Framing the issue:
• Driven by the increasingly shared vision of managing population health, officials for hospitals and public health departments are working together more closely.
• These two types of health organizations do not have a tradition of working as true partners, but resources are available to aid in the process from such organizations as the Institute of Medicine, the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation.
• The form that a given partnership should take and the kind of organizations that join the partnership should depend on the community’s needs.
• Key to a partnership’s success will be committed, trusting partners, a clear mandate and organizational structure, and adequate funding from at least one anchor member.
Mandated community health needs assessments — a less-talked-about provision of the Affordable Care Act — may turn out to have a big impact on the transformation of health care.
The ACA requires nonprofit hospitals and health systems to conduct the assessments every three years and then develop community health improvement plans. Many public health departments already perform needs assessments as part of their accreditation process.
All of this sows the seeds for greater cooperation among hospitals, public health departments and other community organizations. In turn, that could accelerate the process of transforming the health care system into one that manages health at the population level.
“I absolutely believe that the Affordable Care Act is serving as a catalyst to bring together the two sectors,” says Peggy Honoré, director of the Public Health System, Finance, and Quality Program in the Office of the Assistant Secretary for Health at Health & Human Services.
“It really has changed the dialogue because the focus of the ACA is so much on improving population health,” Honoré says.
Some hospital leaders who feel they’re being force-fed reform by regulators, payers and competing providers may welcome the opportunity to adopt their own approach when partnering with public health departments. And their efforts are likely to produce a real payoff. According to Honoré, research has shown “definitively” that “if you have a medical condition and you target it with a public health intervention and a medical intervention, you get better outcomes.”
The changing nature of the things that ail us is also driving the trend. “We’ve gone from a time when most diseases were acute to now when most are chronic,” many related to social and environmental factors, says Brian Castrucci, chief program and strategy officer for de Beaumont Foundation, a public health-focused nonprofit. However, “physicians don’t have the tools to go beyond the clinic walls.”
Collaboration vs. competition
Even hospitals that might compete on some level are discovering the benefits of cooperating on certain health initiatives. It’s less expensive and easier for two or more hospitals to create a needs assessment together, likely in concert with local public health departments. Because the ACA also mandates the creation of an implementation strategy, the natural next step forward is to take action.
At first, that typically would entail tackling some of the more easily identified community health obstacles, such as smoking or obesity, says Somava Stout, M.D., executive external lead for health improvement at the Institute for Healthcare Improvement. “As they do that, they begin to discover where they need to go. And they learn how easy and much more fun it is to have all [parties] at the table,” she says.
An Institute of Medicine report in 2012 highlighted synergies that can be captured as a result of public health and health care organization collaboration. It can improve care coordination and access, as well as quality and cost-effectiveness, according to the report “Primary Care and Public Health: Exploring Integration to Improve Population Health.”
In addition, the report notes that such cooperative efforts can improve the use of clinical practices to identify community health problems, encourage community campaigns to promote health and strengthen the community’s hand in policy decisions.
One such partnership, the Healthy Columbia Willamette Collaborative, comprises 15 hospitals, four local public health departments and two coordinated care organizations, and spans four counties in two states.
“It’s great [that] all the various entities have the same prioritized issues and use the same qualitative and quantitative data,” says Kari Stanley, director of community benefit for Legacy Health, one of the members of the Oregon and Washington state-based collaborative.
Stanley says Legacy’s membership in the collaborative coincides with a shift in how it operates in the region. “Yes, we started with community health needs assessment requirements, but our whole mindset has changed,” Stanley says.
The focus now for participating organizations is more on keeping people healthy, preventing illness and trying to limit the onset of chronic conditions.
“The ultimate goal is that the hospital’s role will be reduced because people will be cared for more on the outside,” she adds.
That altered mindset is fed by cooperation among groups that previously would not be inclined to work together because of competitive reasons. “We all have this goal together that maybe we didn’t independently have before,” Stanley says. “For us all to have gotten this far is amazing.”
She says that members of Healthy Columbia Willamette have advanced the effort and began working together to develop strategies to solve community health problems. Initially they have been working to promote breastfeeding and the use of breast milk, as well as trying to prevent prescription opioid misuse.
Another factor that’s promoting more cooperation has been the advancement in health information technology.
“We’ve come a long way as an industry in being able to automate information about the care of patients in most environments and most communities,” says Bruce Henderson, managing director and leader of the health care strategy practice at Navigant Healthcare, a consulting company.
“It wasn’t so much that people didn’t want to collaborate before; it was that it was challenging to do so in a manual fashion,” Henderson says. Health IT enables hospitals and public health departments to work in concert to collect and report information on potential public health problems more quickly than they could previously. “The exchange of information is at an all-time high,” he says.
Programs encourage cooperation between hospitals and public health
iven that communities can vary widely in makeup and population health needs, there’s no single formula for how hospitals and public health departments should work together. But guidance and examples of success can be found at such organizations as the Commonwealth Center for Governance Studies Inc., the de Beaumont Foundation, the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation. Industry associations such as the American Hospital Association and its Association for Community Health Improvement, the National Association of County and City Health Officials and the Association of State and Territorial Health Officials also offer resources.
The Commonwealth Center in November published a report identifying the common traits of 12 successful partnerships and issued a list of 11 recommendations on how others might want to proceed when forming their own [see Executive Corner, Page 37]. The report was funded with support from Grant Thornton LLP, Hospira Inc. and the Robert Wood Johnson Foundation.
The researchers concluded that membership buy-in is key. “You’ve got to begin by having the right partners around the table — partners who share the vision, share the commitment and are willing to invest time and effort,” says lead author Lawrence Prybil, Norton Professor in Healthcare Leadership at the University of Kentucky and associate dean at the university’s College of Public Health.
Underlying that commitment should be an understanding that the members are going to treat one another fairly and with a shared goal. “If a partnership is not built on trust, it’s not going to work,” Prybil says.
Other organizations are trying to encourage health system and public health partnerships through financial or consultative support. The de Beaumont Foundation, with the Advisory Board Co., the Kresge Foundation, the Colorado Health Foundation and the Robert Wood Johnson Foundation are encouraging partnerships through their BUILD Health Challenge. The challenge will provide $8.5 million in total to up to 17 communities to foster and expand community partnerships.
And in February, the de Beaumont Foundation expanded its backing of an online collaboration tool called the Practical Playbook, which is a how-to manual for better integration of primary care and public health.
The IHI is promoting public health improvement in a number of ways, including as part of its 100 Million Healthier Lives initiative. Within that, the IHI launched the Spreading Community Accelerators through Learning and Evaluation initiative to help connect up to 10 mentor communities with 20 other communities seeking to accelerate community health improvement. The 20-month initiative was funded with $4.8 million from the Robert Wood Johnson Foundation. RWJF also awarded $25,000 to six communities for placing a high priority on health and bringing partners together in the effort, as part of its annual Culture of Health prize.
The AHA, among other guidance, unveiled a toolkit last year called How to Have Community Conversations: A toolkit for advancing health in America. It includes step-by-step instructions for taking action. The introductory letter notes: “As our health care system changes over the coming decade, collaboration and partnership will be crucial to providing quality health care and cultivating healthier communities.
Executive Corner: A study of 12 successful hospital-public health collaborations resulted in the creation of 11 recommendations for groups seeking to work together more closely.
1 | Hospitals and public health departments should be at the core, but a broad range of partners should be included.
2 | When possible, partnerships should be framed around existing, trusting relationships among at least some of the partners.
3 | A partnership should adopt a mission and goals that focus on clearly defined, high-priority needs that will inspire community engagement and support.
4 | One or more anchor members are needed to provide financial support.
5 | A designated body with a clearly defined charter should be created.
6 | Population health concepts, definitions and principles should be well-defined and mutually understood by those involved.
7 | Community health measures, objectives, targets, metrics and tools should be selected.
8 | Develop and disseminate impact statements that measure the effects of the partnership efforts relative to the direct and indirect costs of the partnership.
9 | A deliberate strategy for broadening sources of financial support should be maintained.
10 | Boards of participating organizations should establish standing committees with oversight of their participation in the partnership.
11 | Federal, state and local agencies, hospital associations and public health associations should adopt policy stances that promote cooperation between hospitals and public health departments.
Source: “Improving Community Health through Hospital-Public Health Collaboration,” Commonwealth Center for Governance Studies Inc., November 2014