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Advancing the State of the Art in Community Benefit: Innovative Practices and Emerging Lessons for H


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Title: Advancing the State of the Art in Community Benefit: Innovative Practices and Emerging Lessons for H


Community Benefit, Public Health, and National
Health ReformConnecting the Dots
  • NNPHI Annual Conference
  • Opportunities to Thrive in Changing Times
  • Friday, May 8, 2009 / 900 1000 a.m.
  • Omni Royal Orleans, New Orleans, LA
  • Kevin Barnett, Dr.P.H., M.C.P.
  • Senior Investigator
  • Public Health Institute

Session Outline
  • Summary of community benefit history and
  • Emerging challenges and opportunities
  • Advancing the State of the Art in Community
    Benefit uniform standards
  • A sampling of accomplishments to date
  • Next steps National implementation

Community Benefit Defined
  • IRS definition - The promotion of health for
    class of beneficiaries sufficiently large enough
    to constitute benefit for the community as a
  • Reference to a defined community suggests a
    population health orientation
  • Determining the minimum size for the class of
    beneficiaries needed suggests accountability for
    a measurable impact.
  • IRS Rulings 69-545 (1969) and 83-157 (1983)

Intent of IRS Definition
  • To encourage hospitals to play a role in efforts
    to improve health status and quality of life in
    local communities.
  • To move beyond charity care as the exclusive
    means to demonstrate commitment as a tax-exempt
    health care institution.
  • Expect a primary focus in communities with
    disproportionate unmet health needs.

Trends in Practice
  • There are many
  • examples of
  • outstanding
  • programs in
  • hospitals across
  • the country, but
  • market dynamics
  • have influenced
  • the interpretation
  • of community
  • benefit.

Programmatic Paradigm
  • Business / marketing imperative
  • Many activities focus to a significant degree on
    insured populations, and hence are part of doing
    business not community benefit
  • Political orientation
  • Large number and small scale of activities
    suggests political motive, rather than a
    commitment to produce measurable improvements in
    health status.

Areas for Improvement
  • Programmatic
  • Small scale, poor design with most activities
  • Lack of coordination across programs / activities
  • Lack of infrastructure for program monitoring
  • Lack of community mobilization / leverage
  • Institutional
  • Lack of infrastructure for governance/oversight
  • Lack of knowledge and understanding among
  • Lack of formalized quality improvement mechanisms
  • Narrow, individual-based engagement

Emerging Challenges - Local Level
  • Reduced revenue from elective procedures
  • Negative trends in payer mix
  • Reduction in reserves
  • Crisis operational mode
  • Demands for PILOTs
  • I expect a resurgence of interest among
    municipalities in extracting payments in lieu of
    taxes. Municipal budgets are going to be
    strained. Not for profits are a logical target.
  • Alan Zuckerman, consultant, Philadelphia

Emerging Challenges State / Federal
  • State
  • Move to revise state statutes / guidelines
  • New agencies engaged (e.g., CA BOE)
  • Role of organized labor, other advocates
  • Federal
  • Senate Finance Committee action imminent
  • IRS Revised 990 Schedule H / community building
  • Lack of coordination across administrative
  • Tendency to frame prevention in medical model

Impetus for a New Approach
  • Continuing
  • growth
  • in the
  • number of
  • uninsured
  • calls for
  • definitive
  • action.

Opportunity Support from Business
Healthcare delivery is overly focused on
episodic acute care it must shift to include and
embrace prevention and chronic condition
management in order to respond to the emerging
environment. IBM Institute for Business Value.
Healthcare 2015 Win-win or lose-lose? A
portrait and a path to successful transformation.
New York, NY 2006.
Opportunity Focus on Stewardship
  • Substantial proportion of charity care is
    ER/inpatient care for preventable illness poor
  • Estimated costs for preventable hospitalizations
    for 2004 alone were 29 billion, approximately
    10 of total hospital expenditures.
  • Russo, Allison, et al, Trends in Potentially
    Preventable Hospitalizations among Adults and
    Children, 1997-2004, Statistical Brief 36,
    Healthcare Cost and Utilization Project, AHRQ,
    August 2007

Focus on ACS Conditions
  • Research by John Billings established framework
    of ambulatory care sensitive conditions (ACS).
    Recent studies focused on
  • Medi-Cal managed care
  • Diabetes
  • Chronic heart failure
  • Low income children
  • Co-morbidity and re-admissions among Medicare
  • Preventable hospitalizations for low-income
    children declined by 25 five years after the
    implementation of Children's Health Initiatives.
    The study found that pneumonia, asthma and
    dehydration were the most common causes of
    preventable hospitalizations among children.
    Using data from nine counties, researchers
    estimated that state and federal governments
    could save up to 30 million annually.
  • Cousineau, M., et al. (2007). USC Center for
    Community Health Studies.

Engaging the Public Health Community
  • Address historical dynamics
  • Negative view of hospital commitment to social
  • Lack of awareness of community benefit and assoc.
  • Denigration of programmatic quality/commitment
  • Doctrinaire view of hospital public health
  • Identify synergistic opportunities
  • Build evidence-based framework for shared
  • Hospital investment in population health can help
    make the case for policy reform (e.g., shift away
    from categorical funding)
  • Increased leverage to secure conversion
    foundation support

Q and A / Discussion
Key Issues Which among the challenges
identified are most relevant in your
state/region? What are other relevant emerging
challenges? What, in your mind are the most
significant obstacles to the development of
ongoing working relationships between the
hospital and public health communities in your
state/region? What are opportunities in your
state/region that may help to overcome your
particular challenges and obstacles to
Advancing the State of the Art in Community
  • Uniform Standards

Programmatic Goals
  • Improve health status and reduce health
  • Targeted investment and program design
  • Strategic investment of charitable resources
  • Reduce the demand for high cost treatment of
    preventable conditions

Institutional Goals
  • Establish CB governance infrastructure
  • Increased accountability and oversight
  • Clarity of function - transparency
  • Breadth of competencies
  • Increase competency and organizational support of
    CB management
  • Attention to skills needed for quality
  • De-marginalize CB function

Focus on Governance
  • National study of NP community health system
    governance by Lawrence Prybil, et al Key
  • Low diversity among boards
  • Minimal attention to community benefit oversight
  • Lack of review of core governance processes
  • Almost 30 CEOs report passive/inconsistent
  • Hospital boards tied to systems more attuned to
    community benefit responsibilities

Increasing Focus on Governance
more and more, the IRS looks to the independent
board exercising its fiduciary duty to operate
for the benefit of the community to differentiate
the tax exempt hospital from a for-profit
operation. IRS Commissioner Mark Everson
Testimony before the House Ways and Means
Committee, May 26, 2005
  • Shift the focus of the public debate
  • Ad-hoc approach
  • represents poor
  • stewardship.
  • Move from
  • emphasis on
  • inputs to
  • outcomes
  • and quality.

Demonstration Goals
  • Re-establish the legitimacy of nonprofit
  • Make commitment
  • to engage
  • community and
  • leverage resources.
  • Prevention is
  • part of the
  • identity of
  • nonprofit hospitals
  • in the 21st century.

ASACB Five Core Principles
  • Emphasis in communities with disproportionate
    unmet health needs
  • Emphasis on primary prevention
  • Build community capacity
  • Build a seamless continuum of care
  • Collaborative governance

Emphasis in Communities with Disproportionate
Unmet Health Needs (DUHN)
  • Identify communities with high prevalence for
    health issue of concern or high concentration of
    health-related risk factors.
  • Develop outreach mechanisms to inform members of
    DUHN communities of available services and
  • Facilitate participation of members of DUHN
    communities through program location, timing,
    and/or transportation assistance.
  • Ensure that program design and content is
    relevant and responsive to the particular needs
    and characteristics of members of DUHN

Emphasis on Primary Prevention
  • Health
  • Promotion
  • Disease
  • Prevention
  • Health
  • Protection

Defining the BoundariesBreaking Down Complex
Issues with Problem Analysis
Root Causes
NT Causes
NT Impacts
LT Impacts
En vivo smoking
2nd hand Smoke
Immune Distress
High Morbidity
School/Work Absence
Indoor triggers
Poor housing
Lack of Knowledge
Poor Aca. Performance
Reduced Career options
External Air
Reduced Productivity
Poor medical Mgmt
High Svs Utilization
Low self Esteem
Poor HC Access
Helplessness Stress
Genetic Predet.
Medical care dependence
Build Community Capacity
  • ID and mobilize community assets to address
    health-related problems.
  • Engage as community stakeholders as full partners
    in comprehensive strategies to address both
    symptoms and underlying causes.
  • Focus hospital resources on strategies to
    increase the effectiveness and sustainability of
    community-led efforts to address persistent
    health-related problems.
  • Community-based organizations, neighborhood
    associations, coalitions, informal networks,
    individual skills, physical space, facilities.
  • