Strategic Planning
There's increasing pressure on hospitals to better define and measure community health programs.
Most hospitals hold health fairs, complete with blood pressure screenings and balloons for the kids. They've traditionally been good public relations and a way to funnel a few patients into the hospital.
But there's increasing pressure for hospitals, particularly those that need to defend their nonprofit status, to support more sophisticated community health programs and invest a little more strategically in the health of the community.
That's consistent with the mission statements of most hospitals; improving the health status of the people they serve is a common mission statement, if not a pillar of the strategic plan.
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Keeping such lofty, generic goals on the books is not enough, argue experts in community health. Hospitals need to get more specific, and they need to be able to measure how well the money and effort they invest in community health meets those goals.
"The vast majority of hospitals engage in some variety of community health improvement programs," says Michael Bilton, executive director of the Association for Community Health Improvement. "That group gets considerably more narrow when you count those that make a specific effort to evaluate effectiveness or conduct a community health program because it meets a strategic need of the organization."
For executives and trustees, this means taking community health as seriously as any other program in the hospital's repertoire, and holding it to the same standards as other budget items. Community health experts on the hospital staff are the ones who identify community needs and propose specific interventions. The CEO and board of directors are the ones who set broader goals. "You need to agree on what the goals and objectives are and to agree that those are reasonable, appropriate goals for the organization," says Bill Beery, director of the Center for Community Health & Evaluation at Group Health Cooperative in Seattle.
Community "health" has a slightly different meaning than community "benefit," which refers to all the things a nonprofit hospital might contribute to its community as viewed by Internal Revenue Service regulations on nonprofit status. The biggest dollar items within community benefit are usually charity care and unreimbursed medical care. But the concept includes community health outreach, such as health fairs and projects that focus on specific health problems like childhood asthma or Type 2 diabetes.
Increased focus on community benefit requirements by the IRS and Congress prompted some hospital boards to add a committee on that topic, which likely will oversee community health projects as well. Bilton suggests that hospital boards write and approve a policy on how they will handle community health, since few probably have done so yet. "It's a small minority of all systems, but we are seeing more have that conversation," he says.
Lancaster (Pa.) General Health elevated community health to the board level and assigned a committee to it. That panel, created about three years ago, has the same status as the other high-profile board committees that handle finance or medical affairs, says committee chairman Alex Henderson, a local attorney. "We think that's very important to set the tone of mission and community benefit," he adds.
The committee gets regular reports from the community health staff, which monitors the hospital's performance on specific indicators on two different scorecards—one for the hospital and one for the community.
For Henderson's hospital, measuring community health not only raises the profile of these projects, but helps the board decide what to invest in. "We don't want to be in a position of making choices without the information we need," he says. Another factor that strengthened the role of community health was the establishment of a top-level chief mission officer a few years ago.
Hospital executives and trustees are thinking about the strategic reasons for improving community health. Beery, whose department at Group Health helps health care organizations plan and evaluate their community health programs, says a few motivations predominate:
• It's good business as a hospital to support prevention and reduce the number of chronically ill people making unnecessary trips to the emergency room.
• It's good stewardship and participation in the community, as stated in the hospital's mission.
• It's required that nonprofit hospitals report on their charitable work to the IRS as part of the community benefit portion of their nonprofit status.
For others, it's really more about public relations and that's fine, says Beery. You just need to be clear about your motivations so you can establish goals and measure progress. "The organization needs to have a discussion about that and, if it decides that the reason for this is public relations or marketing, there's nothing wrong with that. The organization just needs to think about what its objectives are."
So, in that instance, the goals might be more focused on projects that can be easily communicated to the public. Similarly, he says, if it is about a business goal, such as reducing inappropriate use of the emergency department, the projects stemming from that would be different and focus on the types of chronic diseases or other problems that prompt people in the community to use the ED when they shouldn't.
At Lancaster General, community health is a longtime mission-based priority, but the board also sees the business case for it. "If we can use our resources more efficiently [through prevention] we can use our resources more efficiently when we care for people whose diseases are not preventable," Henderson says.
For the Lancaster board, trustees are motivated by their duty to spend the organization's money wisely, says Henderson. "It's the community's money, and we have a responsibility to spend it well," he says.
As hospital leaders found in the area of quality improvement, it's nearly as important to document the change as to make the change itself. The evolving science of outcomes research is starting to become more relevant to measuring community health programs, elevating them from feel-good PR to giving the hospital a more substantial role as a player in the local public health community.
Devising clear goals is a vital first step to creating community health projects that can be evaluated when they're done, says Beery. He suggests being more specific than a lot of health care organizations tend to be. "Far too often we work with organizations that say their goal is to improve the health of the community, or decrease the burden of illness in the community," he says.
"Those things sound good but they're so general and they're so 30,000-foot-level that it's very difficult to talk about what evaluation means. To some people that might mean diabetes rates for the community go down significantly, and to other people it might mean that the community and its organizations feel more empowered. It can mean a lot of different things."
When working with hospitals to design goals, Beery's group thinks ahead to evaluation. "We get the trustees and leadership to talk about what their goals mean in terms of indicators, to define what success would look like, what expectations they might have for a year or five years or 10 or whatever," he says. "Then you get people to think about what steps there are in between." He tries to get more specific than "we're going to print a brochure" or "we want to decrease rates of smoking," and talk about specific goals and steps to get there.
