Join the Moonshot for Health Equity in Cancer

Institute for Health Care ImprovementOrlando, Florida

December 12, 2017

A3/B3

Inspired by the Cancer Moonshot

“Every day, every minute matters to patients and we must bring that sense of urgency to our cancer researchand care systems; A zip code should not determineone’s prognosis.”

Danielle Carnivalle, Ph.D. – VP, Biden Cancer Initiativehttps://bidencancer.org/

Introductions

•Jeanne M. Regnante, Sr. VP, Sustainable Healthy Communities, LLC

•Laura Lee Hall, COO and Executive VP of Sustainable Healthy Communities, LLC

•Patricia Doykos, PhD, Director, Bristol Myers Squibb Foundation

•Gary Puckrein, PhD, President and CEO, National Minority Quality Forum

Agenda for today’s Workshop (75 min)

•Background and introduction of workshop worksheet– Jeanne (10 min)

• It Starts with Research- Jeanne (10 min)•Enhancing Cancer Screening in Practice- Laura Lee

(10 min)•Guaranteeing Equity along the Continuum of Care-Patricia (10 min)

•Mapping Cancer Equity in Accountable Communities- Gary (15 min)

• Q &A and Workshop Activity (20 min)

Session Objectives

• Identify the factors that make equity in cancer research crucial

•Discern community and health system strategies for promoting cancer screening, treatment, and outcomes equity

•Explore the map of cancer disparities in the US

• Join the Cancer Diverse Communities Working Group

These presenters have nothing to disclose

NMQF Mission is to strengthen the ability of communities and policy-makers to eliminate the disproportionate burden of premature death and preventable illness in special populations through the use of evidence-based, data-driven initiatives.

“Sustainable healthy communities in every zip code”

SHC’s mission is to promote sustainable healthy communities, especially those with diverse and underserved populations, through the provision of actionable data, research, and engagement/training of clinicians and community leaders.

Who do we Represent?

Founded in 1998, non profit heath careResearch & Policy organization

Founded in 2016, A wholly-owned subsidiary of NMQF

Diverse Cancer CommunitiesWorking Group (CWG)

Disparities in disease prevalence and risk

• The most important diseases that disproportionately affect ethnic minorities:

• type 2 diabetes

• cardiovascular disease

• stroke

• infectious diseases (HIV/AIDS, HCV,STDs)

• different types of cancer (lung, CR, prostate, TNBCA, multiple myeloma)

8

2016-17 NCI SEER data and ACR facts and figures report confirms inequalities in the US remain despite innovations

(1) Documented cancer health disparities include:• higher incidence of breast cancer (the triple-negative subtype) among African American women than women of other racial/ethnic groups•substantially higher rates of prostate cancer incidence and death among African American men than men of other racial/ethnic groups•higher rates of cervical cancer incidence and death among Hispanic and African American women than women of other racial/ethnic groups

(2) Lung cancer is the leading cause of cancer deaths in African Americans

(1) https://www.cancer.gov/research/areas/disparities(2) https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2016-2018.pdf

“Patient Centered” Contributors to HC Disparities in Cancer

• Access to Health Care• Mistrust– leading to delays• Socioeconomic status• Tobacco use• Alcohol consumption• Co-morbidities • Access to Genetic Testing• Biologic factors

REF: Multiple publications in 2016-2017 from NCI, ACR, ASCO, ACS

Notable Publications

1. http://www.commonwealthfund.org/interactives/2017/july/mirror-mirror/2. http://jamanetwork.com/journals/jama/fullarticle/2612013?utm_source=twitter&utm_campaign=content-

shareicons&utm_content=article_engagement&utm_medium=social&utm_term=041217#.WO5grfwYB7Q.twitter

The US is dead last out of 11 countries in health equity, Mirror, Mirror, The Commonwealth Report July 2017, (1)

“Health begins in Communities…we need community leadership to reduce disparities”IMP National Academy of Sciences, Vital Directions for Health and Health Care, April 2017 (2)

Diverse Cancer Communities Working Group Members (CWG)

We are all here for the privilege of helping medically underserved and diverse cancerpopulations in America be given the same chance at innovation as the rest of America has. We choose to do this by engaging and creating local communities for sustainable cancer care”- Jeanne M. Regnante, Chair, Cancer Diverse Communities WG

