Nature Rx: A Gateway to Better Health

October 16, 2018 | Robyn Paulekas

With support from the Aetna Foundation, on Tuesday, October 16 in Jackson, Wyoming, as part of The 2018 SHIFT Festival, approximately forty of the nation’s leading experts from health care, outdoor recreation, land management and conservation participated in a think tank to discuss opportunities for mainstreaming “Nature Rx*” as an integral element of national healthcare delivery systems.

Participant list

The think tank was led by Dr. Michael Suk, the System-Wide Chairman of the Geisinger Musculoskeletal Institute. The event had two major components: 1) a series of presentations featuring a range of perspectives on the connection between public health and nature contact; and 2) a workshop in which small teams of participants explored the topic in more detail.  

This document provides a high-level summary of key points and major take-away messages from those two components. 

*: “Nature Rx” is trademarked by Dream Tree Film & Productions, the organization that made the viral video series Nature Rx, and is used here by permission. Those interested in partnering or using the Nature RX name should reach out to Justin Bogardus, DTFP’s Founder, at justincbogardus@gmail.com. 

Link to presentations

Michael Suk,  MD JD MPH FACS

System-Wide Chairman, Geisinger Musculoskeletal Institute

One of the country’s earliest and leading proponents of the health benefits of nature contact, Dr. Suk provided an overview of how time spent outside in nature can and should be incorporated into health care as a social determinant of health. Some of his major points included: 

• The United States healthcare system is at a crossroads and changing dramatically. There are currently several trends converging, including mergers that are resulting in larger-than-ever health care systems, and the advent of new health-care settings and health-care delivery systems. 
• Nature has a significant role to play in the treatment and management of chronic diseases such as diabetes, heart disease, and obesity, and has the potential to be a cost-effective component of comprehensive health care. 
• The future of medicine in the US will focus on changing patient behavior, which contributes up to 40% of health and wellness. This includes things like jobs, food, education, neighborhood or physical environment. New solutions are emerging that build out the system of support and/or seek to change physical behavior through self-care or community care. New partnerships (e.g., the merger of CVS and Aetna) are also changing the point of care as well as the fundamentals of the marketplace. 
• There is an opportunity to bring together advocates, health care networks, the scientific community, and others to advance nature and health as part of the future of healthcare in the country. 

Diana Allen

Chief of Health Promotion, Healthy Parks Healthy People, National Parks Service

Diana Allen provided an overview of the National Parks Service’s (NPS) Healthy Parks Healthy People (HPHP) program, which advances parks and public lands as a health resource. Some of her major points included: 

• NPS recently developed a five-year plan for their Healthy Parks Healthy People program that focuses on: 
  • Encouraging NPS employees to be healthy in the workplace and serve as ambassadors of healthy living
  • Promoting parks as a health resource
  • Developing programs that enhance the economic and physical wellbeing of local communities
• Practically, NPS achieves these goals through healthy food concessions, and through specific objectives such as green, quiet, night-sky friendly, or smoke-free parks. They also support physician-led, ranger-led, community-led, or self-led activities that integrate health and nature. NPS has a current park prescription program and is evaluating how doctors, insurance, and others from the health care community engage on this topic.
  

Brenda Schmidt

Founder and CEO, Solera Health

Solera Health integrates highly fragmented programs and services into one high-access, lower cost network to prevent and manage chronic health conditions paid through medical claims. Solera’s personalized prevention network drives consumer engagement and has a significant impact on improved patient outcomes.

Solera Health’s Founder and CEO, Brenda Schmidt, provided an overview of how Solera Health is building a bridge between health care and the network of partners and community organizations who can support health outcomes using a digital platform. 

• Solera Health is working to encourage care to continue from the clinic to the community. 
• Her organization has developed a specialty network for community resources, which tend to be hyper local. Using a digital platform, they provide a curated network of community resources that can be paid through medical claims. 
• This type of model could be part of a near-term solution for integrating nature as part of lifestyle choices, into a comprehensive approach to health care, especially for chronic disease. 

