August 24, 2019
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Decades-long Franklin County health initiative praised in national medical journal

FARMINGTON, Maine — Forty years ago, the concept that the health of an entire community could be improved if everyone worked together for their shared benefit was launched by a handful of doctors and nurses at Franklin Memorial Hospital.

That concept is earning high praise from the Journal of the American Medical Association, along with the Journal of the American Medical Association’s recommendation that the accomplishments in Franklin County deserve international study.

In the 1970s, recognizing that low-income residents were not getting the health care they needed, Dr. Burgess Record and his wife, Sandra Record, R.N., solicited the help of co-workers and volunteers who teamed up and went to churches, town halls, schools and businesses to talk to people about high blood pressure and do health screenings, combining social outreach and individual medical care.

At the suggestion of Dr. David Dixon of Franklin Memorial Hospital, they tracked their efforts and patient outcomes and have since proven this community-based health care model works to help prevent chronic disease.

According to their data, this team approach reduces hospitalizations, reduces deaths, increases quit-smoking rates, improves the lives of people suffering from chronic diseases and increases workplace productivity.

The community-based health care model — The Franklin Model — is the subject of what is being called a tremendously important Journal of the American Medical Association study titled “ Community-Wide Cardiovascular Disease Prevention Programs and Health Outcomes in a Rural County 1970-2010.”

The study was released Tuesday.

Included in the Journal of the American Medical Association report is an editorial recommending the Franklin approach be studied for possible replication in rural areas of the United States and other parts of the world.

In fact, Franklin Memorial Hospital Chief Operating Officer Gerald Cayer, one of 10 study co-authors, said the proof of improved health under the Franklin approach is so clear and the process so well-documented in the Journal of the American Medical Association study that it supports the idea “that this approach is replicable and may be a piece of the surprising solution for fixing our health care system.”

At a news conference announcing details of the Journal of the American Medical Association study Tuesday at Franklin Memorial Hospital, Dixon said the idea of teams reaching out to their neighbors to improve health care seemed straightforward and attainable in the 1970s, but “it was a deceptively difficult task” to document the work and prove that their approach works. And in the early years, not everyone in the county supported their efforts.

Less comprehensive efforts in other communities failed, including in Minnesota and Rhode Island, but Dixon attributes the success in Franklin County to its community base.

Dr. Daniel Onion of the Maine-Dartmouth Family Medicine Residency and another co-author of the Journal of the American Medical Association study said he moved to Franklin County “in the 1970s with a 1960s zeal to help the community.”

That zeal propelled, Dixon, Onion, the Records, Dr. Roderick Prior and Fenwick Fowler of Western Maine Community Action, among others, to come up with a plan to improve access and document patient outcomes. They describe it as a frugal, efficient and effective plan.

Due in great part to a federal grant, Franklin Memorial Hospital increased staff and established three satellite clinics, creating a nurse-directed communitywide effort to reach people where they shopped, worked, worshipped and their children attended school.

After years of continued outreach, including finding and reaching out to patients who didn’t attend appointments, Prior said the result was that Franklin County started to produce good health statistics, better than elsewhere in Maine. That is despite its low-income population, which is generally a statistical indicator of poor health.

In time, and after then-Gov. Angus King and then-Public Health Director Dr. Dora Anne Mills designated tobacco settlement funds for quit-smoking programs, the quit-smoking rate in Franklin County was higher than anywhere in Maine and higher than the U.S. average. The hospitalization and mortality rates for those living in Franklin County were lower than in Maine and elsewhere in the country, and those successes have since continued.

According to Onion, health care workers and volunteers “created peer support for a community culture change,” demonstrating that, by working together, “low-income counties may not be doomed to low health outcomes.”

Angus King, a U.S. senator, joined the news conference by video and said the Journal of the American Medical Association study “is a big deal. This is a big national deal. It verifies what some of us have known for years,” and that is “community health can be improved.”

King’s wife, Mary Herman, joined him in the videoconference. A nurse, she praised the study participants for their work and said her favorite part of the Franklin story was how volunteers worked in the community among their friends and neighbors “to bring about behavioral changes.”

King, who said he hoped other communities will look to the Franklin model to improve their health, said he has faith it can be done if people remain committed.

“This is a national model that can be replicated and can save money,” King said, a combination “that is a good thing for Maine, for Franklin County, but really for the entire United States.”

He called the Franklin results “an important direction for health care.”

Franklin’s success, according to Sandra Record, was to go where people are rather than expect everyone, particularly those who don’t have insurance or can’t pay for health care, to seek medical attention.

“We go to where the people are, was our motto,” she said, including outreach at the University of Maine at Farmington, five school districts and 60 community and civic groups across Franklin County. And in an effort to lead by example, Franklin Memorial Hospital became the first smoke-free hospital in Maine.

Dr. Thomas Pearson, executive vice president for research and education at the University of Florida Health Services Center and a co-author of the Journal of the American Medical Association study, called the 40-year commitment in Franklin County “just amazing.” He described it as a group of people “who decided to do the right thing and then stuck with it.”

He predicted more communities would see programs develop as part of mandated outreach under the Affordable Care Act, but in Franklin County, the work was done because it “was the right thing to do, and not because the government forced them to do. And that’s really special,” Pearson said.

The community’s shared work to change its behaviors “is really a model for the nation, and bully to you” for proving it works, he said.

Asked what others could do to replicate the Franklin model, Prior said people should bring together “the social forces that exist in your communities” among schools, businesses, government and social services, and then “look at your problems and figure out what you might do about it, recognizing you’ll need persistence, so plan for the long term.”

The Journal of the American Medical Association study doesn’t include much information on who or how many others have adopted a team approach similar to Franklin, but Pearson pointed out that the National Action Plan of chronic disease prevention adopted by the U.S. Centers for Disease Control and Prevention was “built on the broad shoulders of Franklin County.”

“The lesson in Franklin County,” he said, “is there’s proof that with relatively small resources, a poor community can do this. Others can do this.”

Prior and Onion said they believe the Franklin model, which centered on prevention and tracking cardiovascular disease, is a model that can be used to battle other diseases, perhaps even cancer.

Cayer called it “an honor” to work with the study authors, of whom nine of the 10 are from Franklin County and formulated the Franklin model. He said the work reflected in the Journal of the American Medical Association study “demonstrates the ingenuity of good common sense, blended with collaborative community health approaches, and the sciences of public health and medicine coming together to support individuals and their communities in achieving optimum health, despite social and economic barriers.”

Although the Journal of the American Medical Association recommends further study to implement Franklin-like programs, there is no mechanism to force that change. Instead, the study authors hope the international exposure of their success will be enough encouragement for others to follow in their path.

To read the Journal of the American Medical Association study, visit jama.jamanetwork.com.



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