Merck & Co.Amgen, Inc.Bristol-Myers Squibb CompanyBristol-Myers Squibb FoundationNIH Precision Medicine: All of UsTakeda OncologyAbbVie, IncCelgene CorporationWake Forest Baptist Medical Center

Biden Cancer InitiativeCancerCareEli Lilly and CompanyAmerican College of SurgeonsUniversity of Kentucky HealthcareGenentech, Inc.American Society of Clinical OncologyHorizon Blue Cross Blue Shield of New Jersey

Four Project Goals and Sub Teams

➢Better understand the distribution and impact of cancer among underserved and diverse populations around the country (Cancer Index)➢Help clinicians increase cancer screening, prevention

counseling, and specialist referral in minority and poor communities– focus on QI (QI and Clinician Engagement)➢Promote patient and community understanding of the

importance and opportunities for improving cancer outcomes among diverse populations (Patient and Community Engagement)➢Better understand and increase diversity in cancer

clinical research (Diversity in Clinical Research)

Our Call to Action

Spotlight existing inequities in order to identify and deliver solutions and innovations in cancer screening, referral, access to treatment, care, support and inclusive research for all.

Access to Care/ Screening

Access to Treatment/ Clinical Research

Referral Support/SurvivorshipCare

Development and Delivery of a sustainable, stakeholder community

The CWG : How do we achieve results?

• Three Years (July 2017- July 2020)• For-profit corporation membership $25K annually• Engage multiple expert stakeholders (in CWG and in

cancer communities in the US) • Year 1: Capture and add to what is known, Deliver Big

Data Analytics, assessments, frameworks, rubrics, uncover best practices, convene, expert roundtables, publish

• Year 2 and 3: Establish, implement, measure and monitor scalable demonstration projects with QI in medically underserved/diverse communities, publish

• Sustainability and Communication plans

How to Join the Moonshot for Healthy Equity: WorkhopExercise

Reflection questions on specific cancer equity issue

Assessment of current status in your organization

Next steps you and your organization can take to advance issue `

Is health equity in cancer care a strategic priority for your organization backed by resources and attached to clear goals?

Which patient population and/or cancer type do you need to improve cancer care access, prevention, screening, treatment, quality and/or outcomes?

Is there a domain of the care continuum that you would like to improve?

What research or data can help you identify targets for improvement and measure impact of changes made?

What non-medical barriers to cancer equity are important in your community?

It Starts with Research…..

ASCO ABSTRACT’ 201733 NME, 156 Cancer Trials, 2011-2016

Conclusions:

• The proportion of White patients enrolled in the US (88%) is higher than the proportion of Whites in the US population. However, the enrollment of AA and NHPI/AIAN patients is low and below the proportional representation of AA and NHPI/AIAN in the US.

• While enrollment targets may differ across cancer type and by race, the racial composition of patients enrolled in the trials that support the approval of cancer therapeutics should be reflective of the likely US patient population for whom these agents will be prescribed.

• The data on enrollment by ethnicity (i.e., Hispanic) was missing or incorrectly reported as “race.” This trend may contribute to gaps in data regarding clinical trial participation and outcomes among this demographic subgroup. Improvements in collection of ethnicity data are needed.

Racial composition in trials supporting the US approval of anti-cancer new molecular entities (NMEs), 2011- 2016 Lola Fashoyin-Aje1, Laura L. Fernandes2, Steven Lemery1, Patricia Keegan1, Rajeshwari Sridhara2, Jonca Bull3, Richard Pazdur1 1Office of Hematology and Oncology Products, Office of New Drugs, Center for Drug Evaluation Research; 2Office of Biostatistics, Center for Drug Evaluation Research; 3Office of Minority Health, Office of the Commissioner; US Food and Drug Administration

What are some of the reasons this is so hard?

Lack of Investigator outreach to community groups Lack of knowledge of trials amongst Primary Care Physicians and lack direct involvement in the process

Lack of Investigator outreach to community groups

Lack of knowledge of trials amongst Primary Care Physicians and lack direct involvement in the process

Lack of Patient trust in research

Lack of standard data and language systems that note capabilities of sites to sponsors

Who are the minority serving sites ?

