Category Archives: Hospitals and hospital systems
There is great promise in leveraging the strengths and resources of both the health care and public health systems to create healthier communities. Hospital community benefit is one critical area of opportunity for greater collaboration. Historically, nonprofit hospitals, as a condition of their tax-exempt status, have been required to enhance the health and welfare of their communities. Through the Affordable Care Act, nonprofit hospitals will have the opportunity to direct their community benefit efforts toward public health interventions and collaborate more effectively with local health departments.
Paul Kuehnert, MS, RN, senior program officer and director of the Public Health Team at the Robert Wood Johnson Foundation (RWJF), shared his insights on the opportunities and challenges that lie in integrating health and health care. Prior to joining the Foundation, he was county health officer and executive director for health for Kane County, Ill., where he led a partnership between the health department, hospitals and other partners to assess and address the community’s health needs. Paul is a Pediatric Nurse Practitioner and worked as a primary care provider in schools and other community settings in Missouri and Illinois.
NewPublicHealth: There has been lots of conversation across the public health field about the need for more strategic coordination or integration with health care. Why is there so much focus on this now?
Paul Kuehnert: There are a couple of reasons for that. One of the primary reasons is that we know that there are increasingly limited dollars for public health. We really have to be as efficient and effective as we can be in trying to improve health in our communities. There’s a common interest between public health and health care around controlling the overall cost of health care. At the same time, we’re not getting the kinds of health outcomes we need. There’s this dynamic of mutual interest in controlling cost and finding ways to improve health and get to the best health outcomes for the community.
Several sessions at this week’s American Public Health Association meeting in San Francisco urged nonprofit hospitals and public health departments seeking national accreditation to join forces on community assessment reports that both are required to file.
Assessments can reveal critical needs in a community, such as asthma trends that could point to poor housing conditions. In a growing number of cities, such reports are providing the evidence needed to marshal resources and action such as dispatching case workers to make home visits to help prevent and reduce asthma emergencies. Such expenditures can reduce the cost burden of paying for emergency care and prevent more health crises in the first place.
In San Francisco, the health department and the city’s non-profit hospitals have been collaborating on community benefit and needs assessments reports since 1994 and have achieved much more than “just a sheaf of papers that sits on a shelf,” says Jim Soos, Assistant Director of Policy & Planning at San Francisco Department of Public Health. The collaboration has resulted in a number of critical efforts to improve health here, including San Francisco’s Community Health Improvement Plan (CHIP), which will be launched by early in 2013.
>>EDITOR'S NOTE: On 9/13/2012 CeaseFire changed its name to Cure Violence.
Sheila Regan manages hospital partnerships for Cure Violence, formerly CeaseFire, an organization based in Chicago that has pioneered a public health approach to stopping shootings and killings. A grantee of the Robert Wood Johnson Foundation, Cure Violence has been successful at reducing violence in cities across America.
This week at APHA, Cure Violence shared how violence presents all the same characteristics of an infectious disease. Like tuberculosis or cholera, violence appears in clusters; it spreads and can be transmitted. By changing the frame on violence, Cure Violence is able to use proven public health strategies from other epidemics to stop shootings and killings. Hospital partnerships are a key part in stopping the spread and transmission of violence.
NewPublicHealth: Can you explain how Cure Violence’s hospital partnerships work?
Sheila Regan: We have a number of partnerships with level I trauma centers that are committed to the public health approach to violence prevention. We serve patients who are violently injured, typically shootings, stabbings or beatings and work to prevent further violence, retaliation or re-injury, which are seen as normal in our culture. There are the doctors, police, nurses, social workers, and everybody you’d expect to see in the hospital. What we’re trying to do is introduce a third party—our workers—who can impact behavior and mindset around violence at an opportune moment.
NPH: When someone has been injured, what is the goal of Cure Violence working with them in the hospital?
