Moving Upstream: Health System Partnerships Addressing Social Determinants of Health through Community Wealth Building

doi:10.21203/rs.3.rs-2443976/v1

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Research Article

Moving Upstream: Health System Partnerships Addressing Social Determinants of Health through Community Wealth Building

https://doi.org/10.21203/rs.3.rs-2443976/v1

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Journal Publication

published 19 Sep, 2023

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Background

Health system interventions addressing social needs such as food and housing generally fail to impact the upstream wealth and power inequities underlying those needs. However, a small number of health systems have begun addressing these upstream inequities by partnering with community wealth building initiatives. These initiatives include community land trusts, resident-owned communities, and worker cooperatives, which provide local residents ownership and control over their housing and workplaces. While these partnerships represent a novel, upstream approach to the social determinants of health, no research has yet evaluated them.

Methods

To assess the current state and key aspects of health system-community wealth building partnerships, we conducted semi-structured interviews with thirty-eight key informants across ten partnerships identified through the Healthcare Anchor Network. To analyze the interviews, we used a two-stage coding process. First, we coded responses based on the phase of the intervention to which they corresponded. Then we assessed responses within each aspect for common themes and variation on salient topics.

Results

We identified themes across four phases of the partnerships – motivation, initiation, implementation, and evaluation. Partnerships were generally motivated by a combination of community needs, such as affordable housing and living wage jobs, and health system interests, such as workforce housing and supply chain resilience. Initiating projects required educating leadership and utilizing de-risking strategies to obtain health system buy-in as well as conducting a health system landscape analysis to identify both internal capacities and external partners. Implementation took various forms, with health systems providing financial capital in the form of grants and loans, social capital in the form of convening funders and other stakeholders, and/or capacity building support in the form of strategic planning or technical assistance resources. To evaluate projects, health systems used process and community-level metrics rather than metrics based on individual health outcomes or returns on investment. Based on best practices from each partnership phase, we provide a road map for health systems to develop effective community wealth building partnerships.

Conclusions

Our findings suggest community wealth building represents a promising and largely untapped approach for health systems to address the upstream causes of poor health.

social determinants of health

housing and health

community benefits

health and wealth

community economic development

A potential paradigm shift is quietly emerging in the way health systems address the social determinants of health. In the wake of the Affordable Care Act’s requirement of Community Health Needs Assessments for non-profit hospitals,(1) the growing role of value-based payments,(2) and a proliferation of evidence linking social needs to health, it is increasingly common for health systems to assess for social needs, offer referrals, and even provide patients direct food, housing, or job-training support.(3) While these interventions can provide crucial assistance for patients facing toxic exposures like housing or job insecurity, they do little to address the upstream wealth and power inequities underlying those insecurities. That is beginning to change.

A small number of health systems have begun incorporating community wealth building (CWB) strategies into their approaches to addressing the social determinants of health. Community wealth building is defined by The Democracy Collaborative – the organization that coined term in 2005 – as “an economic development model that transforms local economies based on communities having direct ownership and control of their assets.”(4) The CWB approach addresses housing and job insecurity in an upstream way by changing the ownership and control of land and businesses. Three increasingly popular models that embody this approach are community land trusts, resident-owned communities, and worker cooperatives.

Community land trusts (CLTs) are non-profit organizations that acquire housing and then sell it to low- and moderate-income households at an affordable price in exchange for a guarantee that the price will remain affordable upon resale.(5) The CLT board is democratically governed by residents of the CLT and other local stakeholders. The CLT model has been shown to provide permanent affordability and wealth-building for residents while preventing displacement.(6, 7) There are currently 225 land trusts in the US with approximately 12,000 units of housing.(8)

In a similar model, resident-owned communities (ROCs) are groups of mobile home owners who cooperatively purchase the land under their homes instead of paying rent to an outside owner.(9) Like CLTs, the ROC model promotes long-term affordability and stability for low- and moderate-income households.(10) There are currently 1,065 resident-owned communities in the US, representing 2.3% of all manufactured home communities.(10)

