Public Lands, Public Health Exhibition Trail

October 16, 2018

Dr. Richard Zarr, Founder of Park Rx America, gets in the spirit during the Public Lands, Public Health Exhibition Trail walk

On Tuesday, October 16, at 10 a.m., on the opening day of The 2018 SHIFT Festival, a guided walk of a “Public Lands, Public Health Exhibition Trail” was held to highlight successful public lands/public health trail models. Land managers from various agencies and health care professionals who are currently prescribing or are interested in prescribing time outside in nature were invited to attend.

The walk proceeded from May Park, a municipal park in Jackson, WY, to the top of Nelson Knoll on Bridger Teton National Forest land. Along the way, the walk:

  • Showcased attributes of successful public lands/public health trail models
  • Identified opportunities to expand public lands/public health trail collaborations into replicable models for communities nationwide
  • Provided the federal land managers who were meeting at SHIFT ideas and opportunities for integrating optimal trail attributes into their work
    • This included the USFS Region 4 Planning meeting, which took place during SHIFT, as well as a Public Land Manager’s Meeting that was held on Thursday, Oct. 18, at 2 p.m.

The walk was led by Farjana Islam, a participant in the 2018 Emerging Leaders Program and the Health and Nature Navigator Program Coordinator for the USDA Forest Service. Islam is developing a pilot program with the United States Forest Service to connect national forests with health care providers in communities around the country.

SHIFT organizers developed the trail with Jodie Pond, Teton County Health Department Director, and Linda Merigliano, Bridger Teton National Forest Recreation Manager.

Presenters included:

  • Jason Urroz, Director, Blue Ridge Parkway Foundation (2018 SHIFT Awards Official Selection)
  • Dr. Stephen Bannar, Medical Liaison, Barton Health/Lake Tahoe Basin Management Unit (2018 SHIFT Awards Official Selection)
  • Dr. Richard Zarr, Founder, Park Rx America (2018 SHIFT Awards Official Selection)
  • Dr. David Sabgir, Founder, Walk with a Doc (2018 SHIFT Awards Official Selection)
  • Dr. Nooshin Razani, Founder, SHINE Program at UCSF Benioff Children’s Hospital Oakland Hospital (2018 SHIFT Awards Official Selection)
  • Ryan Jenkins, Founder, Healthy Parks Healthy Person Tennessee (2018 SHIFT Awards Official Selection)
  • Mona Koh, Community Director, East Bay Regional Parks District (2018 SHIFT Awards Official Selection)
  • Eva Garcia, City Planner, Brownsville, TX

An overview of highlighted initiatives is as follows: 

OrganizationBarton Health & the United States Forest Service
InitiativeWellness Outings: Prescribing Nature
LocationSouth Lake Tahoe, CA
Year Founded2016
LeadershipStephen Bannar, MD
Khristy Gavigan, RN
Joseph Flower, Wildllife Biologist, USFS

Initiative Overview

In 2016, Barton Health, a not-for-profit health care facility, partnered with Lake Tahoe Basin Management Unit, South Lake Tahoe’s local United States Forest Service (USFS) branch, to host cooperative Wellness Outings: guided walks that promote nature as medicine by teaming patients with a U.S. Forest Service ranger and physicians or nurses from Barton Health for guided outings in the national forest. In South Lake Tahoe, CA, a town of less than 22,000 people, hundreds have participated in the Wellness Walks, including the general public and target audiences such as the chronically ill, those recovering from surgery, and at-risk youth.

People are spending less time out in nature despite the significant health benefits nature provides. Patients suffering from physical and emotional ailments are at the highest risk to not go outdoors and enjoy nature despite being the population who could benefit the most from nature’s healing effects. The barrier for most patients is not knowing where to go or not feeling safe going out to explore. The partnership between Barton Health and the USFS provides this at-risk population with guided outings in nature with the safety net of healthcare providers accompanying them.

Impact

The comprehensive program includes options for people with chronic or terminal illness, patients recovering from surgery, and at-risk youth. Research indicates that time in nature lowers blood pressure, heart rate, and cortisol levels; it increases concentration, memory, and attention spans; it has been shown to boost immunity and is particularly beneficial for at-risk populations, such as those recovering from surgery, who often spend less time outside. This partnership is improving community health, one walk at a time.

