Improved Population Health Through More Dynamic Public Health and Health Care System Collaboration
Introduction
Growing evidence suggests that in order to improve a population’s health in a significant and sustained way there must be clear direction, commitment, and effective collaboration between the many entities that provide care or engage in community improvement. Effective collaborations can make positive strides in addressing the social determinants of health, which affect population health. Hospitals play a significant role in care delivery, from basic attention to the most sophisticated interventions, but certainly all organizations want to provide the highest quality services to the populations they serve. Key but often missing pieces in the U.S. health system are (1) how to connect the menu of services to a population’s actual needs, and (2) how to systematically use hospitals’ high social capital to consistently and systematically address the needs that greatly affect a population’s health outcomes.
Under the Patient Protection and Affordable Care Act (ACA), the Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct community health needs assessments (CHNAs) every 3 years and develop an implementation strategy to address the resulting identified needs. Public Health Accreditation Board standards also require local and state health departments to conduct or participate in collaborative processes for assessing, prioritizing, and addressing community health needs. The accreditation standards have increasingly led state health departments to develop state health assessments and state health improvement plans. Schools are also required to do needs assessments as part of the Healthy and Hunger-Free Kids Act, and federally qualified health centers are required by their federal funder, the Health Resources and Services Administration, to assess their own communities’ health needs (NACHC, 2015; USDA, 2014).
Although governmental public health organizations, hospitals, and other community entities have collaborated for years, these assessments and strategies create an important opportunity to improve community health through increased collaboration and partnership. As stated in a report by Larry Prybil and his collaborators:
There now is an extraordinary opportunity for mutually beneficial cooperation among hospitals, public health departments, and others who share commitment to improving community health. It is hoped that hospital and health department leaders seize this opportunity and collaborate in bringing about transformational change, rather than simply complying with IRS regulations (Prybil et al., 2014).
Much of this work is already happening between state and local health departments and individual hospitals. However, state health departments can play an important role in driving what hospitals are doing, convening this collaboration, and facilitating success at the local level. Below are challenges and barriers that state and local partners face related to collaborating on the above needs assessments, as well as examples of successful state strategies that can overcome these barriers.
Assessments Should be Coordinated to Avoid Duplication and Maximize Resources
The community assessments required of hospitals, local and state health departments, federally qualified health centers, community action agencies and other federal grantees, United Way affiliates, and banks subject to Federal Reserve requirements are overlapping and largely uncoordinated. There may be significant assessment duplication in any given community, and hospitals, as potential partners, are often unable to easily identify and map relevant agencies’ priorities, implementation strategies, and outcome measures across shared constituent populations.
Partners in North Carolina have taken steps to synchronize CHNAs and community health assessments (CHAs). The North Carolina Department of Public Health requires local health departments to complete regular CHAs, so local health leadership reached out to the state hospital association to explore aligning the CHA and CHNA assessments. The hospital association responded by endorsing fully integrating its hospitals’ CHNA work with that of local health departments and their communities. They also worked together to synchronize the frequency of both assessments.
In Massachusetts, the Determination of Need (DoN) program, the state-mandated certificate of need requirement, requires program and funding linkages between capital investments in health services and public health planning. Massachusetts has taken steps to align the DoN program’s CHNA requirements to allow hospitals to jointly satisfy reporting responsibilities for its attorney general.
State Health Officials can Lead Community Engagement Efforts
To maximize the promise of population health improvement, CHNAs and community health improvement plans (CHIPs) should be conducted openly with full public health agency participation. While most hospitals genuinely want to improve the health of the communities they serve, without meaningful community participation, some hospitals could perform CHNAs and CHIPs in a manner that only minimally satisfies federal requirements. Without review, a hospital could also possibly steer CHNAs and CHIPs to prioritize preferred clinical programs and interventions. In addition, without crucial information from health agencies and communities, hospitals could inadvertently underrepresent vulnerable populations in their CHNA processes. To counter these risks, local and state public health officials can vigorously educate and engage their communities and assertively seek partnerships with local hospitals’ top leadership to share data, assessment methodologies, and evidence-based interventions, and connect hospitals with existing community coalitions (Rosenbaum, 2013). Given the opportunities presented by the fundamental health system changes underway across the country, governmental public health should join forces with hospitals by playing a leading role in this aspect of the community health improvement process.