Kathy Higgins

President and CEO, Blue Cross Blue Shield of North Carolina Foundation (Retired 12/31/2018)

Kathy Higgins shared highlights of the Blue Cross Blue Shield of North Carolina Foundation’s (BCBSNC) investment in the Blue Ridge Parkway Foundation’s “TRACK Trails” program. 

• BCBSNC has invested in nature and trails, through a number of grants totaling $2 million, with the Blue Ridge Parkway Foundation’s efforts to connect children and families to parks. It includes a self-guided interaction with Blue Ridge Parkway National Park that is tied to education and learning activities. 
• Corporately, the TrackRX program engages physicians to write park prescriptions as part of the BQPP incentive program. Five hundred doctors in North Carolina are involved in the program. Many also support their own “walk with a doc” program. 
• BCBSNC Foundation has valued the relationship and success of this program and thanks Dr. Olson Huff for bringing it to the Foundation. 

John Whyte, MD MPH

Chief Medical Officer, WebMD

Dr. John Whyte shared context and provided framing on how the “health benefits of time spent outside in nature” concept may be received by individuals for whom it is not a priority. 

• Nature and the outdoors are not “friendly” to everyone. There are concerns about disease (e.g., Lyme disease), discomforts and safety threats. 
• Dr. Whyte pointed out that leading social media influencers are largely not focused on health, and there is even less emphasis on time outside or nature. Many of the organizations promoting an outdoor and health message may be ineffective at using social media platforms (e.g., government use of social media often considers it a broadcast platform, rather than engagement tool). 
• There are significant cultural and systematic barriers to getting doctors to consider nature as a social determinant of health. 
• To effectively market and message the health benefits of nature contact will require tools, information, and resources targeted to specific audiences. It will also require that nature contact is easy to access.

Breakout group discussions

Following the panel discussions, participants broke into five groups, each discussing a specific question. The participants rotated after 30 minutes, and thus were able to discuss two questions each. Below is a summary of major points taken away from the conversations. 

How do we mainstream parks and public lands as elements of national healthcare?

Facilitated by Diana Allen

• Leverage community parks and recreation departments: Every parks and recreation department should have health professionals on staff (e.g., a medical student, resident, or rotation on outdoor recreation). 
• Leverage offices of outdoor recreation: Health objectives could be integrated into outdoor recreation leadership positions at the state level. Brochures for these offices, or state parks, could be shared at doctors’ offices. 
• Leverage community organizations: Community organizations, rather than just the government agencies, can support nature and health (e.g., greenways, PTAs, etc.). 
• Integrate planning: State health and recreation plans should be coordinated. 
• Consider specific barriers and messaging: Unique challenges exist for inner-city communities, where the barriers to access may be significant and include cultural challenges. There could also be opportunities to answer the question: Why go to a park? Also, consider reaching out to community leaders who already visit parks and enlisting them as advocates with peers and with the health care providers. 
• Opportunities to define nature for all: Expand or scale existing resources, such as Find Your Park or the Discover the Forest app so that they are available for everyone. They should be searchable, contain relevant information (safety, pet friendly) and provide a strongly consumer-friendly experience. An integrated map (e.g., such as the ones available in California and Delaware) could support provider-side interventions. 
• Consider security, economic, and health outcomes: There are complex and often symbiotic relationships between population health, national security, and economic issues. 
• Stewardship: Care for the resource and land stewardship could be an important part of encouraging its use. 
• Research and data: Is there evidence that Walk with a Doc has positive outcomes for participating doctors and staff? 
• Next steps: The group identified the following specific next steps: 
  • Each state should have a plan
  • More data is needed
  • Clarify the messaging (and include national security and the economy)
  • Partnerships should be developed between Department of Defense, state outdoor recreation offices and land managers. 

How do we incorporate Nature RX as a benefit of insured health? 