Objective Measurements for Impact of Nature on Health

  • Lowers the stress hormones cortisol and adrenaline
  • Suppresses the sympathetic, or “fight/flight,” system
  • Enhances the parasympathetic, or “rest and recover,” system
  • Lowers blood pressure and increased heart rate variability
  • Immune Function after 3 days, 2 nights in the forest:
    • Natural killer cell numbers increased by 50%; NK cell activity increased 53%
    • Anticancer proteins granulysin, granzyme, and perforin increased 28-48%
    • Increase lasted for 30 days

Innovation

There is a direct connection between community wellness and ecosystem health. USFS provides the interpretive piece supporting logistics and identifies appropriate outings and Barton Health provides the medical support to share the healing power of nature with patients to promote the improved well-being of the community.

Replicability

With the model established between Barton Health and the USFS, this can be replicated with healthcare systems throughout the country to promote wellness. The partnership between healthcare systems and land management promotes a shift from healthcare just treating illness to now promoting wellness. 

Biggest Challenge to Advancing This Work

The biggest challenge is the shift in our culture from pharmaceutical prescriptions to a prescription for nature. In order for this program to be successful on a large scale, healthcare systems around the country have to be on board to promote wellness in their patients and create healthier communities.

OrganizationBlue Ridge Parkway Foundation
InitiativeKids in Parks
LocationAsheville, NC
Year Founded2017
LeadershipOlson Huff, MD, Program Founder, Board Member
Brad Wilson, Board Member
CAPT. Chuck Higgins, Board Member

Initiative Overview

People have become increasingly disengaged with nature, spending less time outdoors and more time interacting with electronic media. These lifestyle trends have devastating impacts on the health of our nation’s young people and our parks and public lands.

Jason Urroz, Director of Blue Ridge Parkway Foundation’s Kids in Parks program

Kids in Parks is addressing these issues through the expansion of its national network of self-guided hiking trails, called TRACK Trails, that promote park use and health to kids and families. Through the program’s TRACK Rx initiative, more than 100 doctor offices and hospital systems are prescribing outdoor recreation and TRACK Trails to patients, linking healthy lifestyles with spending time in nature.

Impact

The Kids in Parks program uses self-guided materials to reduce pressure on park staff, crosses agency boundaries to create a network of opportunities for kids and families to get outdoors, and incentivizes participation, all while capturing vital data. Observational studies, in collaboration with registration data, suggests that 450,000 kids have hiked 450,000 miles, spending nearly 225,000 hours outdoors, and burning more than 60 million calories on TRACK Trails since the program’s inception in 2009.

Impact by the numbers

  • 170+ TRACK Trails in 10 states
  • 100+ doctor offices, with 500+ prescribing providers
  • 53% had never been to the park before
  • 54% intentional visits
  • 47% return rate, with 88% visiting more than one TRACK Trail location

Innovation

The Kids in Parks TRACK Rx initiative is new and innovative in two ways: (a) the utilization of  individualized serial numbers to capture data when patients fulfill their TRACK Rx prescriptions and (b) its ability to provide immediate feedback to their enrolled providers regarding patient fulfillment.

Replicability

Kids in Parks installed their first TRACK Trail in 2009. Today—due to the replicability of the program’s design—there are more than 170 trails in 10 states and Washington, D.C. The program’s TRACK Rx materials are equally replicable, with 80 new practices joining their network of providers in 2018. 

Biggest Challenge to Advancing This Work

Balancing the rapid expansion of the program while simultaneously maintaining relevance with our current park partners and healthcare providers is a challenge, especially given turnover rates and rotating park staff nationally.

OrganizationUCSF Benioff Children’s Hospital Oakland
InitiativeCenter for Nature and Health
LocationOakland, CA
Year Founded2016
LeadershipNooshin Razani, MD MPH, Director, Center for Nature and Health
Morgan Green, MD
Jennifer Matthews, MD

Initiative Overview

Home to one of the first park prescription programs in the nation, and the first to receive insurance reimbursements for their park prescription program, UCSF Benioff Children’s Hospitals have spearheaded a therapeutic revolution in pediatric health care. We conduct original research relating to nature and health, provide clinical care in nature, and train health care providers as thought leaders in the field. We improve health equity through access to nature for health and well-being by creating opportunities for Bay Area children to spend time outdoors. We also advance the science of nature and health, disseminate best practices, and advocate for nature as a human right.

Doctors Morgan Green and Nooshin Razani accept the SHIFT Award for Clinical Research

Impact

CNH conducted and published the first ever randomized trial of a park prescription program; created the first billable nature clinic in the country; and are the first medical residency program to integrate nature into doctors’ training.

