Advancing the State of the Art in Community Benefit: Honoring the Trust

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Advancing the State of the Art in Community
Benefit Honoring the Trust

• Catholic Health Association
• February 6, 2007
• Eileen Barsi, Director Community Benefit, CHW
• Maya Dunne, VP of Community Outreach, SJHS

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Getting Acquainted

• Who are we?
• What we do / what weve done

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Learning Objectives

• How can we together move our Catholic health
  systems to a point of distinction?
• How can we foster a transforming environment that
  achieves measurable change in community health
  outcomes?
• How can we best honor the covenant we have with
  our communities to improve the quality of life?

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Presentation Overview

• Impetus for ASACB
• ASACB Core Principles
• Institutional Policy Measures
• Uniform Programmatic Measures
• Uniform Reporting Standards
• Update on System Implementation
• Challenges / Successes
• ASACB Vision

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Community Benefit Defined

• IRS definition - The promotion of health for
  class of beneficiaries sufficiently large enough
  to constitute benefit for the community as a
  whole.
• Reference to a defined community suggests a
  population health orientation.
• Determining the minimum size for the class of
  beneficiaries needed in order to produce a
  benefit for the larger defined community suggests
  accountability to achieve a measurable impact.
• IRS Ruling 69-545
  (1969) and IRS Ruling 83-157 (1983)

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Community Benefits Defined

• a planned, managed, organized, and measured
  approach to. . . meeting identified community
  health needs.
• VHA/CHA

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Recent Trends - National

• Billing and collection practices
• Public reports (e.g., Yale-New Haven Hospital)
• Scruggs class actions (50 suits 370)
• Provena Covenant tax exemption challenge
• Nonprofit hospital functions and roles
• Led by Rep. Thomas and Sen. Grassley
• Hearings started in 2004
• Issues include compensation, contracting, B of D
  functions, transparency
• IRS audit to determine hospital spending on CB
  programs

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Communities of Concern

• Hospitals Downward pressure on reimbursement
  increasing costs, and growing number of uninsured
  threatens financial viability.
• Community/Consumer Advocates Anger about the
  impact of poor access and collection practices.
• Policymakers Focus on charity care is a
  convenient (if ineffective) strategy to address a
  systemic problem.
• Public Health Financial pressures and safety
  net obligations impede efforts to engage
  hospitals in substantive population health
  initiatives.
• Sponsors- Movement to Laity Leadership- Opening
  the door to revisit our continual call to our
  mission/vision.

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Purpose of ASACB

• To develop and implement a national model for
  community benefit programming to
• Increase program effectiveness and sustainability
• Ensure access for diverse communities
• Increase institution-wide alignment and
  accountability to our nonprofit status
• Deepen hospital engagement in local communities

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Major Outcomes

• Improve Health Status and Reduce Health
  Disparities
• Through targeted investment and design of program
  activities to address disproportionate unmet
  health-related needs.
• Reduce Health Care Costs
• Proactive investment to reduce the demand for
  high cost charity medical care to treat
  preventable conditions.

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A New Vision for Hospitals

• The hospital of the 21st century should be fully
  engaged as a partner with diverse community
  stakeholders to address both the symptoms and
  underlying causes of persistent health problems,
  and to advocate for public policy strategies that
  address the systemic problem of access for
  uninsured people.

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Five Core PrinciplesAnchors for Planning

• Emphasize disproportionate unmet health needs.
• Emphasize primary prevention.
• Build a seamless continuum of care.
• Build community capacity.
• Emphasize collaborative governance.

Advancing the State of the Art in Community
Benefit, PHI. Nov. 2004
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ASACB Partners

• St. Joseph Health System
• 9 facilities in CA, 5 facilities in TX
• Catholic Healthcare West
• 36 facilities in CA, 3 in AZ, and 4 in NV
• Lucile Packard Childrens Hospital at Stanford
  (Palo Alto, CA)
• Presbyterian Intercommunity Hospital (Whittier,
  CA)
• Texas Health Resources
• 13 facilities in Northern TX

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Phase I

• Following a baseline assessment of our community
  benefit programs, we collaborated with CHA / VHA
  in a comprehensive review and revision of content
  categories. We also developed guidelines for the
  calculation of community benefit expenses.

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Phase II

• Pilot sites field tested a set of tools designed
  to facilitate comprehensive review and
  enhancement or discontinuation of existing
  community benefit programs to ensure their
  alignment with five core principles.
• Phase III
• Systemwide implementation

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Quick Check-in

• Where are you as an organization in terms of
  organizational frameworks to support community
  benefits?
• What ways can you strengthen your partnership and
  response to the community?
• How can you further build communities of healing
  and hope?

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Community Benefit in your settingwhats in place
now

• Exercise A
• Community Benefit Quick Assessment

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ASACB Uniform Standards

• 1 - Institutional Policy Measures
• Governance, management, and operations aligned
  for accountability on an institution-wide basis
• 2 - Detailed Content Categories
• All activities documented in the same way
• 3 - Programmatic Measures
• Measures aligned with ASACB Core Principles
• 4 - Accounting Methods
• All activities counted in the same way

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Institutional Policy Measures

• Purpose
• To ensure optimal quality and sustainability of
  community benefit programs through alignment of
  governance, management, and operations with the
  charitable mission of the organization.
• Address three levels of organizational function
  governance, management, and operations, with a
  focus on
• Transparency
• Competence
• Quality
• Sustainability
• Refer to Handout

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14 Institutional Policy Measures

• Governance policies approved by the
  organizational board of trustees.
• Management and Operations policies approved by
  senior management and adopted at the departmental
  level.
• Institutional Policies compiled as a formal
  policy manual for the community benefit
  department to support continuity in function and
  facilitate easy access by external stakeholders.