Worker cooperatives are businesses that are owned and democratically governed by their workers. Compared to traditional businesses in the same industries, employment at a worker-owned cooperative has been associated with improvements in wages, benefits, work conditions, job stability, and wealth-building opportunities.(11–13) There are approximately 900 worker cooperatives in the US employing about 10,000 workers.(14)

Health system partnerships with CWB organizations like CLTs, ROCs, and worker cooperatives have been reported in the gray literature but have not been systematically studied. This study aims to identify and assess health system partnerships with CWB initiatives to better understand key aspects of those partnerships and inform future collaborations.

We partnered with the Healthcare Anchor Network (HAN) – a nonprofit organization that facilitates a “national collaboration of 70 + leading healthcare systems building more inclusive and sustainable local economies”(15) – to identify and assess health system partnerships with CLTs, ROCs, and worker cooperatives. We employed a multiple case study approach to more deeply understand each partnership, while also identifying common themes and variation among partnerships.

We employed a two-level sampling strategy to select partnerships and participants within each partnership. First, we identified all relevant partnerships through HAN’s membership network and reviews of academic and gray literature. We included in the multiple case study all identified partnerships in which a health system funded, invested in, or purchased from a CLT, ROC, or worker cooperative. Second, within each partnership we identified key informants from both the health system and CWB organization involved in the partnership. We identified health system key informants through HAN’s network and community organization key informants either through snowball sampling from the health system informants or through the community organizations’ websites. In identifying key informants, we sought to speak with individuals most familiar with the partnership from its inception to the present and those who could offer a variety of perspectives to provide both a depth and breadth of information.

We conducted semi-structured interviews with the key informants that explored four domains of each partnership: motivation, initiation, implementation, and evaluation. For example, we assessed initiation by asking “walk me through the steps taken to start this project from the earliest stage.” Interviews were conducted in English over Zoom between October 2021 and April 2022.

Interview analysis consisted of a two-stage coding approach. First, we coded responses according to the four domains of the partnership. Then, we assessed the range of responses and common themes among responses within each domain.

Through our sampling approach we identified 10 relevant partnerships – 6 with CLTs, 1 with a ROC, and 3 with worker cooperatives. We conducted 29 interviews with a total of 38 respondents from a variety of roles and institutions. For every partnership, we interviewed at least one key informant from the health system and at least one key informant from the CWB organization partner, except for one CLT partnership for which we were unable to get a response from the health system. Table 1 summarizes the characteristics of the sample of partnerships and key informants.

We assessed themes within the four domains of the partnerships: motivation, initiation, implementation, and evaluation. We found that CLT and ROC partnerships shared many similarities across these domains, but worker cooperative partnerships often had unique aspects. Therefore, we report our findings for each domain separately for CLTs/ROCs and worker cooperatives.

Table 1

Key Informant Interview Respondent Sample by Category
Category	# Respondents
Total	38
Partnership Type
Community Land Trust (CLT)	24
Resident-Owned Community (ROC)	3
Worker Cooperative	11
Organizational Affiliation/Role
Health System Staff	21
Community Wealth Building Organization Staff	17
Region
Northeast/Mid-Atlantic	12
South	9
Midwest	13
West	2
National	2
^a“Community Wealth Building Organization” refers to a community land trust, resident-owned community, worker cooperative or organization directly supporting one of those entities

Motivation

CLT/ROC Partnerships

The motivation domain assessed health systems’ rationales for engaging in the partnership, the why of the partnership. Informants described motivations for the partnerships as deriving from both community needs and health system needs. Informants from every health system interviewed described housing unaffordability and/or gentrification-related displacement as primary motivators for the partnership. In several cases, Community Health Needs Assessments played an important role in identifying housing security as an investment priority.