Several sessions at this year’s American Public Health Association meeting include brass-tacks guidelines for initiating and furthering partnerships between public health and hospitals to improve community health. In a session yesterday, Michael Bilton, who co-founded and leads the Association for Community Health Improvement of the American Hospital Association, spoke about the value of partnerships between public health and hospitals, since both have requirements to complete similar community needs assessments.
Health departments seeking public health accreditation must complete a community needs assessment, and non-profit hospitals must complete community benefits reports every three years under the Affordable Care Act.
Bilton pointed out that for many communities, the collaboration won’t be one that starts from scratch. San Francisco has had a community benefit requirement for non-profit hospitals since 1994, “which promoted a sense of collaboration in many communities,” Bilton told the audience at the APHA session.
Bilton says the collaboration also aligns with the National Prevention Strategy, released by the Surgeon General last year, which is promoting partnerships across federal agencies to improve community health.
>>Read an interview series on the National Prevention Strategy on NewPublicHealth.
Bilton says the Strategy specifically points to community needs assessments as a way to identify and begin working on many of the priorities in the Strategy. “And those priorities have already been identified by many hospitals,” says Bilton. The joined forces of hospitals and public health departments also help achieve the “triple aim” of additional goals stressed in the Affordable Care Act including improving improving care, improving health care quality and reducing costs. These collaborations underscore the notion that helping to manage population health is the role of hospitals as well, said Bilton.
Bilton advised public health officials anxious to collaborate with hospitals on community benefit requirements to do several things including:
- Become acquainted with hospital regulations
- Approach hospitals as early as possible in your process
- Find out who is leading the assessment
- Ask hospitals about their assessment process and goals
- Offer to help hospitals with with data, communications, facilitation or staff expertise, as appropriate
- Balance short term needs such as fulfilling IRS or accreditation requirements with longer term opportunities—sustained health improvement collaboration.
>>Bonus Link: Read a NewPublicHealth interview with Laurie Cammisa from Children's Hospital Boston on community benefit collaboration.
The Community Health Initiative (CHI), a program of the Cincinnati Children’s Hospital Medical Center in Ohio, includes work with nontraditional community partners to support community organizing and address critical children’s health issues in the community. For example, using geocoding technology to identify areas of greatest need—“hotspots”—by mapping clusters of readmitted asthma patients to substandard housing units owned by the same landlord. CHI partnered with the Legal Aid Society of Greater Cincinnati, which helped tenants form an association and compel the property owner to make repairs. CHI also makes referrals to Legal Aid for patients who need help with Medicaid benefits or require other legal assistance. CHI has developed specific health metrics with which it evaluates the effectiveness of its programs and shares these data with local community organizations and CHI’s community partners.
The CHI work was featured in a new community benefit issue brief from The Hilltop Institute at UMBC, “Community Building and the Root Causes of Poor Health.”
NewPublicHealth recently spoke with Robert Kahn, MD, MPH, who is the Director of Research in the Division of General and Community Pediatrics at Cincinnati Children’s Hospital.
NewPublicHealth: What are the goals of the Community Health Initiative?
Robert Kahn: The Cincinnati Children's Hospital board established in its strategic plan for 2015 four goals that relate to the health of all 190,000 children in our county. The goals relate to: infant mortality, unintentional injuries, asthma, and obesity rates as they relate to hospital readmissions. Our plan is to build a strategy and an infrastructure to cover the ground between a more traditional clinical approach and a truly public and social wellbeing approach to these conditions.
NPH: Why are partners so critical?
Jose T. Montero, MD, director of the Division of Public Health Services at the New Hampshire Department of Health and Human Services, was elected president of the Association of State and Territorial Health Officials (ASTHO) during the association’s recent annual meeting in Austin, Texas.
