For hospitals, engaging the community involves a lot more than offering blood pressure screenings in shopping center parking lots.
With the Affordable Care Act — and its focus on wellness and the health of patient populations — community engagement has taken on a new dimension. Hospitals are forming strategic partnerships with a broad spectrum of local organizations, from churches to schools.
In the not-too-distant future, payers will measure hospitals’ performance based on quality measures that go well beyond just patient safety or health care outcomes, notes David Nash, M.D., dean of the Jefferson School of Population Health in Philadelphia. Nash sits on a committee of the National Quality Forum that is tasked by the government to come up with new, reimbursable measures to gauge how well hospitals are working to engage their communities and improve the health of patient populations. Those could include, for example, a “wellness index” for the community or even whether the hospital is growing crops to feed the poor.
Most hospital leaders are “woefully unprepared” for this new reality, Nash says, predicting that many organizations could take five years to retool for it. “The analogy I make is they’re turning the battleship around inside the Panama Canal,” he says.
The American Hospital Association’s Health Research & Educational Trust aims to make that turn less arduous. In October, HRET released a guide, “Hospital-Based Strategies for Creating a Culture of Health.” With funding from the Robert Wood Johnson Foundation, researchers pored over community health needs assessments of some 300 tax-exempt hospitals and interviewed more than 25 leaders to identify best practices to promote community health.
Framing the issue:
- Health reform is tasking hospitals to focus on wellness and treat the health of populations.
- Doing so requires hospital leaders to look outside their institutions to partner with community stakeholders.
- Community health needs assessments can be a key first step to unearthing issues and finding the right partners.
- Obesity, behavioral health and substance abuse are some of the top community health concerns for hospitals, a recent survey found.
They found that access to care, prevention and screening services, and chronic condition management are some of the biggest community health drivers. Meanwhile, obesity, behavioral health and substance abuse rank as the top health concerns for hospitals around the country.
Two key factors hospitals must consider, the report notes, are how aligned their mission is toward population health and the level of commitment and engagement demonstrated by their boards and executive teams. Hospital leaders also must assess their readiness — in terms of resource commitment, core competencies, participation in financial models that reward population health, and the like — along with the depth of their influence in the community, according to the report.
HRET President Maulik Joshi says hospital leaders need to broaden their thinking when forming partnerships to engage communities. Those collaborations go well beyond post-acute providers and community health agencies, stretching to mayors’ offices, YMCAs, and civic, social and religious organizations.
“Hospitals are doing amazing work in health care, and now they’re branching more and more into health,” Joshi says. “We know that, to impact health, it is about socioeconomics, healthy behaviors and the physical environment. It’s much more than the actual medical care. As hospital leaders, we need to continue to broaden our thinking of who we partner with to get to those things and sharpen how we go about it.”
Beyond the data, listening matters
When Allina Health attempted to roll out a strategy in 2008 to reverse some of the negative health trends in the densely populated, multicultural neighborhood of south Minneapolis surrounding its Abbott Northwestern Hospital, there was immediate pushback. The strategies were based on data, but little community input. Residents felt change was being dictated to them from afar, says Ruth Hampton Olkon, manager of community health improvement.
Allina scrapped its plans and started anew, with a rigorous process of polling community members on their needs — conducting nearly 700 phone and door-to-door interviews and convening “listening circles” in which residents discussed the factors affecting their health.
Common themes emerged. For instance, the feedback clearly showed that isolation is detrimental to an individual’s health, while social connections are key to maintaining it.
Allina formed a dozen Citizen Health Action Teams, or CHATs, to bring community members together to chew over neighborhood health issues and come up with solutions. The health system quickly found that it didn’t have sufficient in-house expertise to drive the effort, Olkon says, so it partnered with the Cultural Wellness Center in south Minneapolis.