Facilitated by Dr. Morgan Green

• Share language: There is a need for a layman’s explanation of health finance, including terminology, especially as the conversation expands to include non-traditional partners.
• Build on existing examples: Many existing health care programs cover gym membership (often with evidence of use), so there may be an opportunity to expand those to include the costs associated with outdoor activities (gear, memberships, etc.). In many states Nature Rx is covered by Medicare, but not Medicaid. 
• Performance metrics: Doctors are currently measured against a set of performance metrics. It may be possible to add categories and build evidence for including this in the performance metric system. That may require evidence of use or activity. 
• Demonstrate cost effectiveness: There is a need for demonstrated, cost-effective results. It may be worth exploring acupuncture as a case study, since it is now frequently covered by insurance but once was considered alternative or unproven. 
• Bridge the clinical and community settings: 
  • One barrier is that much of the activity takes place outside a clinic or health care facility. A few potential solutions include: having doctors involved to support it being classified as a clinical activity or consider the prescription model. 
  • There is a need to create a community-level inventory of what resources are available. The Diabetes Prevention Program could be a good model. It needs to be community specific and there needs to be sufficient support for patients to navigate the resources. 
  • There are other examples of initiatives that consider integrative and function health that could provide best practices or offer opportunities for integration. 

How do state outdoor recreation leadership positions such as State Offices of Outdoor Recreation provide leadership for Nature Rx? 

Facilitated by Luis Benítez, Director, Colorado Office of Outdoor Recreation

• Information sharing: State offices can provide content and information, such as reports, booklets, etc. 
• Access and leadership from state government and policymakers: State offices provide an opportunity to consider state-level policy makers’ perspectives, since they are typically reporting to the Governors and have strong relationships to the outdoor recreation community and industry. They also can support coordination within state departments (e.g., transportation, education, etc.) and can be helpful in navigating state-level government. 
• Build on the Confluence Accords: The country’s state offices of outdoor recreation recently agreed to the Confluence Accords, which include three principles specific to public health and wellness. These include addressing social determinants of health through outdoor recreation opportunity; partnering with health and wellness stakeholders to determine shared values and common goals; and assist in quantifying impacts of access to outdoor recreation on healthcare outcomes and costs. 
• Convening power: State offices of outdoor recreation can also create space for location action to happen. They could convene one-day pilots. 
• Recognize capacity challenges: There are some significant barriers to state offices of outdoor recreation leading Nature Rx activities. They are often part-time positions without staff capacity to support this type of activity. 

How can we use media to shift attitudes? 

Facilitated by Marc Berejka, Director, Government & Community Affairs, REI

• Messaging: 
  • What is the outdoors? Consider what “nearby nature” looks like. There is a need for accessible messages—even sidewalks in New York City can and should be considered “outside”. Messaging should be not intimidating or inaccessible. Shift from physical education to physical education outdoors. Consider messaging that focuses on “let’s just get out” in a way that is accessible for everyone. 
  • Need good information, not just fluff: Be specific with ideas for outdoor activities, more beyond generalities, and get specific, e.g., “Be active by doing ____. “ 
  • Location-specific messaging: The focus should be on different things in different areas. Make it local. 
  • Meld seemingly conflicting messaging to break through the noise: Consider using active message curation or google analytics to customize and micro target. 
• Messengers: mayors, diverse groups, and the right influencers can be powerful messengers. In some communities this could be salsa dance studios, music history, churches. The messages could be customized (e.g., church service outside). There could be a “bring a buddy” campaign to encourage community-led campaigns. 
• Need: There is a need to understand metrics and what defines success. There is also an opportunity to align under a “collective impact model” towards shared goals such as social determinants of health. This could address the currently fragmented groups that struggle to do this work. 

