by Emily Hough, 2021-22 Harkness Fellow and Senior Fellow at Brown University
It is now well evidenced that the health services people receive are a relatively small contributor to their overall health outcomes. Up to 90 percent of an individual’s health outcomes are driven by wider social determinants of health (SDOH), so what role should healthcare organizations be playing when it comes to improving health outcomes in their local communities? Making best use of the assets they have to improve health outcomes may seem like an obvious choice for healthcare organizations. But with healthcare demands and backlogs from the COVID-19 pandemic growing, are hospitals able to maintain a focus on how they can have a broader impact on local community health and if they are, how are they doing that successfully? These questions have been the driver behind my work over the last year as a U.K. Commonwealth Fund Harkness Fellow. It is a question that builds on my experience as Director of Strategy for the National Health Service (NHS) in England where I led a number of projects looking at the role health can play in the built environment, sustainable development, supporting people into employment and as an anchor in the community.
To better understand action currently being taken in US health systems, I interviewed 25 leaders across nine U.S. health systems that are currently delivering projects aimed at improving the health of their local communities, seven of which are members of the Healthcare Anchor Network (HAN). All of the health systems interviewed include either not-for-profit or public hospitals and therefore have some kind of commitment to improving the health of the communities they serve—although the definition of what that means in practice seems to have widened in recent years. A number of leaders reported that their organizations are starting to look beyond treating the symptoms of SDOH to explore how they can address the root causes of problems being experienced in their communities. This work aligns with the anchor mission adopted by HAN members, to leverage their hiring, purchasing, investing, and other key assets to build inclusive local economies that sustain healthy communities.
The most commonly referenced challenges in my discussions were food and housing insecurity, areas which many HAN members are already working to address in their communities. Some HAN members have developed food system programs that are connected to the anchor mission and community wealth building. All the hospitals I spoke with reported having some kind of partnership with a food pantry, or equivalent community group, that provides immediate food relief to those in the community.
Yale New Haven Health’s #GiveHealthy is an example of how hospitals are donating, as well as helping to distribute much needed food across local communities. Health systems are also investing in projects that aim to provide longer term solutions that address underlying food insecurity facing local residents. In 2015, HAN member Spectrum Health was one of seven founding partners of Community Food Club, a membership grocery store where a $11-15, 30 day membership gives households points to spend on food, with healthier food costing less than processed and snack foods.
In 2019, another HAN member, Dartmouth Health established a Food is Medicine strategy centered on identifying food insecurity, referring patients to nutrition supports, and hosting healthy food provision and nutrition services. Patients identified as having food insecurity through social screening in primary care can access services including emergency shelf stable food bags provided in partnership with the local food pantry Upper Valley Haven. In addition, free organic farm shares for pregnant women at risk of substance abuse are provided through a partnership with Dartmouth College Organic Farm and a Farmacy Garden, a 6,000 square foot garden on the main medical campus managed through a partnership with Willing Hands. In 2022, HAN member Hartford Health opened its new Food As Medicine facility that partners with Foodshare to provide Hartford Hospital patients with a prescription access to a local “grocery story” that only has healthy items on the shelves. They have also partnered with Compass One and CT Foodshare to donate unused food from the Hospital of Central Connecticut to people in the community, starting with the Salvation Army men’s shelter.
Housing and homeless may be an even more complex challenge to address than food insecurity. Some health systems are providing immediate relief, such as HAN member Bon Secours Mercy Health’s Cincinnati Housing Response Program which has provided immediate financial support to those at risk of losing their housing. However, for many their focus is on longer term solutions that will create an increase in affordable housing in the community, which aligns with HAN’s principles for healthy and affordable housing that have been endorsed by 32 health systems. A number of HAN members participated in the Accelerating Investment in Healthy Communities program to advance affordable housing as a way to create more equitable, sustainable, and healthy communities. In Baltimore, Bon Secours Mercy Health leveraged $1.1M to support the creation of a landbank in West Baltimore and the development of three homeownership zones, creating new affordable homeownership opportunities in West Baltimore. In Cincinnati, the health system leveraged $300,000 to provide direct assistance to more than 170 renters, homeowners and landlords to avoid eviction and foreclosure during the COVID-19 pandemic.
As part of the Massachusetts Determination of Need process, which requires community investment as hospital capital improvement projects are approved, HAN member Massachusetts General Hospital (part of Mass General Brigham) has invested $1.1M with a community development financial institution to support affordable housing projects in local communities. Through their Homeless Health Initiative HAN member CommonSpirit Heath is working with local community partners to strengthen the continuum of care for those experiencing housing insecurity with the aim of improving the health and wellbeing of those experiencing homelessness or at risk of becoming homeless. Their program builds partnerships that can provide vulnerable populations with case management and ready access to social services and medical and mental health services.
Across the health systems I spoke with I found a set of core principles that are supporting the set up and delivery of these, and other, initiatives aimed at improving community health and tackling SDOH:
- Strong leadership and governance
Many health systems reported having a board level sponsor or lead for work to improve community health outcomes. This recognizes the importance an organization places on the work and can help make the case for investment in programs. In addition to system support, senior support within individual hospitals is also key. A number of health systems reported a matrixed approach where local community health teams are accountable to both hospital leaders and a central system team overseeing work on community health improvement. This approach supports local teams as they engage with their community to determine their needs and the programs that will help address them. System level teams focus on understanding shared priorities and opportunities for innovation. They also provide technical and admin support and resources to support local problem solving, standardization of processes, and sharing best practice. HAN members working to do this can draw on HAN’s Advancing the Organizational Imperative (AOI) Initiative Group, which works with health system leads to align all organizational assets, including core business practices, to prioritize equity, inclusion, sustainability, and community, and developing tools to more powerfully define the organizational imperative for adopting an anchor mission.