Each resident-led CHAT receives $5,000 to $25,000 a year to help tackle projects related to community health. They include initiatives such as Growing in the Backyard, which helps residents plant fruits and vegetables on their properties, or Out in the Backyard, to help lesbian, gay, bisexual and transgender residents who feel isolated build a sense of community. As of last year, about 6,600 residents had taken part in Allina’s Backyard Initiatives.
The primary influences on health are environmental and social, Olkon notes, yet most health dollars go toward medical care. Quizzing people in the community about their needs can help to bridge the divide. “Ask what people care about, be clear what the system cares about and see if there’s a place to work on it together,” she says. “Don’t decide the problem or the solution ahead of time; do so in partnership and in a relationship with the community.”
In the past, Olkon says, such research was met with skepticism from some residents, who thought the health system would send staff into the neighborhood, talk to some people and produce a report, with no lasting benefit for the community. Now Allina and the Cultural Wellness Center involve residents in designing surveys to track the progress of the various Backyard Initiative programs. Self-reported stats show that about 80 percent of participants believe their health has improved because of the initiative.
“We have to demonstrate if it works,” Olkon says. “It would be irresponsible not to evaluate as you go.”
Under the Affordable Care Act, nonprofit hospitals must perform a community health needs assessment every three years. That, along with a commitment from senior leadership, was a key jumping-off point for Henry Ford Health System, based in Detroit. The six-hospital system gathered data from multiple sources and used that information to improve engagement with populations through focus groups and surveys, says Kimberlydawn Wisdom, M.D., chief wellness officer and senior vice president of community health and equity. Every three years, Henry Ford collects the health needs information, assesses progress made and decides what changes should be made.
Issues that have emerged include a high infant mortality rate, lack of transportation to make appointments and a dearth of healthful food options. The system staff designed one intervention to teach students how to prepare nutritious meals and sent them home with a bag full of groceries. Another, called Sew Up the Safety Net, deploys health navigators to help mothers through various means, such as home visits and connecting them with providers.
On the horizon, Wisdom says, Henry Ford will be seeking ways to “hardwire the safety net.” She hopes to get reimbursement through the Centers for Medicare & Medicaid Services, rather than rely on unpredictable grant funding, and pursue more seamless integration between the health system and the various navigators and volunteers it deploys to address community engagement.
“We need to find a way to sustain these efforts and build them into the health system, so that the safety net is hardwired and, over time, there won’t be the need to write this grant or find this funding; it’s part of what we do as a health care organization,” she says.
But until those seams disappear, forming unique partnerships with other organizations in the service area is essential, experts say. Henry Ford’s safety net program alone required the participation of more than 30 community partners, including competing health systems in the Detroit region.
HRET’s report, “Hospital-based Strategies for Creating a Culture of Health” points to one study that found that the most common partners for hospitals and health systems are primary and secondary schools (78 percent), local public health departments (77 percent) and chambers of commerce (71 percent). Which ones a hospital aligns with depends on the health needs it’s addressing. Community health centers are most often tapped to tackle access to care, behavioral health and substance abuse, while schools are typical partners in addressing obesity and screening services.
Kaiser Permanente — an integrated system with a health plan and 38 hospitals — has found schools to be key to its community engagement strategy. The Oakland, Calif., organization estimates that about one of every five members spends the majority of his or her day in a school, and those institutions should be seen as an extension of the delivery system, says Loel Solomon, vice president of community health.
‘Sailing into a fierce headwind’
Stemming from its community health needs assessment, Kaiser has pursued an exhaustive approach to community engagement and wellness. Through a program called Thriving Schools, launched across several states last year and now in 312 locations, Kaiser works intensively to engage teachers, staff and students. Kaiser awards grants to schools, used for health coordinators and a curriculum that encourages more physical activity in school. Through another effort, called the Healthy Eating Active Living (HEAL) Cities campaign, dating back several years, Kaiser has worked with city managers to enact policies that include so-called “complete streets” designed and maintained to enable people of all ages and abilities to travel safely and conveniently whatever their mode of transportation. They’re also working with cities to promote activities like biking and walking, and to provide healthful eating options in food deserts. Already, that effort has reached some 246 cities in which Kaiser operates, Solomon says.