Impact by the numbers:

  • Four peer-reviewed publications, seven abstracts
  • 64 nature outings conducted to date
  • ca. 2,000 park visits for patients and families
  • Improved stress in parents, resilience in children
  • Billable clinic following health outcomes in patients
  • CNH team of five MDs
  • 81 doctors in training

Innovation

Through numerous national and international events, we have advocated for the importance of gathering an evidence-base for nature as important to clinical medicine. With one trial completed, we now have 2 more trial results in process for publication, and will be starting a systematic review and qualitative study this fall. Measuring the health impacts of a nature prescription program required interdisciplinary and imaginative collaborations in order to know what to measure. We worked with UC Berkeley Master’s students to identify that stress relief in parents and resilience in children were the outcomes that were of importance to the famlies we serve. While the national dialogue focused on physical activity for park prescriptions, we knew that for the families we serve, physical activity would be a piece of the prescription, but not necessarily the motivator in getting outside. We also created the first clinical scripts on how to talk to patients about nature and health, and evaluated them in our clinical trial; and we are the first program to create tools for what to measure and how to follow patients in an actual billable clinic.

Replicability

Through our peer reviewed publications, others can build on our work of establishing an evidence-base for the role of nature in clilnical care. Our emphasis on research is to ensure that an evidence trail is collected as this nature and health movement gains traction. The randomized trial is the language of the medical world and quality research is what will help move medical professional societies (such as the American Medical Association) as well as insurance agencies to reproducing nature and health programs.

Biggest Challenge to Advancing This Work

Articulating the difference between our public health and clinical missions. Being focused and effective in the clinical message. What are we treating, how are we treating it, how are we measuring that, and how are we billing for that service.

OrganizationEast Bay Regional Park District
InitiativePark Rx and SHINE Program
LocationSan Francisco Bay Area, CA
Year Founded1934
LeadershipMona Koh, Community Relations Manager
Carol Johnson, Assistant General Manager, Public Affairs
Dr. Nooshin Razani, Director, Center for Nature and Health

Initiative Overview

To improve health outcomes in two of the largest counties in CA with 2.7 million residents, EBRPD has integrated community health into its parklands. We’ve collaborated with 15 health clinics and 80 multicultural community organizations to educate, motivate, and prescribe nature to under-resourced patients/members to walk in our parks. We’ve partnered with 15 school districts in our Kids Healthy Outdoors Challenge program by providing transportation and curriculum books. Annually, 4,000 third grade students and their teachers visit our parks for Nature Study and a healthy outdoor experience. Our signature self-guided Trails Challenge program brings 10,000 people annually to hike our regional trails. 

Mona Koh, Community Relations Manager for East Bay Regional Park District, discusses elements of EBRPD’s programming

Impact

EBRPD’s mission to connect health and nature in public lands has benefited thousands of children and adults who historically have underutilized parks. By participating in our wellness walks and outdoor programs, they have increased their physical activity and social connection while reducing mental and emotional stress. EBRPD’s 2017 Economic Impact Analysis concluded that we contribute a range of benefits totaling $500M annually to the local economy, including $20M towards healthcare cost savings through presence of parks, trails, walks and programs.

Impact by the numbers

  • Park Rx and SHINE: 5 years, 3,000 participants/year
  • Kids Healthy Outdoors Challenge: 7 years, 4,000 students/year
  • Trails Challenge: 25 years, 10,000 participants/year
  • EBRPD park system comprises 121,397 acres in 73 parks with 1,250 miles of trails in Alameda and Contra Costa counties

Innovation

In 2014, EBRPD and UCSF Benioff Children’s Hospital Oakland (UBCHO) launched the SHINE (Stay Healthy in Nature Everyday) program to bring their underserved patients with chronic illnesses to our parks for health intervention. Every month, EBRPD provides staff, transportation, healthy snacks and a day of outdoor activities for the children and families. The first randomized clinical study on health and nature, conducted by UBCHO in 2015, determined that cortisol levels and feeling of loneliness decreased by 28% and 20% respectively for SHINE participants. Over100 physicians in UBCHO now prescribe SHINE, and new doctors receive training modules and toolkits. EPRPD has also installed park posters throughout the clinic to connect patients to nature.

Replicability

The UBCHO study and mounting scientific evidence substantiate that time spent in nature has measurable physical and mental health benefits. The SHINE program – an integration of nature into the medical care system – is replicable. This interdisciplinary intervention between parks and health clinics increases patients’ access to nature; provides consistent programming to serve patients’ health needs; and informs park administrators about public healthcare priorities.

