When it comes to making connections with communities in order to improve the health status of their members, the leaders of patient care organizations are learning that there are several key strategies that must be pursued, including building a business case for community connection with the c-suite and board; prioritizing the initial focus of community connection efforts; strengthening existing community partnerships; and designing seamless screening and referral protocols.
Those are some of the highlights of a new report from The Advisory Board Company, the Washington, D.C.-based consulting organization. Published in December, “Building the Business Case for Community Partnership: Lessons from the BUILD Health Challenge,” looks at some of the major challenges facing patient care organizations as they pursue population health management strategies. Its lead author was Rebecca Tyrell, a senior consultant in the Research Division at The Advisory Board.
As Tyrell and her colleagues note in the report, “Healthcare extends well beyond care settings—into homes, schools, and neighborhoods. Transforming health outcomes requires a coordinated effort to tackle such contributing factors as socioeconomic conditions, transportation, housing, environmental issues, and access to healthy food. Partnerships among health systems, public health bodies, and community organizations are the most effective ways to address community health. However, most organizations are traveling on separate but parallel paths toward building healthier communities, and as a result, valuable data, information, and resources are often siloed. Increased collaboration among key stakeholders, the researchers note, “will unlock tremendous power and drive better health outcomes. This research highlights innovative partnerships across the country to transform community health. Specifically, there are four critical steps to build the business case for community partnership.”
Those four, the report’s authors note, include engaging in leadership: “build[ing] a compelling business case to garner executive buy-in and needed resources”; prioritizing initial focus—“determin[ing] what services or programs to start with, recognizing process will be iterative”; strengthening partnerships through “leverag[ing the] unique strengths of community organizations to extend care team reach; and designing seamless screening and referral protocols, through “clearly link[ing] these two steps to ensure timely follow-through and improved patient and provider satisfaction.”
These conclusions are connected to research that Advisory Board leaders have reached, based on experience with efforts by providers to create community connections, including, though not limited to, BUILD Health Challenge communities. As its website explains, “The BUILD Health Challenge encourages communities to build meaningful partnerships among hospitals and health systems, community-based organizations, their local health department and other organizations to improve the overall health of local residents.” The initiative is supported by The Advisory Board and by broad range of foundations and initiatives, including the Robert Wood Johnson Foundation, the Blue Cross and Blue Shield of North Carolina Foundation, the Telligen Community Initiative, and several other foundations and initiatives.
As Tyrell and her colleagues note in their report, “The first challenge is narrowing down the list of potential focus areas. The wide range of social determinants of health—economic stability, physical environment, education, food, social context—lead to either decision paralysis or an overwhelming number of initiatives that stretch resources too thinly, resulting in limited impact. Instead, leaders in this space work with their community and use their own data to prioritize a subset of initiatives. Across BUILD participants, food and nutrition emerged as the most common area of partnership. Forty-one percent of BUILD communities are designing innovative programs that link residents to food pharmacies, fruit and vegetable prescription programs, cooking demonstrations, nutrition education courses, and an expanded network of food suppliers to expand access to healthy options.” They go one to note that, “To prioritize efforts in your own community, BUILD leaders recommend organizations: “utilize a mix of qualitative and quantitative data; be transparent about how decisions will be made, especially when priorities may differ across stakeholders; define terms to avoid assumptions and misunderstandings; [and] prevent [the] perfect from being the enemy of [the] good.”
According to Tyrell, round 1 of BUILD projects put their emphasis on the following areas of activity: food and nutrition (41 percent); neighborhood and build environment (35 percent); housing (18 percent); and crime and violence (18 percent), as factors influencing the health of communities.
Shortly after publication of the report, Rebecca Tyrell spoke with Healthcare Informatics Editor-in-Chief Mark Hagland to discuss what patient care leaders are learning in this important area. Below are excerpts from that interview.
Can you tell me about the core objectives of the BUILD Health Challenge?
The BUILD Health Challenge is really designed to bring hospitals and health systems with public health bodies and community health organizations, to go more upstream to look at social and economic factors that influence health. All the results really come from phase one of this project. And there’s a new application round. But fundamentally, we want to address these social determinants.
What has been the timeline for the forward evolution of the BUILD Challenge?
It has come together within the last year.
How many of each type of organization are involved in the BUILD Challenge?
Each of the 18 projects requires at least one of each of [different types of organizations]—a hospital, a public health body, and a non-profit. And the average number of partners per project was about eight.
What did you find, overall, based on the experiences of the leaders of these initiatives?
A lot of health systems know that they should be addressing the issue of the social determinants of health, but don’t necessarily have the time, resources, or expertise. And in some cases, it’s not for them alone—regardless of where you are, community health resources will be essential under value-based payment models. So we’ve distilled four steps. It’s about formalizing the business case. To date, we’ve seen these activities be one-off projects. But we need to embed this into the fabric of our organizations.
And what were the most important elements involved?
Engaging leadership was one. Prioritizing your initial focus was the second (there are a lot of issues you can address in any one community, but you can dilute your efforts, so get good at one thing first). The third: build and strengthen your partner relationships. How do you bring these stakeholder groups together? And the fourth is, how you actually design the screening and referral protocols? Because you can set up a program, but if you don’t’ identify who needs the service, and identify those folks, you won’t have the ROI that you’re looking for.
Where do hospital-based organizations most stumble, with regard to those four important elements that came out of your research?