Unhealthful behaviors are so ingrained in society, he says, that hospitals have to get creative with their assets to build an infrastructure that forces change. And, hospital leaders must shed the mindset that they can go it alone.
“We’re sailing into a fierce headwind in terms of chronic disease,” Solomon says. “There are billions of dollars spent advertising unhealthy food. There’s a sedentary life industry that is encouraging us to sit in front of our TVs and our videogame consoles. We have workplaces that have us sit all day. Many of us have commutes that make it impossible for us to get exercise as part of the day. These are all huge forces driving this epidemic of noncommunicable disease.” To counter those forces,” he says, “we need to fight fire with fire and focus on the kinds of interventions that are going to change people’s behavior in light of those prevailing winds.”
Reaching the church crowd
In the Memphis, Tenn., area, Methodist Le Bonheur Healthcare has found that churches are key partners in community engagement. Methodist’s community health needs assessment determined that the African-American population had a much higher rate of readmission and a lack of support following discharge from the hospital.
Methodist formed the Congregational Health Network. Methodist deploys volunteer liaisons to some 500 congregations and faith communities in the region, who keep in touch with paid navigators at the system’s hospitals. Congregants who enroll in the network are flagged after being admitted to a hospital and meet with the navigator after discharge to go over their instructions.
Afterward, the liaison keeps in contact with the navigator to ensure that patients get needed services and make a smooth transition to home. The volunteers also help to educate congregants about their care and provide comfort when needed.
Methodist is now experimenting with giving “micro grants” to participants to close small gaps that might interrupt care, be it a prescription refill or a cab ride to the doctor’s office. The program has shown promise thus far, lowering health care charges and inpatient utilization while upping patient satisfaction.
“The level of health in our community was declining at a rapid pace and we knew that the hospital couldn’t just sit back behind its walls and wait for people to get sick,” Baker says. “We had to be proactive, embrace the community’s intelligence and try to blend that intelligence with our clinical expertise to create a true partnership.”
Payers also look to engage patient populations
While hospitals and health systems are seeking ways to engage their communities before health issues arise, insurers are testing their own methods to meet members upstream. Those are taking a variety of shapes, from lower co-pays if patients hit certain health metrics, to conducting cooking classes for people with diabetes.
Humana, based in Louisville, Ky., sees engaging members as key to controlling health care costs, says Roy Beveridge, M.D., chief medical officer. The company has created a series of products to help members stay healthy. For instance, with its Humana Vitality program, members must complete a health assessment at a doctor’s office each year. Based on the results, they can earn points for exercise and healthful eating, to be used for online shopping. Members also can earn 10 percent savings on groceries for buying nutritious items.
“We believe that member/patient/person engagement is really crucial in how we’re all going to control costs and improve health care in our country,” he says. “If we don’t have engagement, then we stand no chance of moving the needle.”
Beveridge says that moving to a value-based model of care will require collaboration across all facets of the industry, and stresses that Humana is working with doctors to ensure that its programs are integrated into care plans.
Blue Cross Blue Shield of Michigan links similar wellness products to the patient’s trusted physician. While any incentive might temporarily change actions, BCBSM is seeking ways to ingrain positive behaviors and turn them into lifestyles, says Cindy Bjorkquist, director of wellness, care management and health promotion programs development. The insurer offers programs such as its Connect 2Bfit, which allows members to build networks with friends and family, set health goals to share with others, and meet fitness challenges. In just the first four months of implementing its programs, members walked some 2.6 billion steps and lost nearly 17,000 pounds, according to self-reported data.