In this context, health systems saw CLTs/ROCs as well-suited for addressing various aspects of housing insecurity. Several health systems were drawn to the permanent affordability created by the CLT/ROC model in contrast to time-limited rental subsidies or traditional homebuyer programs that only benefit the first purchaser. Health systems also saw the homeownership aspect of CLTs/ROCs as important for “turning neighborhoods around” while preventing displacement. Finally, some saw CLTs/ROCs as an important racial equity intervention, as several of the CLTs/ROCs primarily served minoritized communities disproportionately excluded from traditional homeownership.

In addition to community needs, health systems were also motivated by their own needs, what one respondent described as “enlightened self-interest.” One key health system need was preserving affordable housing for their own workforce, which was also facing displacement. While none of the ROC/CLT partnerships focused exclusively on workforce housing, several targeted areas where lower-income staff members lived. Another health system need was for good relationships with the local community. In some cases, CLT/ROC partnerships provided health systems the opportunity to demonstrate a commitment to respond to local problems like the housing affordability crisis.

Worker Cooperative Partnerships

Worker cooperative partnerships were also motivated by community needs and health system interests. High rates of poverty and the scarcity of stable, living wage jobs in local neighborhoods were key community factors motivating worker cooperative partnerships. Worker cooperatives not only provided living wage jobs but also wealth-building opportunities as worker-owners share the firms’ profits. Two of the worker cooperative partnerships also explicitly sought to address racial wealth inequity by focusing cooperative efforts in minoritized communities.

Worker cooperative partnerships also addressed health system needs. In some cases, cooperatives provided local, reliable, and environmentally sustainable services not otherwise available within the hospital’s supply chain, such as energy-efficient laundry services. Like CLT/ROC partnerships, worker cooperative partnerships also provided a means for the health system to strengthen its reputation in the community by channeling its purchasing power into local economic development and wealth-building.

Initiation

CLT/ROC Partnerships

The initiation domain assessed the ways in which health systems started the partnership, the how of the partnership. Responses emphasized two major aspects of the initiation process: obtaining buy-in within the health system and identifying partners outside the health system.

Most CLT/ROC partnerships were initiated by the health system’s community health leadership who then sought buy-in from the executive and/or finance team. Two main strategies were used to obtain buy-in: education and de-risking. Because CLTs/ROCs are relatively uncommon, educational meetings were set up between CLTs/ROCs and health system leadership to explain the benefits of the models and answer any questions. The uniqueness of the CLT/ROC models also raised concerns about risk, especially since most health systems did not know of any other health systems investing in CLTs/ROCs. One de-risking approach health systems took was making small, incremental investments and utilizing both grants and loans based on the community partner’s needs and capacity. Another de-risking approach was developing long-term relationships with CLT/ROC organizations, including having a health system representative on their board, to develop deeper trust and knowledge of their business operations.

In addition to obtaining internal buy-in, health system respondents also discussed the importance of identifying external partners. These included existing CLTs/ROCs, but also city and county housing departments, neighborhood associations, and technical assistance providers. Community Development Financial Institutions (CDFIs) – lenders with expertise in economic development investing – were noted to be particularly helpful financial intermediaries for the partnerships.

Worker Cooperative Partnerships

Worker cooperative partnership informants also emphasized the importance of internal buy-in and external partnerships for initiating the partnership. Several informants noted that while executive-level buy-in was ultimately necessary, buy-in from the health system’s middle managers who control spending decisions was most important.

As with CLT/ROC partnerships, they also sought this buy-in through education and de-risking strategies. In terms of education, informants from all three partnerships emphasized the crucial role visits with successful worker cooperatives played in getting buy-in, with one noting “a tour over two to three days is worth a year of talking.” For worker cooperative partnerships, de-risking strategies included having a health system representative on the cooperative advisory board and converting existing businesses into worker cooperatives rather than starting a new business. Finally, key external partners for worker cooperative partnerships included existing worker cooperatives, worker cooperative development entities, and technical assistance providers.

