EILEEN BARSI is corporate senior director of community benefit for San Francisco-based Dignity Health, formerly known as Catholic Healthcare West. Barsi has overseen the development of a sophisticated data analysis system that identifies five factors that lead to health disparities, by ZIP code. In 2011, Dignity made the Community Need Index available online to anyone interested in a granular understanding of local population health needs. | Interviewed by Jan Greene
What is Dignity Health’s approach to community health?
Barsi: Our mission compels us to address the unmet health needs of our communities. So that’s where the community health program had its origins. We not only have a community benefit program, we have a community grants program and a community investment program, so combining these is the comprehensive approach we take to community health.
Dignity Health has a long history with the community benefit health needs assessment, and all of our hospitals have been doing them since 1994. That started in California when there was interest in requiring nonprofit hospitals to document community benefit. The Alliance for Catholic Healthcare came together to sponsor legislation in our state so we could influence the law rather than have it imposed on us. So we’ve been doing community health needs assessments and developing comprehensive community benefit plans since 1994. We required all of our hospitals to have a standardized approach.
The Community Need Index is a sophisticated approach to measuring health disparities by ZIP code and can be layered with other data to gain greater understanding of unmet needs. How did the CNI project originate?
Barsi: It was 2004 before technology brought us all the data that are so readily available today. Our board asked us if there were a way to collect data from our communities to provide them with at a glance to easily understand what the needs might be and how serious they are. So we partnered with Solucient, which is now Truven Health, and convened an internal ad hoc committee to identify what specific data would provide that at-a-glance look at the communities we serve.
We decided to look at the socioeconomic barriers that put people at the greatest risk of needing health services. The prime areas or categories included education, insurance, housing, culture and language barriers, and income. And from there Solucient began to look at a methodology to offer us a scoring by ZIP code of all of our service areas based on these socioeconomic barriers.
They also did a correlation to utilization data and found there was a 97 percent correlation to utilization for ambulatory care-sensitive conditions — the conditions that, if treated in the community, in a primary care setting, would likely not result in a hospitalization — things like diabetes, asthma, chronic obstructive pulmonary disease and congestive heart failure.
Our eyes were opened to what the poor and vulnerable in our communities were experiencing. They are in our hospitals every day, and the utilization data tell us what their unmet needs are.
We looked closer at the financial data and saw that in one year the net inpatient losses in our system were in excess of $47 million for the care provided to the uninsured and underinsured patients with ambulatory care-sensitive conditions.
What kinds of things has the index illuminated for you?
Barsi: When you couple the sociodemographics of the community with the utilization data, you have a much more rigorous community health needs assessment. It’s really delving down into what’s happening on a neighborhood basis. For instance, in Stockton they shared the index findings with their partner organizations working on community health and identified a ZIP code that had not been considered high-risk in the past, but it had changed. United Way loved this because it was able to document with scientific backing what the need was in that community. And it helped give credence to some of the proposals it was making for program funding.
We’ve found that you don’t want to just do the same thing every three years with your community health needs assessment. You can use these tools to delve further into it. We look at what is driving the demand for care, and what could have been handled sooner. It is compelling, because these are people who are disenfranchised, who are socially and economically challenged. They don’t want to be in the hospital either.
How has Dignity Health used the CNI to carry out health improvement projects?
Barsi: This has led to a systemwide initiative focused on chronic conditions, which we identified as a major unmet need in our communities. The initiative led to specific projects in our communities. For instance, utilization for certain ZIP codes leapt off the page for late-stage breast cancer. So our local hospital moved a mobile mammography van to that ZIP code. Our hospital in Oxnard Camarillo identified a large Latino population with high risk and prevalence of diabetes. We began with education of physicians in the community [which] led to a very comprehensive program for the community to educate and address unmanaged diabetes and prevent it where possible.
We also use the tool for focusing our community investments in areas of high need — it isn’t enough to know why it is happening, you have to do something about it. So we have offered low-interest loans and lines of credit for a community clinic that wants to achieve federally qualified health center status. In Merced, we served as a convener for an economic roundtable to address the needs of the community, including the effect of the drought on agriculture in our state. Challenging the community to solve its problems together is another way we’ve used the scores.
How has that initiative helped to reduce your costs?
Barsi: In the last year alone, our focus on providing evidence-based chronic disease self-management programs resulted in a systemwide investment of $1.9 million and we served more than 7,800 individuals with chronic conditions. Among the participants in the hospitals’ intervention programs, only 8 percent utilized either the emergency department or inpatient services in the 90 days post-participation. When you consider that the average inpatient stay for a chronic condition is about $10,000, each avoided unnecessary stay is a significant savings.
Why did Dignity choose to make the index available for public use in 2011?
Barsi: The tool offers a clear picture of where the disparities lie. With the passage of the Affordable Care Act and the requirement that every hospital in the country carry out a community health needs assessment, we felt it was an important tool to share. Dignity Health owns the score, so we’ve shared the score. Truven Health owns the data underlying the score and will make it available for a reasonable fee.
The Barsi File
Barsi oversees Dignity Health’s community benefit initiatives and expense reporting.
She is active in the Catholic Health Association and also serves as a member of the National Advisory Council of the American Hospital Association’s Association for Community Health Improvement. She serves on a national committee of leading health care systems convened by the White House Center for Faith-based and Neighborhood Partnerships to advance community benefit in an era of health reform.
She has been with Dignity Health, formerly Catholic Healthcare West, for 25 years.