparities. The plan lays out 467 objectives in 28 focus areas over a 10-year period to improve the Nation’s health. The report found that, “the major barriers most people face when trying to increase physical activity are lack of time, lack of access to convenient facilities, and lack of safe environments in which to be active.”15

This is where Healthy

Urbanism steps in.

Imagine a community where you walk or bike to places of work, play, shop, worship. Where your health needs are met in fewer locations by combining market sectors. A community with available diverse housing and accommodations to support people through the different financial and age stages of their lives. A place where older family members can be in closer proximity to their families while still accessing the resources they need in their continuum of care. By creating a community that supports a healthy, active, engaged lifestyle, we can improve what the World Economic Form refers to as the Return on Health, (RoH)16 where we are not just

living longer lives, but reducing the rate of lifestyles diseases and therefore living better lives.

U.S. Census Bureau estimates released June 25, 2015 show that the Baby Boomer generation has now been out numbered by the Millennials (born between 1982- 2000). Millennials now represent more than a fourth of the nation’s population.17 “Investing in Place: Two generations’ view on the future of communities, millennials, boomer and new directions for planning and economic

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15. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000. http://www.healthypeople.gov/2010/document/pdf/uih/2010uih.pdf?visit=1

16. World Economic Forum, “Future of Health, How to Realize Returns of Health,” January 2016.http://www3.weforum.org/docs/WEF_Future_of_Healthy_How_to_Realize_Returns_on_Health_2016.pdf

17. United States Census Bureau, “Millennials Outnumber Baby Boomers and Are Far More Diverse, Census Bureau Reports,” June 25, 2015. https://www.census.gov/newsroom/press-releases/2015/cb15-113.html

development” is a research report by the American Planning Association that explores the relationship between planning and economic growth. The report references polls conducted in two demographics Millennial (age 21-34) and Active Baby Boomers (age 50-65). The report points to some interesting common desires among both groups, “One of the most striking findings of this survey is the sharp decline across demographic groups of interest in traditional, auto-dependent suburban living. Fewer than 10 percent of Millennials, Gen Xers, or Active Boomers see themselves in this type of community in the future despite 40 percent of them living there today. This doesn’t mean they are universally forsaking suburbs. Instead, the data indicates a desire for living in various types of communities- urban, suburban, rural and small town alike- but with greater mobility options, particularly walkability, and easy access to key amenities. Auto use, while continuing to be dominant, is plateauing. These trends will likely be accelerated by the desire of many to grow older in their existing homes and communities. Across geographies and generations, people seem to be embracing a common set of lifestyle and community goals. This will not only pose important design and planning challenges but also offer unique opportunities to reimagine many communities and neighborhoods.”18

According to the report, 56% of Millennials and

46% of Active Boomers would prefer to live someday in a walkable community, whether an urban, suburban or small

town location.18

The opportunities for change are great in both emerging and existing communities, in large urban environments and mid-size towns. The opportunity for healthier built and supported communities needs to span across all zip codes and income levels. Only one third of the poll respondents think the best way to grow the economy is by investing in recruiting companies to the area, while the majority, two-thirds, believe investing in schools and community features like transportation choices and walkable areas is a better option.18 The benefits of a healthy work force generates community investments from both large and small companies.

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18. American Planning Association, “Investing in Place: Two Generations’ View on the Future of Commodities,” May 2014. https://www.planning.org/policy/polls/investing/

ConclusionWith so much thorough research and enthusiasm happening with regards to Healthy Urbanism, there is hope that we can stop or reverse some of the unhealthy outcomes we have nurtured in the past century. We know that hope alone is not a strategy and what we are facing will be a difficult, time consuming, costly and challenging battle. We didn’t get here alone and it will take a united and optimistic effort to recreate a healthier future.

How do you affect the health

status of an entire

community?

The shift to a healthier built environment needs to be multi-faceted and include a shared responsibility from all segments of the built community. Thorough planning and phased community changes will help alleviate the financial burden and ensure the best circumstances for a RoI (Return on Investment) and a RoH (Return on Health). Establishing community teams of public, not for profit and business to engage in planning and funding will help ignite and clarify a picture of the new ecosystem of health and wellness. Health systems must lead the way, unite the various parties and create a winning opportunity for all involved.

