It may be a modest exaggeration to credit seven paragraphs in the Affordable Care Act (ACA) for a hospital system breaking ground on a $40 million behavioral health hospital. It certainly wasn’t the sole reason a Paducah hospital opened medical clinics in the public schools or started a Congregational Care program in partnership with area churches. And there were plenty of other factors that prompted KentuckyOne Health to launch a Health Connections program that has garnered considerable national attention.
Nevertheless, several administrators and leaders from Kentucky hospitals and health systems do credit the Community Health Needs Assessment (CHNA) provision in the ACA as a key motivator for those projects and others ongoing throughout the commonwealth. It is also credited with stimulating innovations in health education and public outreach, and – most importantly – to have promoted even stronger collaborative relationships among hospitals, public health organizations and the communities they each serve.
What is a CHNA?
The ACA requires hospitals with not-for-profit tax status to complete a Community Health Needs Assessment every three years. Given the political rhetoric regarding the ACA as a whole, a natural assumption might be that there is a level of resentment toward the CHNA requirement. But general attitudes actually are quite favorable toward CHNAs if the sentiments expressed by Annabelle Pike, manager of healthy communities with the KentuckyOne Health system, and Dr. Alison Davis, executive director of the Community and Economic Development Initiative of Kentucky (CEDIK), are any indicator. In fact, Tim Marcum, regional director of planning for Baptist Health Kentucky, said the CHNA provision is easily his “favorite aspect of the ACA.”
The goal of a CHNA is relatively simple.
To maintain not-for-profit tax status with the Internal Revenue Service, a local hospital must take the lead in assembling a community steering committee to conduct a comprehensive survey identifying the most pressing issues affecting overall health in the primary service area. The committee develops a report outlining the area’s unmet health needs, ranks them by priority, then proposes an implementation strategy of possible solutions.
Importantly, the hospital does not produce a CHNA alone. It is expected to lead the effort, but the law requires that the steering committee include:
• Representatives from local public health agencies.
• Leaders in local government, education or civic organizations.
• Members of the general public. (In particular, CHNAs must include feedback from families who are part of the medically underserved population.)
The first rounds of CHNAs were complete by the end of 2013. Near the end of 2016, most hospitals have completed their second round. The second includes reports on the progress made on implementation strategies from the first. All CHNAs and implementation strategies are available to the public through hospitals’ websites.
It is an easier process to describe than to carry out.
Time consuming, but well worth it
It took one of Kentucky-One Health’s Louisville hospitals about 18 months to complete its first CHNA and implementation strategy, said Annabelle Pike, but this is about normal considering the area’s population and the extensive list of health needs that crop up in a diverse population.
“It’s important to make sure we get a reliable representative sample of the population, particularly of those in underserved areas, if the data is going to be valuable,” Pike said.
The time commitment is less for smaller hospitals, but not by that much, said Dr. Alison Davis. The CEDIK program, based at the University of Kentucky, provided CHNA coordination for over 33 rural hospitals in 2012-13. CEDIK has assisted about 22 hospitals, which includes the Appalachian Regional Healthcare (ARH) system, with their second round of assessments so far, Davis added.
Rural hospitals lack the staffing to dedicate themselves wholly to the CHNA process.
“We recognized that CEDIK had the experience to provide coordination on behalf of small hospitals,” she said. “We provided cost-effective assistance in organizing the steering committee, scheduling community forums, and compiling the information. Being a part of UK, we are also in a position to follow up in the implementation strategies and develop measures of their effectiveness.”
When administrators knew CEDIK could walk them through the process, it allowed them to see beyond the work process to the value of needs assessments, especially to a hospital struggling to keep their doors open, Davis said.
“A persistent concern for small hospitals is why residents choose to drive past them to get services in Lexington and Louisville,” she said. “This (CHN) assessment provided some answers. … And it certainly made the process more palatable to hospital CEOs.”
It is legitimate to regard CHNAs as a rudimentary marketing tool, she added.
For most regional and community hospitals, the process takes about nine months, according to Davis. Though it takes time to get public feedback, working with public health providers makes the task of reaching medically underserved populations much easier.
“For most communities, the relationship between hospitals and public health can be tenuous. One of the positive consequences of these two rounds of assessments is closing that gap,” Davis said.
The CHNA effort enhanced relationships with public health providers for Baptist Health, a statewide provider with seven hospitals, Marcum said.
“The communication helped us find ways to work together,” Marcum said. “A result of my participation was helping some organizations complete their Mobilizing for Action through Planning and Partnerships (MAPPS) surveys.”
One of the primary goals of the ACA is to demonstrate that healthcare providers do more than just care for people after they get sick. The CHNA implementation strategy, which Marcum regards as the core of the process, “demonstrates how Baptist’s partnership activities help improve community health.”
