How can health care professionals continue to expand their thinking about health?
Health is more than what happens in a doctor’s office. Clinical care -- the quality of and access to care -- is estimated to contribute 20% to health outcomes in the County Health Rankings model. But the root causes of health problems often occur outside of the health care system. Think education, income, community safety, housing, and discrimination.
The Robert Wood Johnson Foundation’s Commission to Build a Healthier America examined the factors outside of medical care that influence health. The group’s recommendations have sparked a national conversation on the social determinants of health. Leaders in the field have broadened their definition of health and are exploring how social factors impact patient health and health care costs.
Four key factors are driving health care leaders’ interest in building healthy communities:
- Health care costs. The U.S. spends more on health care than other developed countries, yet does not experience better health outcomes.1
- Changes in reimbursement. The health care sector is seeing a shift in how we pay for care, from volume-based to value-based payment. That shift in payment shifts the focus from the quantity of treatments to the quality of treatments and related outcomes.
- Mission. Health care leaders see community investment as another way to advance their mission.2,3
- Community Benefit. Federal rules require not-for-profit hospitals to engage community stakeholders in a community health needs assessment and implementation plan. Learn more about Specific Assessment Requirements that impact public health and health care.
Beyond Health Care
Health care is critical to health, but health care alone is not sufficient. Patients must also have social and economic resources in the community that address the underlying causes of health.
Social Determinants of Health
The World Health Organization defines social determinants of health as the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities -- the unfair and avoidable differences in health status seen within and between countries.
Put more simply, we’re talking about the things that make your zip code have a stronger impact on your ability to live a healthy life than your genetic code.
What can health care professionals do to build healthy communities?
Health care leaders have the power to influence decision makers within and outside of their organizations. They can use their power to influence change in the workplace, within the health care system, and in the community. They can help shape government policies.
Within clinic walls
Internal policies set within health care organizations impact patient care, as well as the workforce.
Many health care leaders are committed to the Institute for Healthcare Improvement’s Triple Aim, which is focused on:
- Improving the experience of care;
- Improving the health of populations;
- Reducing per capita costs of health care.
Patients. Health care professionals are largely responsible for ensuring quality of care -- one of the health factor focus areas in the County Health Rankings model. Changemakers are working on a variety of approaches to address quality including:
- Patient safety
- Care coordination
- Unnecessary spending and overtreatment
- Culturally competent care
- Patient and family engagement
Learn more about what health care leaders can do to address quality in What Works for Health.
Employees. Health care organizations are often among the largest employers in a community. Health care employment makes up 9% of total employment in the United States. Some experts say the industry can't achieve the Triple Aim's core ideals unless it first improves the work life of health care providers.4
Health care organizations set internal policies that impact the health of the people they employ. For example, as employers, these organizations can help ensure:
- All of their employees earn a living wage.
- Employees have access to comprehensive benefits, including quality health care.
- The work environment supports healthy choices.
Learn more about what employers can do to impact the health of their workforce in What Works for Health.
Beyond clinic walls
We know the root causes of health problems often occur outside of the health care system. Think poverty, blighted neighborhoods, poor educational systems, or lack of access to health care services. So, health care changemakers are looking beyond clinic walls to improve patient and community health.
Health care organizations and their leaders are beginning to go beyond their “community benefit” strategies. They are changing their institutional business practices to benefit the community where they are based. This can include examining things like:
- Where they purchase goods and services
- Where they locate their services
- Hiring and workforce development practices
- Where they’re investing their money, and more3
Health systems wield great economic power in their communities. According to the American Hospital Association, hospitals employ nearly 5.7 million people and spend nearly $852 billion on goods and services from other businesses.5
Health care providers can be influential advocates for community-wide policies to address the root causes of poor health.
Build bridges. When health care leaders partner with changemakers outside of health care, they can impact a specific patient population or the broader community. Going Beyond Clinical Walls: Hats Matter, a 2.5 minute video, illustrates the power of partnership across sectors to improve health outcomes.