Biggest Challenge to Advancing This Work

Establishing Park Rx/SHINE partnerships with more diverse health clinics and community groups, and supporting them to lead walking programs. Expanding training for healthcare providers on the benefits of nature; developing evaluation instruments and toolkits. Enabling physicians to bill Park Rx trips to insurance carriers.

OrganizationTennessee State Parks
InitiativeHealthy Parks Healthy Person TN
LocationChapel Hill, TN
Year Founded2016
LeadershipRyan Jenkins, Park Manager/Henry Horton State Park
Greg Wiley, User Experience Developer

Initiative Overview

The Healthy Parks Healthy Person TN app was created as a way to get more people outdoors and improving their health by incentivizing their efforts. Tennessee ranks among the lowest five healthy states in the country in physical and mental health statistics. Tennessee is also filled with an abundance of free public natural resources available to its citizens. This resource of nature has been proven to have a positive effect on health. As the evidence for lifestyle based treatment grows in the medical community, the need to get more people into nature remains. App users earn points and rewards for getting outside into any park in Tennessee; National, State, County, or City.  Healthcare providers are also writing park prescriptions for the program.

Ryan Jenkins explains the Healthy Parks Healthy Person TN app during the Exhibition Trail walk.

Impact

The Healthy Parks Healthy Person TN app was created in 2016 with a goal of 600 users in the first year. Since then 3000 users have signed up for the program with an average weekly use of 900 activities logged. Now the program is being shared by National, State, County, and City parks as well as in healthcare facilities, private businesses, and communities throughout the entire state. The vision of Healthy Parks Healthy Person TN is to create positive change in Tennessee’s health outcomes while at the same time creating new stewards of Tennessee’s natural spaces. 

Impact by the numbers

  • 3,000 users
  • 127,688 activities logged in a park
  • Over 90 communities are sharing the program within their parks, private businesses, and government operations
  • Every Health Department in TN is mandated to participate in the Park Prescriptions program
  • 11 private hospital groups are sharing the program

Innovation

Healthy Parks Healthy Person TN brings together the many aspects that drive a person towards spending time in nature.  Healthcare providers write park prescriptions referring patients to the outdoors.  The app provides a technology connection and gamifies the experience by giving points.  The participant earns rewards with those points as an incentive to continue the action. 

Replicability

One of the visions for Healthy Parks Healthy Person TN is to create a framework that can be replicated in any fashion imagined.  Soon any state or healthcare provider that wishes may be able to utilize the app by simply inserting their logo and getting more people outdoors. 

Biggest Challenge to Advancing This Work

Currently the Healthy Parks Healthy Person app is the original proof of concept that has outlived its test phase.  This has become a challenge when it appears to be operating fully but is not providing the back end data we need to grow the program with healthcare providers and potential funding sources. 

OrganizationUAB Birmingham’s Minority Health & Health Disparities Research Center
InitiativeParks Rx: Your Prescription to Better Health
LocationBirmingham, AL
Year Founded2014
LeadershipDr. Mona Fouad, Principal Investigator
Dr. Mark Wilson, Co-Principal Investigator
Dr. Theresa Wallace, Program Director

Initiative Overview

Alabama ranks 6th in the nation in rates of physical activity (29.4%). In the city of Birmingham, 30% of adults self-report no leisure time for physical activity. Parks Rx was developed to connect patients to parks through a searchable online database. Parks Rx allows providers to prescribe outdoor physical activity to their patients. Currently, over 17,000 prescriptions have been written; the program has expanded beyond Birmingham city limits to Jefferson County; the population size served has nearly doubled from 212,157 to 447,364; and permanent Parks Rx signs have been installed in 95 parks.

Impact

Unplanned urban growth caused a disconnect between residential and recreational areas. To address this disconnect, the city maintains 130 parks and trails. Limited and unreliable public transportation makes these spaces inaccessible to low-income African-Americans. As a next step, Parks Rx will partner with REV Birmingham’s Zyp BikeShare (an affordable bike transportation system) to bridge this divide by installing bike kiosks in African-American neighborhoods using safe routes to park maps.

Impact by the numbers

  • 17,000 prescriptions written to date
  • Due to Parks Rx expansion from the city to the county level, the population size served has nearly doubled from 212,157 to 447,364

Innovation

Leveraging successful Parks Rx models, our transdisciplinary coalition integrated policy, systems and environmental strategies into our program by: 1) incorporating permanent Parks Rx signs in 95 parks; 2) offering physical activity programming in local parks; and 3) making Parks Rx part of a medical practice. 