The vision of what a community becomes in supporting and enhancing the lives of its residents will gain clarity when multiple stakeholders have a buy in and accountability for the big picture. Creating a walkable, livable, bikeable, healthcare accessible community where residents have the framework to create healthier living is the goal. Healthcare Systems have the opportunity to lead the change and reinvest in the future of their community, a great return for the investment. The health of an individual leaves the hospital and impacts the entire community where care is embedded. Investing in a well-designed walkable environment can create a community connection with vital health systems and other influential community members.

The time has never been better to rewrite our history and improve our healthy outcomes. By changing the way we live, we have the opportunity to reduce heart disease, cancer, chronic lower respiratory disease, stroke, Alzheimer’s disease and diabetes and create healthier future generations. Hockey Coach Herb Brooks said it best during his speech to the 1980’s U.S. Olympic Hockey team, “Great moments are born from great opportunities.” That is what we have here today in the land of opportunity.

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Research,Writing, Layout Design: Jennifer M. Bobbitt As Marketing Director, Jennifer brings over 20 years of service and product marketing experience to the team. She enjoys written story telling and creating highly visual, clear and concise marketing tools to promote products and services. She has been writing and observing people in their environments since the age of 5 when she penned and published her family vacation newspaper,“The Sunny Day Report.” Unexpected life events requiring long term care for her son have allowed her to become a frequent flyer in multiple medical systems, which has inspired her to help influence change in the way we live, work and play in our environments.

Contributing Editor: Kathleen Kelly, AIA, LEED® AP BD+C Kathy has 22 years of experience in the field of architecture and design with a majority of her experience focused on health, science and education projects. As a Senior Laboratory Planner and Designer, Kathy brings a depth of knowledge in the design, technology and coordination issues facing research scientists in laboratories today. Kathy has extensive hands-on laboratory programming, planning and design experience with clients nationwide on a new construction, renovation and interior fit-out projects in the higher education, government/institutional, research/development and healthcare sectors.

Contributing Thought Leader: Philip O.“Buck” Wince, AIA, LEED® AP Buck is Founding Partner and President Davis Wince, Ltd. bringing to the firm more than 25 years of de- sign and management experience. Buck leads the Davis Wince Health and Wellness studio and has a passion for developing “Quality of Life” communities focused on population health in urban, rural and suburban settings. Buck conducts extensive research and publishes work around the notion of community and regional health and wellness developments located in mixed-use retail environments that create unique synergies addressing healthy lifestyles.

Contributing Thought Leader: Gary Gray, AIA Gary brings over 35 years of design and planning experience to every project. From new hospital bed towers, to one bedroom apartment units the breadth of his experience is great and his focused compassion and belief in the value of a well built environment are an asset to every project he contribute to. Land planning 1000 acre mixed use communities as well as multi-use health campuses, Gary's design expertise extends from land planning 1000 acre mixed use communities to multi-use health campuses, to master site plan and interior tenant improvements.

Contributing Thought Leader: Hervey Lavoie, F-MA, NCARB In Hervey’s 40+ years as a licensed architect with Ohlson Lavoie Collaborative, he has completed athletic club design assignments in 42 states and 6 countries. In addition to hundreds of athletic clubs, Hervey has designed in excess of 45 medically- integrated, hospital-affiliated, fitness/wellness facilities. He has written extensively on the subject of sports and fitness design and has been published more than 70 times in various books, magazines and trade journals, including the Medical Fitness Association (MFA) Design Guidelines and the ACSM’s national medical fitness manual, as well as IHRSA Club Business International, Athletic Business and Club Industry magazines. Hervey has also been a conference speaker at more than 15 Industry events including IHRSA and MFA.

Contributing Thought Leader: Robert McDonald, LEED® AP Robert McDonald is Senior Principal and LEED® accredited architect with Ohlson Lavoie Collaborative best known for designing and managing large-scale municipal recreation facilities in the U.S. Notable projects include a flagship recreation center in his hometown of Laramie, Wyoming (2004) and Glenwood Springs Community Center at the edge of historic Glenwood Canyon in Colorado. Examples of Bob’s design work and management of large-scale facilities can be evidenced in the nearly 200,000 square-foot Campbell County Recreation Center in Gillette, Wyoming as well as Infinity Park in Glendale, Colorado Bob is also an accomplished public speaker, both as a focus group facilitator and as an industry expert at national conferences for Park and Recreation Associations as well as Athletic Business Magazine and the Medical Fitness Association.

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Authors & Contributors