- Community engagement and partnerships
Intentionally involving the community from the start of projects is key. To help with this some local teams have invested in Community Affairs Coordinators, others are drawing on members of the local community to help develop and deliver their programs—where this happens appropriate financial reimbursement is important. Recognizing that healthcare organizations are often not the experts in wider social issues, partnering with those who are experts is important. Local partnerships vary and evolve over time, but generally I heard that anyone who shares the ambition to help improve community health is welcome around the table and may include community based organizations, Federally Qualified Health Centers, Departments of Public Health, schools, business, local government, health plans, and insurers and local businesses. The role that a hospital plays can vary depending on the stage of the partnership, some are developing local capabilities by sharing skills and expertise, others are providing funding or project management support, and some are acting as neutral convenors in community collaboratives. HAN’s Collaborating with Community Stakeholders (CwC) Initiative Group provides members with strategies and measures for anchor community engagement, a practice that brings a community collaboration lens to the design, development, and implementation of anchor mission strategies and which embodies a commitment to racial and economic equity. In addition to local partnerships, there are examples of health systems establishing more strategic partnerships at scale. One example of this is CommonSpirit Health and United Way, who are partnering to improve the health and quality of life for communities in need through a number of California based pilots.
- Maximizing use of available resources
One of the most critical resources for the success of this work is the people who are leading it. I consistently heard that people who thrive in this field are those who are good listeners and communicators. Values such as kindness, care, and compassion were often deemed to be more important than technical and project management skills, but an ability to be resourceful and flexible is also key. Many of the teams I spoke with are still quite new, so one challenge health systems will have to think about as they progress with this work is how they provide career development opportunities for people working in these teams – supporting them to grow and develop their skills and experience in this field. More broadly, teams are creative in how they identify resources to support community health improvement work. Some health systems reported allocating funding that can be used to award small grants to community projects. HAN works with its member systems to look at leveraging flexible, discretionary, and philanthropic resources to support members’ anchor mission strategies.
Using central resources to secure local or national grant funding for projects is common and many health systems are looking at how they can take a more socially focused approach to impact investment to support work, as described in the HAN Placed-Based Investing Toolkit. Using physical assets within the hospital is also common—for some that means using office space to host community partners, for others it is offering outdoor space to support community projects like Dartmouth Health’s Farmacy Garden.
- Measuring impact
Tracking outcomes and demonstrating impact is key for any project. Demonstrating progress with CHI projects can be challenging due to the complex nature of partnership programs, difficulties gathering data across a whole community, a focus on different outcomes than traditional medical reporting, and the long term impact of programs. New approaches, like social-return-on-investment (SROI) analysis, are being used to demonstrate the broader social, environmental, and economic benefits of programs, as evidenced by the evaluation of Bon Secours Hospital’s Housing for Health program which found a $1.30 and $1.92 of social return in the community for every dollar in yearly operating costs. However, evaluations can be resource intensive and expensive, so while the debate on how to effectively evaluate these programs continues, many health systems are trying to take a proportionate response to demonstrating impact and measuring what they can. Within this, being clear on what the expected impact of a project is and how it will be measured from the start will be key. This may mean using interim process measures (such as number of people seen / treated) and patient experience and being clear on how data can be presented as part of existing dashboards that are tracking health outcomes across the health system. HAN has created a Dashboard which contains a core set of metrics to measure key processes and outcomes related to the three main anchor strategies–hiring, procurement, and investment–in order to create the necessary data foundation to demonstrate the anchor mission’s effectiveness and impact.
- Considering options for sustainable funding
Whilst improving community health is increasingly being seen as part of a health system’s core business, it is rarely a revenue generating activity. Given this, securing funding for multi-year projects can be a challenge. Typically funding is coming from three sources: operational funding, philanthropy or grant funding, or investments. Some health systems have found ways to monetize community health improvement activities and secure sustainable funding for activities that improve specific health outcomes (e.g. A1b scores) through existing contracts. Others are considering how they could include activities within new contractual approaches, such as value based contracting. Finding ways to secure more sustainable funding will continue to build on the view that this work is core business for health systems.
Considering these core principles could help any health system looking to deliver projects to tackle the wider issues in their local community. Beyond these internal principles, health system leaders also reflected on the value of being part of networks of health systems with similar ambitions and activities underway, with many specifically referencing the value that HAN has provided in both setup and development of programs. For some, having a core set of commitments and reporting requirements, including a view on what other health systems are doing, has facilitated organizational buy-in and support from departments that had previously not engaged in SDOH work. Others referenced the HAN toolkits, which provide a useful framework to draw on when setting up new teams and programs. Beyond spreading learning and sharing best practice case studies, health systems also reflected on the value of being able to collaborate with other health systems and HAN on advocating for specific policy changes relating to SDOH at both the local and national levels.
HAN is also sharing learning internationally, including through connections with the UK’s Health Anchors Learning Network (HALN). Much like HAN, HALN provides a way for those committed to the anchor mission to learn with peers and experts. These kinds of networks are providing tools and resources for those who are just developing their anchor missions and those who are already implementing actions that will help improve the health outcomes for those they serve.
Note: The work informing this blog involved interviewing 25 healthcare leaders across 9 U.S. health systems: Bon Secours Mercy Health, Cambridge Health Alliance, CommonSpirit Health, Carle Health, Dartmouth Health, Hartford Healthcare, Mass General Brigham, Spectrum Health and Yale New Haven Health. Interviews took place virtually between February and June 2022. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the author and should not be attributed to the Commonwealth Fund or its directors, officers, or staff.