The 2010 Patient Protection and Affordable Care Act (PPACA) -- more commonly known as the Affordable Care Act -- requires not-for-profit hospitals to conduct a community health needs assessment every three years. (You might hear health care folks refer to these assessments as CHNAs.) Hospitals must:
- Use public data;
- Engage community stakeholders;
- Develop an implementation plan.
This requirement opens the door to partnerships with a variety of sectors. Key partners could include:
- Public health
- Health care payers
- Social service providers
- Community development
- Grassroots community groups
- Local philanthropy and investors
The Practical Playbook supports partnerships between primary care and public health groups by providing resources, lessons-learned, and guidance to help along the way. The CDC Community Health Improvement Navigator (CHI Navigator) also offers tools and resources for those who lead or participate in community health improvement work within hospitals and health systems, public health agencies, and other community organizations.
Partnering for Healthy Communities
We need to collaborate with local business and community leaders, and even our competitors, to create communities that are among the healthiest in the nation. This is critical to fulfill our mission and to make health care more affordable for all.3
Some health care organizations have foundations or make charitable contributions to their community. Changemakers can use this type of giving to fund community health improvement efforts. The Democracy Collaborative estimates that health care endowments amount to at least $500 billion nationally. They’ve found that some health systems have created community investment portfolios that leverage a portion of this money and use it to support the kinds of interventions that create healthy communities. Think affordable housing, federal qualified health centers, grocery stores, child care centers, and local small, disadvantaged, and minority- and women-owned businesses.3
Hospital investments that are focused on certain community building activities are also recognized as community benefit. Catholic Health Association’s What Counts as Community Benefit tool provides additional clarity about what qualifies as community benefit investments. Here are some examples of community-building activities:
- Housing for low-income seniors
- Crime prevention programs
- Advocating for access to transportation, affordable housing, and early childhood development programs
How do I connect with health care?
Do your research
We mentioned Community Health Needs Assessments and Implementation Plans above. CHNAs are a great way to understand the hospital’s assessment of the community’s priorities and to begin to identify where your interests align. The Affordable Care Act requires hospitals to make their CHNA reports widely available to the public. You can generally find them on their website.
Ask questions like:
- How do our interests align?
- How do our assets align?
- What assets do we have to offer?
- What assets might health care partners have to offer?
The Community Benefit Insight website may be a helpful place to start. This site provides data to the public on non-profit hospital community benefit spending. You can use this resource to discover what’s happening locally or nationally and to compare spending across hospitals.
Health care often serves as a convener for or is a member of local coalitions. An existing coalition is an ideal place to explore partnerships.
Once you’ve got some organizational context, look for a way to connect with a person.
Health care organizations are often large with complex hierarchies. Ideally, you’ve identified one or more key changemakers in the organization. This could be the person who heads up community outreach or who is responsible for assessing community needs, community benefits, or population health.
If you have a mutual partner, ask for a warm introduction. If not, introduce yourself. As with anyone, it’s helpful to start by asking about their efforts and priorities and looking for where your interests align.
What’s in it for them?
Health care is often eager to connect with other changemakers. Earlier, we named four key factors that are driving health care leaders’ interest in community health improvement.
- Health care costs
- Changes in reimbursement
- Community Health Needs Assessment requirements
- OECD (2017). Health spending (indicator). https://data.oecd.org/healthres/health-spending.htm doi: 10.1787/8643de7e-en. Accessed November 21, 2017.
- Hacke R, Deane KG. Improving Community Health by Strengthening Community Investment: Roles for Hospitals and Health Systems. Center for Community Investment. 2017. www.rwjf.org/content/dam/farm/reports/reports/2017/rwjf435716 Accessed August 22, 2017.
- Norris, T. & Howard, T. (2015, December). Can hospitals heal America’s communities? Democracy Collaborative. Democracy Collaborative. https://healthcareanchor.network/2019/11/can-hospitals-heal-americas-communities/ Accessed September 11, 2017.
- Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576. doi:10.1370/afm.1713.
- Hospitals Are Economic Anchors in Their Communities. American Hospital Association. 2017. https://www.aha.org/system/files/content/17/17econcontribution.pdf Accessed September 19, 2017.
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