Where healthcare challenges find solutions

Care Delivery

June 02, 2018 01:00 AM

Hospitals address social determinants of health through community cooperation and partnerships

Nationwide Children's Hospital helped Community Development for All People expand its fresh food market program, which offers free produce to low-income residents.

Community Development for All People, a Columbus, Ohio-based not-for-profit organization, works on improving social and economic conditions for residents of the city's South Side.

The group began in 2003, focusing on such issues as housing, workforce training, transportation, and health and wellness.

The organization's first effort was buying and rehabilitating dilapidated homes to create affordable housing, either to rent or sell, for community residents.

But those efforts didn't begin to take off until around 2008, when Nationwide Children's Hospital, Columbus' safety-net provider for low-income children, offered to partner in the affordable-housing initiatives.

"We had just begun on this adventure with some initial houses, and as a small organization, we met with some limited success," said Katelin Hansen, strategic initiatives director at Community Development for All People. "But when Children's Hospital approached us to take our program to scale, it was a huge opportunity."

Health systems and community stakeholders around the country are choosing such collaborations to address the social factors that have created great health disparities between low-income and more-affluent neighborhoods.

"We felt we were doing lots of good work relative to our core business of delivering care but didn't really understand how we were perceived in the community," said Timothy Robinson, chief financial and administrative officer at Nationwide Children's Hospital, regarding the decision to work with groups like Community Development. "We were coming from a deficit in that direction and really did a gut check."

A number of health systems have found that investing with key community groups allows them to leverage those organizations' neighborhood connections to increase community engagement in hospital initiatives.

Nationwide and Community Development for All People, have made progress with their efforts. The two initially worked together on the Healthy Neighborhoods Healthy Families Realty Collaborative, a program to rehabilitate up to 75 homes over five years in an area south and east of the hospital's main campus.

Between 2008 and 2012, the vacancy rate of homes located in the area that was targeted by the program declined by nearly 50%, according to the hospital's most recent impact report. The program eventually was extended and was responsible for rehabbing 47 vacant properties, building 11 new homes on vacant lots and selling 56 residential properties between 2008 and 2015.

The program's success sparked collaborations in other areas. To date, the provider is a leading partner in six out of the nine programs and services offered by Community Development, with the hospital providing $300,000 in annual funding.

The hospital's investment has helped Community Development establish a number of initiatives designed to improve wellness throughout the communities they serve. In March, the organization expanded its fresh-food market program that offers free produce to low-income residents who are food insecure.

Other programs include providing maternal care support and job training, as well as one that promotes physical activity by operating a bicycle shop that sells bikes and repair services at discounts.

Poor adults are almost five times as likely to report being in fair or poor health as adults with family incomes at or above 400% of the federal poverty level, according to a 2015 Urban Institute report. Health concerns such as infant and maternal mortality are closely linked to income. Mothers living in low-income households have higher rates of children born at low birth weight, which has been associated with greater risks of developing health problems later in life, including diabetes, heart disease, high blood pressure and obesity.

Such outcomes have been the basis for many of the clinical community interventions—such as health fairs and mobile mammogram and wellness screenings—that are representative of what most hospitals do throughout the country.

The hospital's investment helps Community Development run a bicycle shop that offers bikes and repair services at discounts.

But such offerings are usually as far as most hospitals go with their community-outreach initiatives. Only a handful of health systems have begun to look beyond the clinical to delve into how societal conditions affect the health outcomes of their patient populations.

According to Robin Hacke, executive director of the not-for-profit Center for Community Investment, many hospitals shifted from volume-based to value-based payment models they began discussing how their community benefit resources could be re-deployed to tackle more preventive and upstream issues. These are what "really matter for health," Hacke said.

She said many healthcare providers tend to approach community outreach as just part of their community health needs assessments under the ACA, a requirement to maintain their tax-exempt status as a not-for-profit institution. Some health systems have incorporated addressing social determinants as an important part of their business strategy as they take on capitated risk.

But Hacke said even health systems using a fee-for-service payment model can more strategically apply their community benefit dollars by investing in ventures that address upstream determinants. "They can take the existing money that they have to apply as part of their tax exemption and get more bang for their buck," Hacke said.

Hacke said the benefit of hospitals working with community groups is that it often opens the door for more opportunities to work on other social determinants. But such collaborations are only possible if the possible community partner can sustain itself financially.

Ties that bind

The related challenges can sometimes induce a health system to not only invest in a community group's programs, but also invest in the group itself to keep it viable.

"The ultimate goal here is to really address those issues that are impacting the community and the best way to do that is to invest in our partners and the community-based partners in the area," said Pablo Bravo, vice president of community health at Dignity Health.

For the past several years the system has used a number of strategies to help community-based organizations get the capital needed to launch or maintain programs.

Aside from Dignity's community health programs that directly link needy patients to not-for-profit and social services, the system's grant program has awarded more than $70 million to more than 3,300 community-based projects since 1991.

A total of $5 million is distributed annually, with an average of $50,000 per grant project.

The health system also contributes more directly to community groups through its community investment program, which provides below-market interest rate loans to not-for-profit organizations that offer community development in underserved neighborhoods.

By the end of 2017 Dignity had approved 70 loans totaling approximately $81.3 million, with nearly half invested in affordable housing programs.

"Investing in community organizations is really addressing the social determinants of health that are going to keep individuals healthy," Bravo said. "As a system that helps the hospital from being used inappropriately."

Lessons from the Great Recession

At Kaiser Permanente, addressing social factors related to health outcomes has been a priority for 15 years, according to Loel Solomon, vice president of community health at Kaiser. But it was witnessing the impact of the economic downturn of 2008 that provided Kaiser with a better understanding of the challenges its community partners face in addressing socio-economic needs.

"We're putting a ton of energy into connecting our members to community-based providers that can address their social needs, but we can't build a bridge to nowhere," Solomon said. "The social sector is incredibly fragmented, in many cases under-resourced, and so we need to have a variety of ways to support those organizations."

Support has come in the form of grants to help community groups develop their core infrastructure and data-collection capabilities. Like Dignity, Kaiser has also invested in community organizations to support their projects.

Recently the system committed $200 million to start the Thriving Communities Fund, which was established to invest in projects that address community needs; the initial focus is on reducing homelessness and housing instability.

Over the next five years, Kaiser's fund will likely seek to invest in initiatives targeting food insecurity and economic development.

Other charitable efforts have included collaborating with Colorado anti-hunger organizations to form Hunger Free Colorado, which connects families and individuals to food resources through a statewide food resource line; it also advocates for state and federal policies to reduce food insecurity.

Social services pilot

Also this year, Kaiser invested in a pilot project with longtime partner organization Project Access Now to coordinate referrals of low-income diabetes patients to social service agencies through a network of social workers and care managers.

Kaiser navigators refer patients to social services through an online portal. Project Access coordinates referrals with social service agencies and addresses any technical issues. The pilot's goal is to refer 100 patients by year-end and track their progress to determine if greater access to social support reduces their use of hospital services and helps them better manage their conditions.

Solomon said a major challenge when investing in community development has been learning how to be strategic to optimize a program's impact. Another is balancing support for initiatives that provide resources for an individual community group but with an eye toward scaling up the work to make a regional impact.

Ultimately, one of the biggest challenges Solomon identified is just knowing where to start. He said it is unclear whether it's better to focus on addressing one need at a time or to use a more comprehensive social-needs strategy with community partners that help patients receive support for whatever need they have.

"It's kind of an unresolved question of what's the most effective, expeditious way to address people's most pressing needs," Solomon said.