A few years ago when BCBSM started Connect 2Bfit, there were few other comparable offerings. Now, such payer-driven social wellness programs have exploded in numbers, and Bjorkquist thinks that trend will continue as purchasers aim to rein in costs. “You’re going to see more and more of the social wellness edge coming up,” she says. “Employers are trying to motivate people to engage in their health because you can only go so far with these premium surcharges or other incentives.” — Marty Stempniak
Social media’s role in community engagement
As hospitals seek ways to engage larger audiences of potential patients, social media could play a key role. Health care innovators already are finding ways to harness such platforms as Facebook and Twitter, beyond being outlets for patients to air complaints or praise.
Websites such as PatientsLikeMe have shown potential for engaging patient populations and finding trends in the results. Launched in 2006, the network allows its more than 250,000 members to connect with others who have the same disease or condition. The site also generates data, allowing providers and researchers, among others, to seek ways to improve care.
In one test project with the Department of Veterans Affairs, PatientsLikeMe helped people with epilepsy to manage their conditions by using tracking tools, interacting with other patients and researching educational resources. Those who completed the six-week process showed measurable improvement in epilepsy self-management, researchers announced in April.
Chief Executive Officer Martin Coulter expects more care to be delivered in a similar fashion — patients will track their conditions, and doctors will follow their data. “With the rise of consumerism, we are beginning to see more and more people who are engaging in their care,” he says.
Meanwhile, researchers are exploring ways to tap into the power of more ubiquitous social media platforms for community engagement, such as Twitter and its 271 million users. In a study by Johns Hopkins University, researchers analyzed some 5 million health-related tweets a day and found that the process could significantly reduce errors in forecasting influenza trends. Such numbers typically are released on a weekly basis by the Centers for Disease Control and Prevention, on a one-week lag, and aren’t revised until weeks later, according to the study. Twitter, however, could offer daily updates.
Mark Dredze, assistant research professor of computer science and author of the paper, thinks Twitter has further potential for addressing community health. Similar data extrapolation could be applied to other public health trends, such as tobacco use, mental health, pollution or vaccination rates. Providers could someday connect with patients over Twitter to help them manage an addiction or address a safety concern.
“Measuring what’s happening on the ground is the first step to addressing any public health problem,” Dredze says. “So, social media provides a very attractive avenue to do this work because we can look at a lot of data in a lot of communities from all over the world and start to answer very basic questions.” — Marty Stempniak
In its October report, “Hospital-based Strategies for Creating a Culture of Health,” the American Hospital Association’s Health Research & Educational Trust spells out four areas in which hospitals can take action to address community health:
ACTION ITEM: Creating social cohesion and shared value of health
- INITIATIVE TYPES:
- Conducting advocacy, public education
- Improving public planning
- Developing civic leaders
- Hosting community health events
- Gathering volunteers to address socioeconomic or physical health barriers
ACTION ITEM: Collaborating across multiple sectors and building partnerships
- INITIATIVE TYPES:
- Convening with community stakeholders
- Collaborating to offer care to the vulnerable
- Pooling resources across sectors
- Blending health care services seamlessly across settings
ACTION ITEM: Improving and equalizing opportunities for healthy choices
- INITIATIVE TYPES:
- Investing in community development to reduce socioeconomic insecurity
- Stimulating the local economy
- Creating affordable housing
- Building assets to rejuvenate neighborhoods
- Addressing food deserts
- Servicing basic social needs
- Bolstering workforce capacity, local hiring
- Reducing environmental hazards
ACTION ITEM: Improving quality, efficiency and equity of health care systems
- INITIATIVE TYPES:
- Expanding access to health care services
- Broadening insurance coverage
- Offering free or low-cost services
- Using doctors to staff community clinics, providing free care to the vulnerable
- Adopting community outreach programs
- Coordinating care, managing disease
- Assisting with navigation and enrollment
- Providing culturally appropriate care
ABOUT THE SERIES
This is the final installment in Hospitals & Health Networks’ four-part series exploring how hospitals plan to take patient engagement to the next level by involving health care users in all aspects of the delivery system. For previous installments, go to www.hhnmag.com/topics/189-patient-engagement.