Hospitals and Public Health can Work Together to Align Public Health Jurisdictions and Hospital Service Areas
Hospital–public health partnerships can experience barriers such as public health agencies’ geopolitical boundaries not matching the hospitals’ service areas or an imbalance in local public health and hospital resources. Many health departments serving large jurisdictions work with many different hospitals, some of which have historically competed or operated in specific neighborhoods without shared engagement. While these urban hospitals may engage with community residents in their traditional service areas for CHNAs and CHIPs, the result may be a highly fragmented array of uncoordinated interventions across the city’s neighborhoods. On the other end of the spectrum, smaller local health departments may not be able to provide the full spectrum of support in this process. Hospitals could address this fragmentation by agreeing to undertake at least one shared intervention for a period of time in order to evaluate the synergistic effectiveness of collective effort. Hospitals have been able to collaborate with public health officials on CHNAs in both Philadelphia and Sanders and Lake Counties, Montana, to highlight projects underway in two completely different geographic locations (Barnett, 2014).
Hospital and Public Health Leaders Need Continued Support to Reframe Roles and Relationships
Both hospitals and public health agencies have expressed difficulty rethinking old norms, shifting from individual medical models to population-based prevention strategies, and extending personal invitations for new relationships. Public health officials may find it challenging to effectively engage with hospital leadership owing to perceived political or economic imbalances. In addition, some hospital leaders may find it difficult to replace appealing individual community programs targeting specific patient panels with less visible but highly effective environmental and policy changes that affect a broader population. Public health agencies can support hospitals’ important work by providing resources like The Community Guide that outline population-based interventions (Community Preventive Services Task Force, 2015).
Hospitals may find that public health methodologies for community engagement and CHNA or CHIP are overly time- and resource-intensive, and may find it easier to purchase a CHNA through a consultant than to partner with public health and the community. However, hospitals seeking to more strongly engage with their communities are instead asking public health officials for streamlined assessment or reassessment tools that adhere to the frequency of ACA schedules while maintaining community participation. Maryland’s Department of Health and Mental Hygiene and the state hospital association are teaming up to develop active assistance for their constituents to overcome these challenges. They have scheduled a series of meet-and-greet sessions so local hospitals and public health agencies can share strengths and interests and form partnerships to improve health, avert unnecessary admissions, and reduce health care costs (ASTHO, 2014).
Hospital Implementation Strategies and Community Benefit Investments can be Tied to Shared Community Health Assessments
Although there is power in aligning hospital implementation strategies with CHIPs, it does not always happen. For example, North Carolina’s Department of Public Health, which reviews all local health department community assessments, reports that hospital community benefit funds are not often used to implement these assessments. Further, many hospitals do not publicly share the implementation plans that result from CHNAs. Even hospitals with strong community health improvement collaborations may isolate population health principles in the community benefits office, removing this framework from the institution’s core strategic decisions. It would be beneficial to work toward integrating not only a community’s multiple assessments, but also the resulting top priorities for action and selected evidence-based strategies to address these priorities.
Change can be Disruptive and Requires Evidence
Public health agencies and hospitals are moving toward the second round of ACA-required CHNAs and implementation strategy reporting. This progression signals an attention shift from assessments to implementation strategies—more energy and focus on “doing” rather than “planning.” In some communities, public participation has been exclusively centered on developing CHNAs, while the work of developing hospital implementation strategies has not been widely understood or is regarded as a hospital’s prerogative. Aligning community benefit investments with CHNA priorities could be disruptive to previous community benefit expenditures or feel threatening to previous interests and grantees. Moreover, public health agencies are still collecting evidence of health and economic returns on investments in many population health interventions, a process that continues to evolve. To bolster confidence in these interventions, state health departments have begun to partner with academic institutions and, in some cases, build agency capacity to analyze public health programs’ economic impact.