Opportunities to incorporate outdoor activity into value-based care 

Facilitated by Robyn Paulekas

• Value-based healthcare in the future: Value-based care is an important concept and a likely future direction for the health care system, but also not currently implemented in most places. Most healthcare providers still incentivize procedures, rather than outcomes. 
• Barriers. The group identified specific barriers: 
  • Doctors have limited time: Doctors have very little time with patients. There may be lessons from other efforts at addressing this barrier, such as elder care. Also, other service providers, nurses, case managers, etc., can play an important role
  • Feedback loop: It is important that information on outdoor activity is reported back to the health care provider or system, which has been challenging. There may be technology-based solutions that make this easier. 
  • Risks: There are hard-to-manage risks of outdoor activities that may be challenging for health care providers or financers to navigate. 
  • No safe outdoor spaces: Many communities may not be within a safe walking distance to local parks. There is also often a mental barrier, with some patients feeling that the outdoors isn’t safe. 
• Near term opportunities: There are some opportunities for encouraging or incentivizing outdoor activity within the current (mostly not value-based care) system: 
  • Tied to outcomes: Mental health and chronic disease such as obesity and diabetes may be ripe for demonstrating the value of outdoor activity and have sufficient research and data to support its integration into the current healthcare system.  The return on investment may be measured in reduced doctor visits, or indirect benefits like reduce screen time. 
  • Bundle with other “lifestyle is medicine” efforts: Consider bundling “lifestyle” related changes, so that it isn’t just about outdoor activities, but builds on momentum for healthy food, healthy lifestyles, etc. 
  • Partnerships are important to success: some good examples exist of the types of partnership that can make outdoor activity as part of value-based care successful, such as one by Fitbit and Beacon. School field trips could be leveraged into community trips or activities. And there could be tools for navigating or integrating the landscape of existing community organizations. 
• Longer-term and transitional opportunities: Transitioning the healthcare system to value-based care is a longer-term goal, but would likely support a more integrated model of care that features a network of healthcare providers, not just doctors. Some specific ideas related to this long-term vision or the transition include: 
  • Documenting outcomes: To be successful, it is necessary to quantify and document outcomes.
  • Patient compliance: One of the challenges with value-based care is that it holds doctors responsible for patient compliance. This may be particularly challenging for outdoor activity, where there may be other significant barriers to compliance. There is also a concern that doctors will be incentivized to get rid of “bad” patients. 
  • May be driven by employers: The initial pilots of value based care may be driven by big employers (e.g., Oak Tree and Melina). 
  • Finances of value-based care: The current healthcare system has limited support for preventative health care (since return on investment is long-term cost avoidance, not near-term savings) Many of the initial pilots of value-based care have been financially unsuccessful. 
• Continuum of outdoor activities: It is worth considering the continuum of outdoor activities, and setting realistic expectations about what type of outdoor activity is ideal for which patient. For some, activity that is indoors may be a better goal (e.g., gym membership). Big outdoor adventures may not be suitable or ideal for all patients. 
• Consistent messaging: There is a need for advocates to consider consistent messages, similar data points, and opportunities to speak with a unified voice so that the mainstream health care community leaders, health care providers, and others are not overwhelmed.

Next steps

The group briefly discussed potential next steps, which included: 

• Incorporating the discussion from this workshop into the rest of the SHIFT events, panels, and discussions
  • An app is under development that: (1) provides the research community—in academia, industry, foundations, and government—with a portable, integrated, digital platform with which to document and quantify the benefits of nature while also providing guidance and analytic capabilities for the preparation of reports about nature experiences and studies; and (2), to provide a version of this app that can be easily used by individuals to assess the benefits of nature experiences on the health of their bodies, minds, and brains.
• Share contact info with all think tank participants
  • Participant list
• Convene a small executive team to further define the path forward for a coordinated Nature Rx movement, building on the momentum from the think tank. 
  • A small executive team is planning to meet in Washington, DC, to develop a pilot project community project that creates a sustainable revenue model for nature contact through health care dollars

2019

Planning is currently underway for a Nature as Medicine follow-up think tank at the 2019 SHIFT Festival.