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There’s a growing recognition that good health depends on “upstream” population health actions (http://bit.ly/1iXkx5p), well before a person enters the health care system, and that community institutions play a key role.
Stuart M. Butler, PhD
But which institutions are well placed to function as hubs to integrate health care and other services within a community to achieve better health? Certainly, community schools, which are public schools that work with partners to provide a range of health and social services to children, have taken on that role with success (http://bit.ly/1qcjE54).
What about hospitals? Some hospital systems, such as Montefiore Health System in the Bronx, New York, have a long history of collaborating with the local community to tackle upstream problems (http://bit.ly/1HKsHEW). Some others, such as Washington Adventist Hospital in Maryland, are now experimenting with multiple approaches to building healthy neighborhoods (http://brook.gs/1MZpBo6). Indeed, there is growing interest in hospitals playing a greater upstream role (http://bit.ly/1HDA5an).
Motivations for Community Involvement
Traditionally, hospitals have focused more on fixing the results of illnesses and accidents, not on addressing nonmedical factors ultimately affecting health, such as poor housing and nutrition. But the success of “hotspot” strategies (http://bit.ly/1HKt2qV), as well as other initiatives undertaken by the medical system to address the social determinants of health, is prodding many hospitals to rethink their role in the community.
There are now some financial and regulatory nudges, too.
Since 2012, for instance, hospitals face financial penalties if a higher-than-expected number of their discharged Medicare patients with certain conditions are readmitted to a hospital within 30 days. That gives hospitals a financial incentive to find ways to cut down on readmissions by working with the community and organizing home-based support services (http://nyti.ms/19uiCQr). That’s led some hospitals, like Washington Adventist Hospital, to form multiple partnerships with community organizations (http://brook.gs/1MZpBo6). Some intermediaries are helping hospitals in this effort. For example, a nonprofit organization called Health Leads provides college volunteers to hospitals to connect patients with community services (http://1.usa.gov/1SLGhOP).
Another influence is the community health needs assessment (CHNA), enacted as part of the Affordable Care Act (http://bit.ly/1MZsg13). It requires nonprofit hospitals to analyze and report on the health needs of their communities and to develop a strategy to address them. Though still in its infancy, the CHNA likely will encourage more hospital-community partnerships.
“Wrong Pockets” and Other Obstacles
Nevertheless, hospitals face several obstacles when they seek to become more active in improving community health.
One problem is information sharing. Differing data systems make hospital partnerships with local organizations and government agencies difficult. Privacy restrictions on data sharing add to the challenge.
Hospitals also often face the disincentive of a “wrong pockets” problem (http://bit.ly/1RRnvVn). For a hospital, investing in community partnerships is an “out of pocket” cost, usually with no direct financial benefit to the hospital itself (other than, perhaps, an avoided readmission penalty). Worse still for the hospital’s bottom line, if the hospital’s community outreach means fewer people need hospital services, then the hospital loses business—a classic example of “no good deed goes unpunished.” On the other hand, the economic benefits resulting from the hospital’s initiatives end up in another pocket—the community and its residents.
The wrong pocket problem is compounded by different government agencies and budgets operating within bureaucratic silos. For example, a good way to reduce health costs and medical emergencies involving elderly people is to focus on such interventions as adapting apartments to reduce the chance of falls and making sure the elderly have good nutrition. Yet when hospitals take the initiative to address these issues, such as Health Leads issuing “nutrition prescriptions” (http://bit.ly/1MZssNC) or hospital nurses making home visits to do safety and kitchen checks, the resultant savings to state or local social service agencies is not identified, measured, and recorded.
Steps Needed for Progress
At least 4 steps are needed if hospitals are to play their full role in improving the health of their communities.
First, there needs to be more attention to developing the metrics required to identify and measure the social and economic benefits of a hospital’s community work—the true return on investment.
Second, action is required to make it easier to share information, so that hospitals, schools, and other institutions in the community, as well as government bodies, can coordinate more effectively. One such promising initiative is the Urban Institute–led National Neighborhood Indicators Partnership, which is developing integrated data for community-based partnerships (http://bit.ly/1Mq3Loe). Meanwhile, the Actionable Intelligence for Social Policy program, at the University of Pennsylvania, is helping some counties and cities to integrate data across agencies and cities, so that they can identify the benefits of cooperation and partnerships (http://bit.ly/1MMkMYX). With more data integration and sharing, it will be easier to view the effect of hospital-led initiatives.
Third, to help address the wrong pocket problem, government budgets and payment systems at all levels need to provide flexibility and to blend funds, with the goal of achieving a joint return on investment. If it makes sense for a hospital to incur costs for prevention or nutrition improvement because that leads to reduced social welfare costs, then it’s in everyone’s interest to provide the right incentive. Thus, part of the savings needs to be shared with the health care budget and the hospital should be appropriately rewarded. Fortunately, some limited progress towards blending housing, health care, and other funds is occurring, thanks to the Medicaid waiver program and pilot programs run by the federal Center for Medicare & Medicaid Innovation (http://1.usa.gov/1NNEhWg).
And fourth, new forms of investment capital are required to finance hospitals to undertake innovative approaches that lead to community benefits but do not result in revenue to the hospital. Some government jurisdictions are beginning to help with this. For instance, the state of Maryland has created a fund to help finance initiatives by hospitals and other institutions that improve community health (http://1.usa.gov/1PqkyNK). Some jurisdictions are also starting to experiment with social impact bonds, which are a type of bond that allows jurisdictions to attract private venture capital that can be used in new ways to fund creative approaches to social goals (http://urbn.is/1Qy5vRj).
Hospitals are usually seen as the last resort in their communities—the place you go when other things fail. Yet they have enormous potential to be partners in improving the general health of the community. Unfortunately, there are obstacles to them playing this role. These need to be fixed.
Corresponding Author: Stuart M. Butler, PhD (email@example.com).
Published online: November 12, 2015, at http://newsatjama.jama.com/category/the-jama-forum/.
Disclaimer: Each entry in The JAMA Forum expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association.
Additional Information: Information about The JAMA Forum is available at http://newsatjama.jama.com/about/. Information about disclosures of potential conflicts of interest may be found at http://newsatjama.jama.com/jama-forum-disclosures/.
Butler SM. Can Hospitals Help Create Healthy Neighborhoods? JAMA. 2015;314(23):2494–2495. doi:10.1001/jama.2015.16749
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