Implementation

CLT/ROC Partnerships

The implementation domain assessed the health system roles and resources involved in the partnership, the what of the partnership. In terms of financial resources, health systems used grants and/or impact investments to support CLTs/ROCs. Table 2 provides a general description of the resources provided within each partnership.

In terms of the overall roles health systems played in supporting CLTs/ROCs, a typology of three basic roles emerged among respondents. Health systems acting as contributors provided financial capital to the CLT/ROC in the form of grants or loans. All the health systems studied acted as contributors. In most cases, health systems were the first major financial contributors to the CLT/ROC, which one CLT representative described as “foundational for other investments.”

Some health systems also acted as conveners, using their social capital to bring together resources to support a CLT/ROC. One health system led a broad fundraising effort for a CLT while another connected a CLT with partners to apply for tax credit funding.

Finally, one health system focused primarily on their role as a capacity builder, providing technical assistance, strategic planning resources, and other supports to help a CLT develop. This role can be especially important with a new or developing CLT.

Worker Cooperative Partnerships

Health systems supported worker cooperative partnerships primarily through purchasing from the worker cooperative and also through grants aimed at cooperative capacity-building. Partnerships took one of two approaches to supporting worker cooperatives. Two health systems took outside-in approaches, which focused on bringing existing worker cooperatives into their supply chains. One health system took an inside-out approach, which focused on identifying businesses in its current supply chain to convert into worker-owned cooperatives. This health system helped fund two organizations with expertise in cooperative conversions to identify businesses interested in converting and support them through the conversion process.

Table 2

Characteristics of Community Wealth-Building Partnerships
Partnership	Investment Type	Role/Approach^a
Community Land Trusts (CLTs)
Bon Secours Richmond Health System – Maggie Walker Community Land Trust Richmond, Virginia	Grant Impact Investment	Contributor Convener
Bon Secours St. Francis Health System – Sterling Land Trust Greenville, South Carolina	Grant Strategic Planning Support Technical assistance	Contributor Capacity-Builder
Mayo Clinic – First Homes Community Land Trust Greater Rochester Area, Minnesota	Grant	Contributor
Nationwide Children’s Hospital – Central Ohio Community Land Trust Columbus, Ohio	Grant	Contributor Convener
Saint Alphonsus Health System – LEAP Housing Boise, Idaho	Grant	Contributor Convener
UMass Memorial Medical Center – Worcester Common Ground Worcester, Massachusetts	Impact Investment	Contributor
Resident-Owned Communities (ROCs)
Dartmouth Health – ROC-NH Sites across New Hampshire	Impact Investment	Contributor
Worker Cooperatives
Baystate Health – Wellspring Cooperative Springfield, Massachusetts	Grant Purchasing Contract	Outside-in
Cleveland Clinic & University Hospitals – Evergreen Cooperatives Cleveland, Ohio	Grant Purchasing Contract	Outside-in
Kaiser Permanente – Obran & Project Equity National	Grant Purchasing Contract	Inside-out
^aContributors provide support through financial capital (grants, impact investments, or purchasing contracts)

Conveners provide support through social capital (fundraising assistance, networking support, etc.)

Capacity-builders provide targeted assistance to develop the ROC/CLT entity

Outside-in refers to health systems bringing outside worker cooperatives into their supply chain

Inside-out refers to health systems helping convert existing suppliers into worker cooperatives

Evaluation

CLT/ROC Partnerships

The evaluation domain assessed the outcomes of the partnership, answering the what impact question regarding the partnership. While respondents referenced the established health benefits of housing stability, affordability, and wealth-building as important impacts of the partnerships, they also noted that capturing these impacts through return-on-investment (ROI) calculations or health outcome metrics would be challenging for two reasons. First, the impacts of wealth-building and neighborhood stability can take years or even decades to be fully realized, limiting the utility of shorter-term assessments. Second, many of the benefits of the CLT/ROC may go to people who are not health system patients or may improve patients’ health and well-being in ways that don’t primarily impact healthcare utilization. One respondent contrasted the broad impacts of CLT investments with “surgical investments” aimed at reducing asthma emergency room admissions through interventions like mold abatement, which can show a positive return on investment. While acknowledging the value of both approaches, he stated “we’re not approaching this from an ROI perspective. We’re doing neighborhood change.”