Replicability

Our adult and pediatric Parks Rx prescriptions in English and Spanish are available for public use by downloading them from our website. There is also a place for interested parties to include their agency’s logo. Our program has been expanded to include a local pharmacy.

Biggest Challenge to Advancing This Work

Currently, we have no way of knowing the frequency, type, and duration of physical activity that patients engage in aside from self-reported responses. Due to the health insurance portability and accountability act (HIPAA), we are unable to ascertain individual health-related changes associated with Parks Rx. 

OrganizationPark Rx America
InitiativePark Prescription Formulary
LocationWashington, D.C.
Year Founded2017
LeadershipRobert Zarr, MD, Founder & Medical Director
John Henderson, Executive Director
Matthew Scribner, Chief Technology Officer

Initiative Overview

Americans are suffering and dying prematurely because of chronic disease that in turn results from poor diet, inactivity, and chronic stress. Despite 300 scientific studies linking improved health outcomes to time in Nature, most doctors are unaware of the relevance and accessibility of the park prescription. Doctors can and should prescribe parks. Brief interventions by doctors change patients’ behavior. Parks Rx American (“PRA”) has developed the first scalable doctor-friendly park prescription intervention by developing a unique digital platform for doctors to FIND green space, PRESCRIBE activity outside, and DOCUMENT the park prescription in any electronic health record.

Dr. Robert Zarr, Founder of Park Rx America, presents during SHIFT for the Planet

Impact

PRA improves a community’s health by educating and equipping doctors with the tools to reconnect patients to Nature and renormalize being outdoors. Access to green space is a social determinant of health. Unequal access to green space is a social injustice. PRA plays a vital role in leveling the playing field among communities by reconnecting all persons to their accessible green space, regardless of a person’s color or income.

Impact by the numbers

  • Number of prescribers: 105
  • Prescriptions issued: 707
  • Prescriptions filled: 20%
  • Total park visits recorded: 323
  • Parks in database: 4,200
  • States represented: 23

Innovation

Patients are more likely to go outside when their doctor actually prescribes it. PRA has developed a unique electronic interface that allows the doctor and patient to agree on which park to visit, but on the patient’s terms. This allows the doctor, real-time, to amplify the patient’s health promoting behavior.

Replicability

PRA has a proven record of expanding in geographically and demographically diverse areas, both rural and urban. We partner with local, regional, state, and federal land management agencies and all sizes of health provider organizations.

Biggest Challenge to Advancing This Work

The biggest obstacle is changing culture–societal norms of sedentary behavior, reliance on fast food, over-scheduling and checklists, and medicine’s myopic focus on medical technology. PRA is well-positioned to effect a paradigm shift in the way doctors understand and treat chronic disease and create healthier communities.

OrganizationWalk with a Doc
LocationColumbus, OH
Year Founded2005
LeadershipDavid Sabgir MD, CEO
Rachael Habash, COO
Bryan Romey, Program Coordinator

Initiative Overview

Dr. David Sabgir, Founder of Walk with a Doc, leads a “walk with a doc” nature intervention at SHIFT.

An abundance of people living sedentary lifestyles and not getting out in nature is leading to a national epidemic of social isolation. Walk with a Doc’s mission is to inspire activity and communication in nature. We provide the inspiration and the infrastructure for health care providers to meet with their community and spend time with them in a non-threatening environment.

Impact

Walk with a Doc has health care providers spending the majority of their days inviting patients/community members into nature. This added awareness to the outdoors has unlimited benefits. Most everyone loves to be outside together. Walk with a Doc breaks down age, racial, socioeconomic, religious barriers and much more. It brings us together.

From an economic standpoint, improved health and wellness of our community has countless benefits including improved production in the workplace, less sick days and more creativity. 

We are happy and content with our 471 international chapters, but there need to be thousands. We are currently addressing getting Walk with a Future Doc into medical schools.

Initiative Impact by the Numbers

In 2018, we added 196 communities and had 160,000 walker visits. 471 communities, 48 states and 25 countries.

Innovation

We believe that we are unique from the standpoint that the health care provider is in the park with the community members. I was personally unsuccessful in asking/telling/prescribing physical activity

Replicability

We’ve been blessed to be replicated in 25 countries. This is made possible by our national partners creating a toolkit, an incredible team, frequent communications through newsletters and always saying ‘yes’ to whatever opportunity presents itself

Biggest Challenge to Advancing This Work

Our biggest obstacle other than funding is awareness. We are so fortunate to have an evidence-based program that is changing communities. We need to continue to get the word out.