No standard, accepted or shared framework

Lack of all Stakeholder Sponsorship of a sustainable set of solutions and goals

Sponsors think it takes too long which then drives cost and limits innovation getting approved

Ethnic Minorities are not asked for inputinto trial design

Our Goal

Deliver real progress and “bend the curve” on Inclusion and Diversity in Cancer Clinical Research in the US consistent with epidemiology of the disease

A Diverse Cancer Sub Team Project

•Interview US Cancer Center leaders in the US (N=8) who engage Ethnic Minorities in Cancer Clinical Research >20-50% of the time - identify their notable practices and publish.

•Topic Areas:• Sponsorship/Leadership• Operations and Metrics• Patient and Community Engagement• Investigator Training and Engagement

Overall Early Results (N=4)

• Inclusion of Ethically Diverse Patient Participants in Clinical Trials (20%-40%)

• Patient and Community input into research questions and driver of engagement of patients and caregivers is a clear driver of success

• Culturally and Linguistically Sensitive Communications is delivered by Trusted Community leaders

• System-wide Engagement and knowledge of community centered Research and Programs (e.g. smoking cessation, screening, resources)

• System-wide Data Collection Standards• Degree of Mentoring for Health Equity practices and research is

High– down to a high school involvement level• Hiring Practices of researchers attract and reflect quality diverse

candidates that reflect the patient population that they serve

A take home idea

Publish a baseline, paper with selected organizational leaders’/sponsors to expose good practices and a call to action• Identify % of ethnic minorities who are participants in cancer clinical

studies in service area (over the last year); find a study where the investigator engaged ethnic minorities consistent with the prevalence of disease– partner with them.

• Identify non-interventional study engagement of ethnic minorities and expose practices

• Develop an interview guide to capture notable practices and gaps• Interview leaders engaged throughout the continuum of care to expose

notable practices and expose their recommendations for change• Understand how race defined and captured in your organization for

studies in general? • Understand who are the cancer community leaders/are they involved?

When, how and by whom?

Enhancing Cancer Screening in Practice: A Pilot QI Program: Laura Lee Hall, PhD

Goal 2: Help Clinicians Increase Cancer Screening, Prevention Counseling, and Referral

•Subteam Leads: Chris Dezii and Laura Lee Hall

“Remember, we are focused on making a real difference for the under-served, who are not the un-deserved.”

Objectives

• Pilot QI program or programs on focused region(s)/cancer(s) • Under-served and minority patient populations at

increased risk or with gaps in care/outcomes• Focus on primary care screening/referral

• Develop template for dissemination of the QI approach more broadly• To be applied and integrated with the results from the

other subcommittees• Targeting specific cancers which are mapped• Targeting providers in specific regions with gaps• Incorporating best practices identified by other

subcommittees (e.g., patient engagement strategies)

Which Cancer and Where?

Top Age-Adjusted Invasive Cancer Incidence Rates

0

20

40

60

80

100

120

140

160

180

Female Breast Prostate Lung Colon

White Black Hispanic

Rates are per 100,000 persons and are age-adjusted to the 2000 U.S. standard population

https://nccd.cdc.gov/uscs/toptencancers.aspx#text

Top Age-Adjusted Invasive Cancer Death Rates

0

5

10

15

20

25

30

35

40

45

50

Female Breast Prostate Lung Colon

White Black Hispanic

Rates are per 100,000 persons and are age-adjusted to the 2000 U.S. standard population

https://nccd.cdc.gov/uscs/toptencancers.aspx#text

Geography of Top Four Cancers

Incidence Death Rates

Breast Cancer

Prostate Cancer

Lung Cancer

Colon Cancer

How to Make a Change?

SHC Toolkit

Advisory group with local expert and community

participation

SHC Index: Predictive

modeling report

Community assessment

Practice assessment

Champion trainingPDSAs/Rapid Cycle

Improvement in Practices

Ongoing coachingPublic

communications

Toolkit Backbone

A Pilot to Sustainably Increase Lung Cancer Screening by Primary Care Practices Working with Underserved and High-risk Populations

•Pilot quality improvement/practice transformation program for sustainably disseminating lung cancer screening and referral among medically underserved patients in eastern Kentucky

•The target is eastern (Appalachian) Kentucky, including up to 10 primary care practices, with an estimated reach of a total of 25,000 patients