Dr. Montero began his medical career in Putumayo, Colombia, where he served as a local, county and state health official. He then went to teach family and preventive medicine and later became Colombia’s public health director. Dr. Montero began his service in New Hampshire in 1999 as chief of the New Hampshire Communicable Disease Section in the Division of Public Health. Before becoming director of the New Hampshire Division of Public Health Services, Dr. Montero was the state epidemiologist. He is an adjunct professor of family medicine and a member of the preventive medicine residency advisory committee at Dartmouth Geisel School of Medicine.
NewPublicHealth spoke with Dr. Montero about the new ASTHO President's Challenge, which will focus this year on the integration of public health and health care.
NewPublicHealth: Why is so critical now to work toward the improved integration of public health and health care?
Dr. Montero: We keep talking about the health system but there is not much that is health-focused—it’s currently mostly about providing care after people becomes ill. From a public health perspective we’re trying to improve outcomes and quality, without spending the amount of money on health that we’re currently spending because we can’t sustain that. The system needs to continue changing and evolving, but we don’t yet know what exactly how it will look or how it should look. We need to create a new system. Based on the experiences of some states, such as Massachusetts and Oregon, we know gaining access to health insurance has expanded use, but we don’t know if they’ve achieved improved health outcomes yet. We’re working toward that. But we need to work on the right indicators that allow us to consistently measure total population health.
When you look across the country, you see that public health entities provide the continuum of care throughout the life cycle. We are already integrating health care and the public health system at several different places and levels, but it’s not consistent. To prepare ourselves for the future, we need to be able to look at public health and health delivery systems and integrate them philosophically. We need to capture examples, decode them, and see what works and what doesn’t and how to use which in different parts of the country. We have different cultures, different investment levels, and different expectations. We can’t just copy and paste.
NPH: What are the critical issues you’re looking at?
Health promoting hospitals—it sounds like an obvious concept, but a reimbursement-driven focus on treatment rather than prevention actually makes this a somewhat novel idea. Now, the World Health Organization health promoting hospitals initiative incorporates health promotion concepts, values and standards into the organizational culture and daily routines of hospitals around the world. The concept also allows all hospital employees and their families, patients and their families, and community residents to participate in health promotion together.
Taiwan has the largest network of health promoting hospitals in the world, Shu-Ti Chiou, MD, director-general of Taiwan’s Bureau of Health, told state health officers attending the ASTHO meeting. In Taiwan, one-quarter of all hospitals have received status as a health promoting hospital and many more have signed on to cancer screening initiatives that give reminders to patients about certain cancer screenings no matter the primary reason for their hospital or clinic visit.
Examples in Taiwan include a tobacco awareness campaign by the Pingtung Christian Hospital for community residents. Participants who smoked were provided with referrals for counseling services, and the outpatient smoking reminder system kicked into gear every three months to create contact with the smoker and discuss their smoking status or quit plans.
At the Cardinal Tien Hospital in Yung Ho, through the health promoting program of hospital, the rate of women hospital employees aged 30 and above who have had a Pap smear has increased from 30 percent to 80 percent, while those aged 50 and above who received mammography screening has reached 82 percent, thanks to a reminder system in place at the hospital.
In an interview with NewPublicHealth, Dr. Chiou says she has seen individual examples of health promotion at a number of hospitals in the United States, and two health promoting hospital networks are now in place—with three hospitals each—in Connecticut and Pennsylvania, both at early stages of their work.
“No matter the reason for a hospital visit, health promotion is an opportunity during an outpatient or inpatient stay,” says Dr. Chiou.
While so far only 25 percent of beds are in health promoting hospitals in Taiwan, the national cancer screening initiative is in place in 232 hospitals that have installed automatic reminder systems for cancer screening in outpatient services. The hospitals provide screening reminders for four types of cancer: oral, cervical, breast and colorectal. When an oral cancer screening reminder is prompted, health professionals also ask about smoking status “and the next step is to invite smokers to join cessation services,” says Dr. Chiou.
“We have found that many hospitals see the concept as a win/win and are applying for [health promoting hospital] status, and we look forward to meeting more hospital leaders in the U.S. to share the concept,” says Dr. Chiou.