Organizations sometimes struggle to pinpoint how to measure progress, and the Group Health Center's staff helps them think creatively about that.
Evaluation tends to be easier the more specific a program is. At Lancaster General, for instance, determining whether the smoking cessation program is working is simply a matter of following patients to see whether they stop smoking and maintain the change over time. Healthy weight management takes longer and has more components—diet, exercise, stress management—and takes longer to be successful, so it can be harder to measure results.
Alice Yoder, the hospital's director of community health, uses sophisticated methods of analysis that track the health indicators the board chose, compares them with state and national benchmarks, and regularly provides the information on scorecards to the board.
The organization keeps evaluation in mind when choosing and designing community health projects, Yoder says. That starts with pulling information from surveys of community health status, such as those carried out by the Centers for Disease Control and Prevention in the Healthy People program.
Once the hospital has chosen a health topic for focus, Yoder looks for interventions that would have the most impact, taking into account whether there is a good way to measure improvement. "We identify what we want to impact and think about whether there's a way to track that before we even start implementing the program," she says. That way they can be sure to have a baseline measurement taken at the start of the project for comparison later.
Yoder considers community health programs as important to the hospital as the inpatient medical care, and believes they should live up to the same standards for proving their effectiveness through outcomes. "Anything else a health system would do would require a standard," she points out. "Why should community health be any different?"
Ideally, she says, the measurement should be an actual outcome, such as the number of people who have stopped smoking, lost a certain amount of weight, or reached a blood sugar level that is significant to managing their diabetes. "You have to come up with measures to say you are making a difference," she says. "You want it to go beyond the number of people reached, and say what happened to those people."
That's not always possible, particularly with projects that have a broader scale or are "further upstream," such as improving the availability of fresh foods to a population or tackling obesity in children.
Still, while Lancaster General tries to choose projects that have measurable outcomes, the lack of an easy evaluation tool won't stop the system from taking on a project it considers important, Henderson says. "We look at the bang for our buck and where we can see the most results for the dollars," he says. "If you go really far upstream and can turn the river upstream, you can make a big impact, but the results and measurability are much slower in coming. Those are the things we balance."
The important thing to remember about evaluation, Beery says, is to plan ahead for it and not try to review a project only after it's over. It's much easier to measure a baseline before you start and measure again afterward.
Evaluation doesn't have to be expensive and intimidating, Bilton argues. "You just need to set aside some dollars to evaluate the results of your projects," he says. He recommends going beyond assigning community health and its evaluation to a part-time person in the marketing department—recruiting a full-time staff member with a public health background and giving them an administrative assistant "takes you a long way in building evaluation capacity," he says.
Some organizations have gone well beyond that in making a commitment to community health. Lancaster General, for instance, has a 120-person department dedicated to it and maintains a large pool of professionals such as health educators and phlebotomists ready to go to work when a new project gets approved.
Other hospitals and systems, and their foundations, dedicate a pot of money for community health and then solicit proposals to divvy up the money in grants for local nonprofits. University Health Systems of Eastern Carolina contributes $1.5 million, plus another $250,000 from the Kate B. Reynolds Foundation, to community projects each year. The dollars are split up among seven hospitals, which are able to send that money to small nonprofits in their communities. "It's an absolutely fabulous program," says Thomasine Kennedy, board chair of Duplin General Hospital and a member of the larger UHS system board. "In just two years [since Duplin joined the system], $224,000 has come into our county that otherwise would not have been there."
In the case of programs like this one, evaluation is usually a part of the grant-making process, where the grantees report back on what they've accomplished. University Health Systems takes the learning process a step further, and holds an event each August where its grantees present the projects and their outcomes. "We're helping build the capacity of the local nonprofits in our region," notes Michelle Brooks, vice president for community benefit and government affairs for the system.
The most common mistake health care organizations make, the experts say, is in having unreasonable expectations about what their intervention can accomplish. "If one has unreasonable expectations, one will be disappointed and will probably stop doing anything or certainly cut back," says Beery. These are most often expecting too much change too quickly.
Another potential barrier is failing to work well with other members of a collaborative community group, such as local nonprofits or public health agencies that may have different goals for the project than does the hospital.
One way the Lancaster General board keeps the lines of communication open with community groups is to maintain a community advisory board that meets occasionally with hospital board members to discuss evolving community health needs and what's being done to meet them.
Community health programs can take a hit when budgets need to be tightened, Berry and Bilton observe. They've seen both trends in the recent economic crunch—some organizations see community interventions as expendable, while others hold the line on the assumption that prevention will ultimately save the organization money.
Either way, the economic downturn has prompted most hospitals to take a closer look at every penny they spend, and justifying community health programs with solid outcomes is becoming more relevant than ever. Programs that lack that data are more vulnerable to cost-cutting, Beery notes.
"Most of these [community health programs] have not had the strategic thinking, so they are not founded in strategy and are seen internally as projects rather than programs and initiatives," he says. "Community health programs need an evidence base for tracking progress and celebrating success."
This article 1st appeared in the October 2009 issue of HHN Magazine.
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