•Partnership with local/regional leaders including the Kentucky LEADS program and the KY-ACP

• Implementation of the SHC Toolkit•State and ultimately national dissemination

Bristol-Myers Squibb Foundation:Pursuing Equity along the Continuum of Cancer Care

Patricia M. Doykos, PhDDirector

IHI National ForumDecember 2017

Cancer Diverse Communities Working Group:Subcommittee on Patient and Community

Engagement

Subcommittee : Diversity and Inclusion in Cancer Clinical Research

•Bernie Rosof, MD, Northwell, SHC, QHC Advisory

•Ellen Sonet, JD, MBA, CancerCare

•Michelle Vichnin, MD, FACOG, Merck & Co

•Patricia M. Doykos, PhD, BMSF

• SHC Staff - Jeanne Regnante

Goal 3: Promote Patient and Community Understanding and Action

•Objectives: Identify gaps and approaches to understanding and promoting patient and community engagement in cancer research, screening, and treatment, both in community-based projects and in general –across the continuum-of-care

Bristol-Myers Squibb Foundation: Global Footprint

Returning Veterans in the U.S.

Lung Cancer in the U.S.Hepatitis in China & India

HIV and Cancer in Africa

Cancer in Centraland Eastern Europe

The mission of the Bristol-Myers Squibb Foundation is to promote health equity and improve the health outcomes of populations disproportionately affected by serious diseases

Cancer & CVD in the U.S.

Goal: Improve access to and utilization of specialty care services and health outcomes of vulnerable populations living with cancers and cardiovascular disease (a-fib, DVT, stroke, heart failure)

Health systems strengtheningComplete systems of care and expand specialty care delivery for Medicaid and medically underserved patients through collaborations among specialists and community based care/primary care providers

Patient engagement and supportEnhance patient engagement and community supportive services to optimize specialty care utilization and self care

Translate the successful models into services and capacity sustained by reimbursement, other funding sources and enabling institution-level and public health policies.

Thought Leadership and Changing Mindset: Equity in Cancer and Specialty Care Briefs

43© FSG |

Disparities exist throughout the patient pathway

44© FSG |

The Briefs highlight solutions for equity in specialty care and what’s

needed to move forward

• Highlights 10 solutions categorized into

three types

• For each solution, the Briefs will provide a

“state of the field,” that includes the

following information:

• The specific challenges addressed by

these solutions

• Descriptions, examples and data for

each solution, with many examples

and references to existing research

• The value proposition of these

solutions for patients, payers and

providers

• What’s needed to scale the solutions,

where to start, and success factors

• We hope to add to this body of research

with case studies, lessons learned and

evidence from your work

Lung Cancer Focused Grants

• ACCC Medicaid OCCM Initiative

• Ralph Lauren Community Cancer Center – Screening in high risk community

• Anne Arundel Medical Center – QI to speed

diagnosis and commencement of treatment

• Maine Lung Cancer Coalition – coordinated statewide screening and care

• Thomas Jefferson University/Jefferson Health -integrated and safety net health system screening and care

Other Cancer Focused Grants

• Farmworker Justice – skin cancer

• Yale Cancer Center – NCI CCC catchment care for lung, breast, prostate and colorectal cancers

• Project ECHO – apply tele mentoring and collaborative care to cancer

• Institute for Health Care Improvement – QI for therapeutic areas and social determinants of health

46© FSG |

Across these examples, we saw five consistent elements that

enabled sustainability and scale.

1

2

3

4

5

Effective use of data to identify disparities and track impact is an

essential component of initiatives to improve equity in specialty care.

Taking a community-based approach is necessary to fully address

health disparities, even for specialty care.

Efforts to address health equity require leadership with a systems

orientation and an equity mindset.

An enabling policy environment is essential to help programs that

reduce disparities in specialty care thrive and to encourage and

incentivize participation from system actors at all levels.

While every organization must take action to address health

disparities, no one provider, payer, policy maker or patient can

change the system in isolation. Collaboration is fundamental.

Government Health Plans Healthcare Delivery Organizations & Systems

Professional Associations Patient Advocacy / Community Development

Health Disparities Data Collection in Medicaid and CHIPThe Affordable Care Act of 2010 (Section 4302) requires the Secretary of HHS to establish data collection standards for race, ethnicity, sex, primary language, and disability status, and calls for these categories to be consistently collected and reported in all national population health surveys that rely on self-report.