GUEST POST by Lisa Junker, CAE, director of communications for the Association of State and Territorial Health Officials (ASTHO)
At the opening session of the ASTHO Annual Meeting in Austin, Paul Wallace, vice president of The Lewin Group, pointed toward the need for collaboration and partnership between the health care and public health sectors to overcome key challenges and trends facing the United States at the federal, state and local level.
>>Read our earlier interview with Paul Wallace on public health and primary care integration.
“What are the opportunities to create a shared conversation around prevention?” asked Wallace, who chaired the Institute of Medicine (IOM) Committee on the Integration of Primary Care and Public Health.
He gave attendees an overview of the process his IOM committee underwent to develop the recently-released report “Primary Care and Public Health: Exploring Integration to Improve Population Health.” The committee was charged with identifying the best examples of effective integration and the factors that promote and sustain those efforts, examining the ways federal agencies can use the provisions of the Affordable Care Act to promote integration, and discussing how Health Resources and Services Agency (HRSA) supported primary care systems and state and local public health can promote those efforts moving forward.
On July 1, John Wiesman, Director of Clark County Public Health Department in Washington State became president of the National Association of County and City Health Officials (NACCHO), which is having its annual meeting in Los Angeles this week. NewPublicHealth spoke to Wiesman about his work in Clark County and his goals as president of NACCHO.
>>Follow NewPublicHealth coverage of the NACCHO conference throughout the week.
NewPublicHealth: What are some health-related accomplishments in Clark County that might serve as models for other communities?
John Wiesman: I think we’ve done a number of important things in our county. We strategically transitioned out of clinical services and partnered with community organizations that could provide those services.
NPH: What were some of the advantages of that change?
Richard J. Umbdenstock, American Hospital Association: Opportunities for Collaboration Between Health and Health Care
The intersection of health and health care was an important theme at this year’s Keeneland Conference—during sessions on recent IOM reports, in hallway conversations, in discussions of Public Health Services and Systems Research that explores the most efficient ways to deliver public health services, and, notably, during the keynote address by Richard Umbdenstock, president and CEO of the American Hospital Association.
In his presentation, Umbdenstock talked about hospitals and public health, "collaborating for communities," and said that as health care providers, hospitals had tended to focus on treating the individual, rather than on prevention for the population. Now, he said, the money is gone and the public cares more about health, meaning it makes less and less sense for either hospitals or public health to be concerned with protecting their turf. “We need to incent health and deglamourize consumption.” Quoting a colleague, Umbdenstock said “what we need to do is create an epidemic of health.”
Umbdenstock spoke frankly when he told the attendees, “hospitals want to improve the lives of their patients, and not just their health care. Rather than wait for an [hospital] admission that won’t be paid, they’d rather get upstream on primary care.”
“Public health departments must be funded and supported so that wellness and prevention touches all and there are enough resources to do that,” said Umbdenstock. “And this is where research can play a big part—collaborative health research. We need to know the most effective collaborative models and the most effective ways to advocate for greater personal and community responsibility.”
NewPublicHealth caught up with Richard Umbdenstock following his talk.
NewPublicHealth: What are you hearing from hospitals about the new IRS community benefit requirement?
Richard Umbdenstock: Some hospitals have had similar responsibilities at the state level and many have had to put out accountability reports to their communities, so for many it’s not a new concept. In addition, hospitals have long been under a microscope and they also understand that community benefit is a wonderful community education tool. If they can tell it in a clear and consistent fashion, there’s a real opportunity for the public to better understand what hospitals and public health departments do.
NPH: Do hospitals and public health understand the critical community roles each one plays?
Richard Umbdenstock: I don’t think there’s any question what public health departments do after you’ve see them spring into action after a disaster, just as a lot of people don’t value what hospitals do until after they’ve been a patient. On a day-to-day basis we can all get so deep in our work that we just don’t see what the other person is doing. What we’re learning is that we all serve the same person.