Implementation separates a CHNA from marketing strategy and it’s a significant distinction, he said.
“It’s important to remember that the hospitals and their administrators do not make these lists of community needs, nor do they prioritize those needs,” Marcum said. “That’s a task done by the steering committee.”
Whether the participating hospital has 40 beds or 400, the implementation challenge posed by CHNAs is whether hospitals, health departments and the community can work collaboratively to improve overall health.
The most time-consuming aspect of the whole process, by far, is prioritizing the list of health needs. Prioritizing and then collaborating on ideas to address those needs is a challenge, Pike said.
“I’m very proud that KentuckyOne Health’s hospitals used their respective CHNAs as an opportunity to study how social issues impact community health and what we can do proactively to address those issues,” Pike said.
Shared findings on safety, substance abuse
One of the principle guides KentuckyOne Health used in producing its assessments was the Robert Wood Johnson Foundation’s criteria to calculate county health rankings, which factors in health behaviors, clinical care, social and economic factors, and the physical environment.
“Community safety was an issue that bubbled to the top of many of our community assessments,” Pike said. Traditionally, community safety is not something most consider a direct health need except, perhaps, those in the ER where trauma teams care for victims of violent crime.
However, a closer look finds that when people feel safe in their community and environment, they are more likely to pursue outside activities – walk neighborhood streets, play in parks, get exercise.
“A sense of security can also relieve stress, which connects to a reduction in a trigger for heart disease,” Pike said.
Though assessments have focused on needs in specific communities, common issues have bubbled to the surface. Prominent on nearly every CHNA was substance abuse. Even in areas where the number one problem was a shortage of mental health specialists, the need for substance abuse treatment was strongly implied. Not far behind was heart disease and diabetes, which are associated with poor nutrition and sedentary lifestyle; and cancer, associated in part with tobacco use, substance abuse and even poor living environments.
But aside from some of the expected issues, many committees placed overuse of emergency rooms as a priority, said Davis. People in remote areas of the state also cited a lack of access to transportation.
“Some families said if it took over two hours to get access to a specialist, they often choose to go without it,” Davis said. Among the most interesting of some CHNA findings for individual hospitals was an acknowledgment from community members that such aspects of everyday living affect overall health.
Marcum reflected a similar sentiment with regard to the priorities identified at Baptist Health hospitals.
“The challenge posed by the CHNA provision is for all three stakeholders – the hospital, public health organization, and community – to work collaboratively to address those needs. Everyone is expected to do their part,” he said.
Implementing plans improves partnerships
Initiatives developed in the implementation strategies are often mundane, non-headline grabbing, Davis said. For example, local physicians experimented with altered office hours to reduce reliance on the emergency room; hospitals got permission to open critical access clinics.
Baptist Health Paducah took that idea one step further, Marcum said. It got permission to place nurse practitioners at school clinics in the Paducah and McCracken County. They provide health services to children, families, teachers and staff. It is also an excellent way to disseminate health education information.
Another Baptist Health Paducah initiative is a “congregational care” program. Professional healthcare staff train volunteers from area churches to follow up on patients with chronic health conditions. Some recently released from the hospital simply need visits and attention such as reminders of doctors’ advice, while others are patients with recurring conditions that require monitoring. They also educate church-goers on ways to assist elderly populations and shut-ins who have health issues.
“They check on medications, look in on them weekly, find out how to get assistive devices for activities of daily living, and alert caregivers if there are signs of deteriorating health conditions,” Marcum said.
Another bonus from this program: Allied health personnel provide free health screenings to congregations after morning worship services at approximately 40 Paducah-area churches, Marcum said. A similar program is being launched by Baptist Health Corbin.
KentuckyOne Health, in collaboration with public health partners, launched Health Connections to focus on patients who habitually overuse ER services. These “super-utilizers” were invited to participate in a program that paired patients with a care provider and social worker.
In one instance, the team discovered a diabetic patient who frequently suffered from “sugar spikes” did not own a refrigerator to keep their prescribed insulin cold. Buying that patient a refrigerator for their medication avoided thousands of dollars in ER visits, Pike said, and such fixes are a no-brainer.
“Instead of always looking to hospitals for answers to chronic clinical problems, we are addressing health issues as a matter of public policy and advocacy,” Pike said. “We believe education and public policy can have a powerful impact on preventing illness and building healthier communities.”
Davis presented a similar view. “Hospitals cannot be the end provider of the sole answer to the issues these CHNAs identify,” he said. “The solutions must have participation from every stakeholder with an interest in improving their community’s health.” ■
Josh Shepherd is a correspondent for The Lane Report. He can be reached at [email protected].