Innovations in care delivery, including the patient-centered medical home model, chronic disease care management, accountable care organizations, hot-spotting and shared savings, and consumer-directed health technologies, can help advance population health if they are more widely understood and implemented with community support. State health departments in Washington and Minnesota are addressing this knowledge gap by developing training to familiarize state and local public health officials with the background, language, quality and performance measures, and financing options required to participate in community care organizations and accountable community health organizations.
Sustained Funding for Community Health Improvement is Needed
Effective community health improvement outcomes require some form of dedicated funding and staff. Massachusetts’ Prevention and Wellness Trust Fund and its DoN Program are two examples of state initiatives that successfully secured funding to specifically support community health improvement. Rhode Island’s Department of Health also achieved this by working with a diverse group of stakeholders to establish its Primary Care Trust. This pool of funding from health insurance providers will support Neighborhood Health Stations that will treat both the whole individual and the whole community.
It is important to note that several contextual factors have influenced work in this area. Previous state budget cuts and the loss of federal Community Transformation Grants jeopardized communities’ already-strained infrastructure for population health improvements. In addition, many hospitals still regard population-level intervention as a discretionary option for community benefit expenditures, one that unfortunately competes with bad debt, Medicare allowances, uncompensated care, and various established educational and community service interests. It is important to find models that can make the business case to hospitals and other decision makers for community health improvements.
Conclusion
Tax-exempt hospitals and local and state public health agencies have a crucial opportunity to improve overall population health through the IRS’ CHNA and implementation strategy requirements. In an era of transformative change, these partnerships are important and worth pursuing to find new opportunities for innovative and sustainable strategies to improve community health. Public health and the broader health care system can work together to surmount their challenges and promote access to vertically integrated delivery systems to improve population health. As health systems become increasingly integrated, public health agencies can play a critical role in ensuring that this integration increases access to care and services and improves population health. State health departments and hospitals should work together to ensure that integration efforts go beyond clinical services and include community-based prevention efforts.
References
- ASTHO (Association of State and Territorial Health Officials). 2014. Successes and challenges in community health improvement: Stories from early collaborations. Available at: http://www.astho.org/Successesand-Challenges-in-Community-Health-Improvement-Issue-Brief/ (accessed January 15, 2015).
- Barnett, K. 2014. Supporting alignment and accountability in community health improvement: The development and piloting of a regional data-sharing system. Available at: http://nnphi.org/CMSuploads/Supporting AlignmentAndAccountabilityInCommunityHealthImprovement.pdf (accessed January 15, 2015).
- Community Preventive Services Task Forces. 2015. The Community Guide. Available at: http://www.thecommunityguide.org/index.html (accessed January 26, 2015).
- NACHC (National Association of Community Health Centers). 2015. Health center information. Available at: http://www.nachc.com/health-center-info.cfm (accessed January 15, 2015).
- Prybil, L., F. D. Scutchfield, R. Kilian, A. Kelly, G. Mays, A. Carman, S. Levey, A. McGeorge, D. W. Pardo. 2014. Improving community health through hospital-public health collaboration: Insights and lessons learned from successful partnerships. Available at: http://www.uky.edu/publichealth/sites/www.uky.edu.publichealth/files/Research/hospital-public%20health%20partnership%20report_12-8-14.pdf (accessed January 15, 2015).
- Rosenbaum, S. 2013. Principles to consider for the implementation of a community health needs assessment process. Washington, DC: Department of Health Policy, George Washington University, School of Public Health and Health Services. Available at: http://nnphi.org/CMSuploads/PrinciplesToConsiderForTheImplementationOfACHNAProcess_GWU_20130604.pdf (accessed January 15, 2015).
- USDA (U.S. Department of Agriculture). 2014. Healthy and Hunger-Free Kids Act. Available at: http://www.fns.usda.gov/school-meals/healthy-hunger-free-kids-act (accessed January, 15, 2015).