Rather than relying on health outcome measures, informants described the use of process measures to assess whether health-enhancing neighborhood changes were occurring. These include the scale of the project (e.g. number of CLT/ROC units), affordability (e.g. median home price, income of residents), neighborhood metrics (e.g. neighborhood vacancy rates), and wealth-building (e.g. net equity for sellers). Some partnerships are also tracking racial equity measures, including the racial demographics of the CLT/ROC and of the surrounding neighborhood. One health system reported a longer-term approach by measuring changes in the social vulnerability index over the next five to ten years in neighborhoods with CLTs and other health system investments.

Worker Cooperative Partnerships

Worker cooperative partnerships noted similar impact measurement limitations and also focused primarily on health-associated process measures. Those include scale (e.g. number of cooperatives and cooperative members), compensation (e.g. wages and benefits), wealth-building (e.g. dividends from cooperatives), and racial equity (e.g. racial demographics of cooperative members).

One notable aspect of the partnerships studied is that almost all of them developed their models de novo. Almost none of the CLT/ROC partnerships were aware of the others and while later worker cooperative partnerships knew of the earlier ones, the contexts and approaches were sufficiently different to require navigating relatively unchartered territory.

A systematic assessment of CLT/ROC and worker cooperative partnerships provides what none of these partnerships had: a roadmap. This section describes key aspects of the roadmap (summarized in Fig. 1), derived from the insights of partnership participants and adapted for the current context.

Motivation

Changes wrought by the COVID pandemic have created additional motivations for health systems to partner with CWB initiatives. Skyrocketing housing prices have made both homeownership and renting increasingly unaffordable across the country, and the expiration of eviction and foreclosure moratoria have left millions vulnerable to displacement.(16) COVID also exposed the vulnerability of health system supply chains, highlighting the need for more local and reliable suppliers.(17)

This new context requires a re-evaluation of the community’s evolving needs and an evaluation of where community and health system needs align to identify win-win solutions. As several interviewees noted, the Community Health Needs Assessments required of all non-profit health systems provided a key tool for identifying priority areas for community partnerships. Data collected by health systems on patients’ social needs can also help target areas of greatest need.

Overall, COVID-related changes have created potential win-wins for health system partnerships with CLTs/ROCs and worker cooperatives. The permanent affordability and stability of CLTs/ROCs provide a unique remedy to the rampant displacement impacting not only health systems’ patients but also their staff. In addition, health system partnerships with worker cooperatives can increase local supply chain resilience while also supporting community economic development and individual wealth building.

Initiation

The past several years have also witnessed a proliferation of CWB models and growing evidence of their impacts. The number of worker cooperatives in the US grew 30% between 2019 and 2021,(14) while ROC USA – the largest national network of resident-owned communities – has more than doubled in size over the past decade.(10) Several recent analyses have further elaborated the economic benefits associated with these models.(6, 18–21) For health systems, this means the initiation phase is now supported by a broader network of potential partners and a deeper pool of accumulated experience.

These new resources support the crucial initiation tasks of obtaining health system buy-in and conducting a landscape analysis that identifies internal capacities and external partners. As emphasized in the interviews, securing health system buy-in requires both education and de-risking. The growth in CWB models has made it easier to conduct site visits and meet with CWB organizations that fit the health system’s priorities and context. Health systems can de-risk their investments by offering incremental investments that include both grants and loans and by participating in the boards of CWB organizations, a practice well-established among the existing partnerships.