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Institutional Policy Measures

• Governance (Examples)
• We had been doing some wonderful work to involve
  the Board but had never written this downIf I
  left I didnt know if it would continue.
• A Board committee with specific roles and
  responsibilities clearly documented.
• Explicit criteria for governing body recruitment
  that address ASACB Core Principles.
• Criteria and process to select priority program
  areas of focus.
• Community benefit planning and organizational
  strategic planning integrated.

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Institutional Policy Measures

• Management (Examples)
• I have a staff member doing community benefit
  but I never identified the necessary competencies
  to do this work
• Formal policies to ensure that senior
  leaders/community benefit managers have
  appropriate competencies and support the
  application of ASACB Core Principles (eg.
  competencies in public health/community health
  competencies in building partnerships).
• Formal policies to give CB managers
  responsibility to evaluate program activities and
  make necessary design changes.

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Institutional Policy Measures

• Operations (Examples)
• Develop formal community benefit plans that
  outline strategies to be implemented.
• Engage outside stakeholders as partners in the
  community benefit monitoring and evaluation
  process.
• Formal policy to solicit input and disseminate
  community benefit information to diverse
  community stakeholders.

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Uniform Content Categories

• Purpose
• Increase internal accountability Clear listing
  of activities by specific content reinforces
  identified links to program priorities, and
  minimizes loss of data, double counting, other
  errors.
• Increase external accountability Consistency
  provides a basis for comparative analysis of
  hospital behavior by outside stakeholders.
• CHA / VHA guidelines published

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Cartoon. Modern Healthcare. 5 June 2006
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Uniform Accounting Methods

• Issues Addressed
• Indirect Costs
• Eliminate padding of costs by excluding broader
  organizational administrative costs.
• Paid Staff Time
• Limit financial accounting to paid activities by
  staff with explicit focus on efforts to address
  DUHN.
• Use of Hospital Space by Outside Groups
• Limit counting to space and purchased materials
  space calculated with formula from Medicare Cost
  Report.

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Five Core PrinciplesAnchors for Planning

• Emphasize disproportionate unmet health needs.
• Emphasize primary prevention.
• Build a seamless continuum of care.
• Build community capacity.
• Emphasize collaborative governance.

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Why Evaluation?

• What will you measure to judge success?
• How will you know you are using resources
  effectively and efficiently?
• of people reached
• of services delivered
• Change in health behavior
• Change in health status
• Change in health care
• delivery system

Easier to collect
More meaningful
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Community Benefit Planning

• Establishing Goals and Objectives
• Identify and dedicate resources up front.
• Consider hiring evaluation, epidemiology or
  related skills.
• Meaningful measure what indicates true community
  benefit.
• Manageable select only a few indicators.
• Practical measure only what you will use.

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ASACB Uniform Assessment Tools

• Preliminary Review Template (PRT)
• Target population, cost of program, persons
  served, identified need being met
• Comprehensive Review Template (CRT)
• Using the Five Core Principles to assess program
• Program Enhancement Template (PET)
• What is needed to bring this program into
  alignment with the Five Core Principles
  intervention strategies
• Program Enhancement Monitoring Template (PEMT)
• Roles, responsibilities, and timeframes

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Comprehensive Review Template

• Exercise B
• Comprehensive Review Template

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Results

• Increases organizational leadership and
  accountability for community benefit.
• Increases the quality of program planning,
  implementation, and evaluation.
• Enhances the sustainability of community benefit
  programs.

Advancing the State of the Art in Community
Benefit, PHI. Nov. 2004.
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Honoring the Trust

• Do we have support from the leadership of our
  organization/hospital for community benefit?
• Do we have adequate staff with the competencies
  needed to do this work?
• Do we have board members with an understanding of
  and a willingness to address the unmet
  health-related needs in our community?
• How do we enhance existing staff and board to
  become more aligned to the principles?

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Implementation Challenges and Successes

• St. Bernardine Medical Center
• St. Joseph Health System, Sonoma County
• California Hospital Medical Center

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Summary of ASACB Vision
Implementing the ASACB vision requires a
transformation in governance, management, and
operations
From
To
Focus on on high cost, ER-based charity care to
treat illnesses that could have been prevented.
Comprehensive strategies to address the
underlying causes of health problems.
Proprietary approaches to planning
and implementation.
Collaborative approaches that mobilize and build
upon existing community assets.
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Summary of ASACB Vision, contd.
From
To
Health improvement with a private
patient/enrollee focus.
Health improvement with a population health
focus.
Broad scattering of ad-hoc services. (RAK)
Coordinated and carefully targeted programming.
Evaluation based upon the volume of inputs
(i.e., of people served).
Evaluation based upon impact upon health status
and quality of life.
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Summary of ASACB Vision, contd.
From
To
Executive decision making based upon
institutional priorities.
Collaborative decision making based upon
an objective assessment of community needs.
Institutional view of community benefit as
an unwelcome legal obligation..
Institutional view of community benefit as
a responsibility to return optimal value of
charitable assets to public investors.
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Contact Us

• Eileen Barsi
• Director, Community Benefit
• Catholic Healthcare West
• Eileen.Barsi_at_chw.edu
• Maya Dunne
• Vice President, Community Outreach
• St. Joseph Health System
• Maya.Dunne_at_stjoe.org
• Kevin Barnett
• Advancing the State of the Art
• in Community Benefit
• kevinpb_at_pacbell.net

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Community Benefit Planning Resources

• Advancing the State of the Art in Community
  Benefit www.asacb.org
• Association for Community Health Improvement
  Community Benefit http//www.communityhlth.org/com
  munityhlth/resources/communitybenefit.html
• Catholic Health Association Community Benefits
  http//www.chausa.org/communitybenefit