NCI scored sections in the NCI CCC designation/redesignation applications starting in 2017

FDA: 2016 Year of Diversity in Clinical Trials- Enrollment dashboard

Aetna’s Racial and Ethnic Equality Chairman’s Initiative- Voluntary self identification for

race and ethnicity of clients- 2015 30% of clients participated- Program development

UnitedHealthcareHealth Equity Services Programto help find and reduce health disparities. The HES Program does this by making UHCinitiatives work better for many different cultures. These initiatives encourage members to be as healthy as they can be, and help members avoid more expensive health care costs.

Cancer Care Equity Program at the Dana-Farber Cancer Institute: bridge between research and outreach efforts to address cancer disparities at Dana-Farber Cancer Institute.

Moffitt Cancer Center Community Benefit: provides patient-centered and culturally competent outreach, education, training, and resources throughout the greater Tampa Bay and FL to support patients, families, and clinicians in advancing cancer prevention, early detection, clinical care, and research, especially for those at-risk populations disproportionately impacted by the disease.

Kaiser Permanente:collaborating with Susan G. Komen Oregon and Southwest Washington, and eight community partners to increase breast cancer screening among Latina women in Oregon.

ASCO Strategic Plan for Increasing Racial and Ethnic Diversity in the Oncology Workforce :- Establish a longitudinal pathway for increasing workforce diversity- Enhance ASCO leadership diversity, and- Integrate a focus on diversity across ASCO programs and policies.

AACR: The Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved (since 2008)

National Medical Association /Congressional Black Caucus Foundation: Professional Development Series to Examine Zika, Cancer Disparities

ONS: Social Determinants of Health: A Framework for Studying Cancer Health Disparities and Minority Participation in Research

Cancer Support Community:CancerSupportSource®, to identify the specific concerns experienced by a patient and provide a tailored and desired response. The 25 items are based upon the IOM’s recommended areas of unmet psychosocial need, cover three critical domains (psychosocial, practical, physical) and include a four-item depression subscale.

Leukemia & Lymphoma Society: Telephone & Web Education Program in Spanish with top cancer clinicians

CancerCare Patient Access and Engagement Report laid the groundwork for understanding the true ‘costs’ – physical, emotional, financial – of the cancer experience for patients and families nationwide.

National Urban League: Take Action for Health strives to increase mammograms

Supporting Policy and Advocacy

- Seizing on emerging enabling policy innovation and change to build implementation projects, e.g. ACA, new lung cancer screening guidelines, new CMS reimbursement for low dose CT-Scan

- Evaluation

- Capacity

- Access, Quality of Care, Health Outcomes, Patient Centered Outcomes

- Cost savings

- Real-Project-Real-Time-Real-Context TA from Harvard Law School Center for Health Law and Policy Innovation

- Storytelling

Resources:Issue Briefs, QI Projects, Thought Leader Talks, Think Pieces on Health

Equity and Philanthropy

• https://www.bms.com/assets/bms/us/en-us/pdf/breaking-the-barriers-to-specialty-care-full-series.pdf

• https://www.bms.com/about-us/responsibility/bristol-myers-squibb-foundation/resources-and-learnings/grantee-summit-2017.html

• https://www.healthaffairs.org/do/10.1377/hblog20160801.056021/full/

• https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.0256

Controlling Cancer Outcomes:From Health Disparities to Sustainable Healthy Communities

Gary Puckrein, PhD

Presentation Overview• Community Health

• About NMQF

• The Geography of Lung Cancer and Cancer

Care

• The Cancer Working Group

Community Health

Community health is a product of collaborative networks, where

all members in a society contribute to and inform population

health.

These collaborations include patients, physicians, hospitals,

policymakers, insurers, social and environmental services, patient

advocacy organizations, medical product discovery and delivery

system, and public engagement.

A Community-BasedCollaborative Health Network

54

Risk Mitigation

Measuring Network Functions

55

These collaborative networks can produce optimal or suboptimal results.

They can be optimized so they deliver effective medical care across diverse populations.

Performance measures can be developed that report on how well the integrated network and their component parts are functioning.

Health Disparities as Suboptimal Performance

56

Health Disparities are a function of community-based collaborative networks operating suboptimally for a specific cohort.

It could be a collective malfunction or the dysfunction could reside in some component part.

The National Minority Quality Forum (NMQF)

57

The Forum has developed a

comprehensive database

comprised of over 2 billion patient

records, which it uses to define

disease prevalence, costs and

outcomes for demographic

subpopulations at the zip code level

Big Data: Challenges and Solutions

Volume Rapidly changing

Complex

technology

platforms

Different

data sets

Expert

analysis

required

Outputs

not always

actionable,

understandable

CHALLENGES

A SOLUTION

MAKE IT VISUAL

GIS-Based Data Visualization

59

NMQF develops maps to provide demographic

intelligence about acute and chronic disorders

at the zip code level – segmented by age,

gender, race/ethnicity – to:

• Map any index disease by prevalence, cost, outcomes, comorbidities, socioeconomic status or other data type for any state, MSA, congressional and state legislative districts

• Define where the unmet needs exist

• Forecast trends using predictive analytics

• Produce customized reports to support educational, advocacy and policy efforts

Geography

matters

Consumption

patterns can

be shaped

Key Learnings

Predictable forces

shape markets

Resource

management

can be improved

Cancer Working Group

Cancer Index Subcommittee Objectives

•Update and expand the Cancer Index

•Develop a collaborative project aimed at improving cancer outcomes for underserved patients using NMQF/SHC/ACS unique and substantial data assets

Cancer Prevalence Vary Geographically

Source data: Medicare Claims 2012

63

Lung Cancer Index

64

Lung Cancer and Blacks

65

Lung Cancer – A Closer Look

66

The Geography of Lung Cancer

In Medicare Fee for Service

Medicare Health Service Areas

68

In 2013 there were over 32,022 zip codes where Medicare fee for

service beneficiaries reside. 70% of these beneficiaries reside in

7,000 zip codes, and 70% of lung cancer beneficiaries reside in

7,000 zip codes.

In 6,809 zip codes, where 510,100 beneficiaries reside, there was

no treated cases of lung cancer in 2013.

In the remaining 25,213 zip codes, the median prevalence for

lung cancer was 1.1% and the median survival years was 1.5

from date of first treatment.

Lung Cancer Consumption Patterns

69

Medicare Fee For Service 2013

CLASSNumber of

Beneficaries

Median Years of

Survival from

First Diagnose

All Cause Cost

Percent of All

Cause Cost

by Class

Crisis Consumers 21,975 0.914 $2,773,026,463 27%

Heavy Consumers 134,685 0.851 $6,039,180,385 59%

Moderate Consumers 85,196 1.689 $1,180,208,838 12%

Light Consumers 43,871 3.288 $177,299,486 2%

Low Consumers 21,742 3.458 $25,645,653 0.3%

Total 307,469 $10,195,360,824

Survival Years by Race

70

Tenth Percentile Prevalence 2013

Race and

Ethnicity

Number of

Beneficaries

Ninety Percentile

Survival Years

Unknown 73 1.10

WNH 12,550 1.46

BNH 1,467 1.15

ANH 513 1.53

Other 910 1.23

Hispanic 430 0.88

Native American 37 1.02

15,980

Ninety Percentile Prevalence 2013

Race and

Ethnicity

Number of

BeneficariesSurvival Years

Unknown 54 0.55

WNH 12,701 0.52

BNH 972 0.54

ANH 65 0.44

Other 63 0.57

Hispanic 39 0.42

Native American 37 0.74

13,931

Community-BasedCollaborative Network Treating Lung Cancer

71

Risk Mitigation

Variations In Survival Years

By Zip Code as Much

as 452%

Cancer Working Group

• The mission of the Cancer Working Group is to ensure that the benefits of the Cancer Moonshot touches all communities, to make sure no community is left behind.

• As the moonshot shortens discovery times, the innovative cancer therapies that are developed will need to be efficacious and accessible to all Americans.

72

Thank you for your participation

Questions?

Contact Information: www.shcllc.info, jregnante@shcllc.info@SHC_Tweetswww.twitter.com/SHC_Tweets

Sustainable Healthy Communitieswww.linkedin.com/company/sustainablehealthycommunities