It’s in understanding the unique strengths that each party brings to the table. So there’s a flowing pace—identifying relationship needs, where to start; it needs to come from the ground up—what does the community want, and what do the hospital and the public health agency and the community-based organization bring to the table? In a lot of cases, the hospital brings the data. But the challenge is in managing the change management aspects of the project.
Do communities ask for the same thing, or different things?
That’s a great question. About 41 percent of the BUILD Health communities chose to focus on food and nutrition issues; that food/nutrition is closely linked to obesity and chronic conditions, and that seems more closely connected to traditional medical care, and folks are more comfortable starting there. More broadly, we see a lot of organizations focusing also on housing and transportation as the other top two issues; but violence and safety are also an issue.
How are the hospital-based organizations finding success?
It comes down to the fact that no provider has the time or resources to manage these issues, even though they strongly impact total cost of care. So it’s about integrating this data into systems, and connect to the community. So the hospital’s role is screening people and providing liaisons into the community. And that’s why the BUILD Health Challenge, by providing the funding and technical support to foster this collaboration, has enabled these organizations to create those links to help follow patients through the new continuum.
Could you provide a couple of examples of how this is playing out?
There are two different types of grants involved here. Some are planning grants, some are implementation grants. And we’ve also in the report showcased some examples from our Advisory Board consulting division. The BUILD Project has only been running for about a year, but we’ve already seen a lot of progress in a variety of areas. West Oakland in the San Francisco Bay Area. There, as in other places, the existence of food deserts represents a huge obstacle to health, putting the health of its residents at risk. Without access to healthy, affordable food, individuals are more likely to experience chronic stress, malnutrition, obesity, and related diseases. San Pablo Area Revitalization Collaborative’s efforts to address the West Oakland food desert led to the creation of the area’s first full-service grocery store in more than a decade.
Another example in California is what’s going on with the Youth Driven Healthy South Los Angeles initiative. In that instance, ten local youth were trained as Community Health Liaisons to help identify and craft upstream solutions for health issues plaguing Historic South Central Los Angeles. The youth have conducted key informant interviews, presented their findings at a series of town hall meetings, and received stakeholder buy-in to solutions for improving their community’s high prevalence of diet-related diseases.
In Cleveland, leaders of a program called Engaging the Community in New Approaches to Healthy Housing, continue to advance their campaign to rid the city of toxic lead paint, which can lead to developmental challenges and lifelong health issues. Their efforts have benefited from the attention and support of Sen. Sherrod Brown, who has drafted federal legislation to better protect Ohio families and called for increased funding from the U.S. Department of Housing and Urban Development (HUD).
And in Seattle’s Chinatown, International District BUILD Health partners coordinated a series of community meetings to better understand barriers to health and wellbeing in the neighborhood. Safety and crime were identified as major sources of chronic stress and sedentary behaviors, especially after last year’s murder of a community leader. The BUILD Health partners spearheaded a survey to inform the development of recommendations to the City for improved neighborhood safety, making direct links between safety and community health. Those are among numerous examples of the kinds of work being taken on in the BUILD communities right now.
What should the CIOs and CMIOs of patient care organizations be thinking about right now, as they and their colleagues consider participating in such community-oriented initiatives?
You bring up an excellent point. The community health needs assessment gives you an excellent direction, in terms of, say, nutritional support. Then you need to identify patients. So we’re seeing a lot of interest in collecting those non-clinical data points during patient interaction. Can clinical leaders support those in standard risk assessments and intake forms, for more individualized information, to refer folks to those community resources or customize their care plan, so we can address those care needs?
What types of functional roles are involved in collecting the data in patient care organizations? Health coaches, nutritionists, etc.?
Anyone who is engaging heavily in risk-based contracting has these potential capabilities. There tends to be a dividing point between the earlier-phase organizations focused only on high-risk patients, and others that are more progressive and who are approaching the rising-risk patients. They’re starting to get more progressive in terms of roles. It can be community health workers, sometimes social workers, dieticians. So it requires proper resource allocation, and it depends on how they organize and deploy those resources. And medical assistants can do it, too, I would underscore that.
How well are the handoffs going to those people?
In physician practices, the handoffs are being conducted quite nicely. Sometimes, it’s a “warm” handoff, meaning that you’re literally walking someone down the hallway. Others have created pop-ups and alerts in the workflow to stimulate handoffs. And there’s a new and emerging role around the community resource specialist. That’s a final link the chain. What’s needed is a high school-educated person, deeply embedded in the community, and connects patients directly to community-based organizations. These individuals are paid by the health system, they’re part of the multidisciplinary team that includes doctors, nurses, Mas, medical directors. Mass General is the organization we’ve profiled.
What will happen in the next couple of years, in all this?
I think that the role of community partnerships will be even more critical than ever, because of the role that social determinants play in total cost and quality outcomes. So if we have to trickle down to reach those social determinants, partnerships are the only way to accomplish that.
Do you have any explicit advice, particularly for our audience?
I would say, recognizing that fundamentally, people don’t want to be patients. So if we want to get into their sphere of activities and be a partner in their health, especially at financial risk, it’s critical to integrate into their daily lives. And we don’t have to reinvent the wheel; there’s a group of organizations set up to do that. We just have to connect the dots; and that’s a key role that a hospital can play.
Is there anything else you’d like to add?
I would just say that the report is really valuable because it pulls together some practices that jumped out as commonalities or lessons learned, so that regardless of who you are or where you’re at, there should be practices that you can implement now. And our best advices is to be proactive and serious about implementing those now, or you’ll be left behind as we move towards more value-based payment models.