An effective initiation phase also requires health systems to conduct a landscape analysis that takes stock of their internal resources and external partners. Internal resources include grants, loans, and purchasing contracts that could potentially be used to support a CWB partnership. Key external partners include CWB organizations and support organizations such as community development financial institutions, workforce developers, and technical assistance providers.

Implementation

Because the partnerships interviewed were diverse in their locations and approaches, there are now several established paths health systems can choose based on their internal capacities and external partners. Based on their landscape analysis, health systems can consider to what extent to play a contributor, convener, or capacity-builder role with CLTs/ROCs. For CLTs ready to purchase properties, being a contributor as a first investor could play a catalytic role in bringing other funders to the table. The health system could also play a convening role by promoting CLTs/ROCs as a strategy among local housing providers and funders. If there are no established CLTs/ROCs locally, the health system can play a capacity-building role by contributing grant funds for a feasibility study or strategic planning for a potential CLT/ROC host organization.

Health systems can also use their landscape analysis to determine whether to pursue a worker cooperative partnership strategy that is outside-in or inside-out. They can take an outside-in approach by providing a purchasing contract to a new or established cooperative. Interviewees noted the crucial role that health system purchasing contracts can play in developing new worker cooperatives, which can also increase the resilience of the system’s local supply chain. Alternatively, health systems can pursue an inside-out strategy where they identify their existing suppliers who may be interested in retiring and/or selling their business to their workers as a worker cooperative. This approach may be preferable in areas where there is already a satisfactory supplier interested in converting to a worker cooperative.

Evaluation

Metrics to assess the impacts of economic development interventions are increasingly being developed and can be useful for evaluating CLT, ROC, and worker cooperative partnerships.(22) These metrics vary based on the time horizon (short-term vs long-term) and their scope of analysis (individual vs community vs equity). Short-term outcome metrics include individual measures of wealth building, wages, and benefits; community measures of vacancy, homeownership, and employment rates; and equity measures assessing the race, class, and gender make-up of CWB program participants and local neighborhoods. Long-term outcome metrics include individual measures of wealth-building, job stability, and housing stability; community measures of changes in social vulnerability of impacted neighborhoods; and equity measures that assess changes in neighborhood and CWB program demographics. While these metrics cannot completely isolate program effects from other factors influencing outcomes, they provide a more comprehensive picture of the partnerships’ impacts across time and population that can guide future program design.

Limitations and Directions for Future Research

This analysis has several limitations. Our sample did not include CWB partnerships that were attempted but did not lead to health system investments, and there are likely important lessons to learn from these unsuccessful attempts not captured in our analysis. Also, given that our interviewees were often reporting about past events, their responses may be subject to recall bias. In addition, many of the programs had not yet begun the evaluation phase, especially around long-term outcomes, so their responses in this area may be more reflective of plans and aspirations than actual practice. Finally, while the health systems interviewed represent significant diversity in terms of geography, community demographics, and partner landscape, it is unclear the extent to which these findings can be generalized to settings such as for-profit health systems or small community hospitals. Additional studies including unsuccessful partnerships, data collection concurrent with each stage of the partnership, evaluation outcome data, or for-profit and small community hospitals could help provide a clearer picture of the challenges, impacts, and applicability of these types of partnerships.

Public Health Implications

Community wealth building strategies like CLTs, ROCs, and worker cooperatives provide health systems an opportunity to transform their housing investments and purchasing practices in ways that have impact further upstream – promoting housing and job security in their communities. One-off housing or income supports, while important, cannot do this.

Importantly, the benefits of these models aren’t limited to the CLT/ROC residents or the worker cooperative members alone. By building wealth and stability, these models promote economic resilience among entire communities and prevent displacement. For example, foreclosures produce well-documented harms to neighborhoods and community health,(23) and CLTs have been shown to reduce foreclosures by as much as 90%.(7) Beyond protection from foreclosures, CLTs have also been shown to reduce gentrification-related displacement at the neighborhood level.(20) Similarly, worker cooperatives provide stable employment and local spending that can promote broader community economic development.(24) Regions with a high density of worker cooperatives have been especially resilient to recessions, laying off less than one percent of their workforce while comparable regions experienced mass layoffs during the Great Recession.(25) Given their participant- and community-level impacts, scaling up these CWB models could have immense public health benefits.

It is important to note that scaling up these models is not solely or even primarily the work of health systems. Other private and public sector institutions have major roles to play. But the case studies above suggest two important aspects of health systems’ role in supporting CWB models.

First, health systems are uniquely situated to pilot and grow early versions of these models. Health systems are major economic engines purchasing over $340 billion in goods and services yearly and investing over $500 billion(26), while being located in some of the most disinvested urban and rural communities in the country.(27) Their own housing and supply chain needs means they have some incentive to contribute to these CWB efforts, even if there is not a direct return on investment.

Second, the cases above suggest these models do not displace additional investment but call it forward. Health systems are understandably concerned that investments in social determinants of health will lead public entities and other funders to withdraw from those sectors. However, CWB partnerships have had the opposite effect. Rather than displacing public investment, CLTs/ROCs and worker cooperatives attract it by increasing its impact. Municipalities are willing to invest in a worker cooperative laundry facility if health systems have agreed to buy from them.(28, 29) Cities and counties are willing to transfer housing funds and abandoned properties to established CLTs because they have shown that they can provide stable, quality housing for low- and moderate-income residents(30, 31)

Health systems have a unique capacity and interest in pioneering these community wealth building models in their local contexts. CLTs, ROCs, and worker cooperatives not only provide immediate housing and jobs but also reduce housing and job insecurity in the long-term. At scale, they have the capacity to fundamentally improve not just the health of their participants but of entire communities. Community wealth building represents a new paradigm of upstream health system approaches to the social determinants of health. The cases presented point to a diversity of paths to pursue this transformative approach.

CDFI

community development financial institution

CLT

community land trust

CWB

community wealth building

HAN

Healthcare Anchor Network

ROC

resident-owned community

ROI

return on investment

Ethics approval and consent to participate: All methods were carried out in accordance with relevant guidelines and regulations. As this study was part of a quality improvement project as defined by the UCLA Institutional Review Board (IRB), it was exempt from IRB review and official approval was not required. All study participants provided informed consent to participate.

Consent for publication: Not applicable

Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: Geoffrey M. Gusoff received fellowship funding from the Los Angeles County Department of Health Services. The Department of Health Services played no role in the study design, manuscript writing, or data collection, analysis, or interpretation.

Authors’ Contributions: GG led the conceptualization of the study, conducted the key informant interviews, and wrote the first draft of the article. GR provided oversight for the investigation, methodological support, and substantive editorial feedback. DZ and BP contributed to the conceptualization of the study and key informant interviews and provided substantive editorial feedback. All authors read and approved the final manuscript.

Acknowledgements: The authors would like to thank the key informants from the health systems and community organizations who shared their insights about health system-community wealth building partnerships.

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No competing interests reported.

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15 Jun, 2023
Editor invited by journal
03 Feb, 2023
Submission checks completed at journal
03 Feb, 2023
First submitted to journal
04 Jan, 2023

You are reading this latest preprint version

Moving Upstream: Health System Partnerships Addressing Social Determinants of Health through Community Wealth Building

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Results

Motivation

CLT/ROC Partnerships

Worker Cooperative Partnerships

Initiation

CLT/ROC Partnerships

Worker Cooperative Partnerships

Implementation

CLT/ROC Partnerships

Worker Cooperative Partnerships

Evaluation

CLT/ROC Partnerships

Worker Cooperative Partnerships

Discussion

Motivation

Initiation

Implementation

Evaluation

Limitations and Directions for Future Research

Public Health Implications

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1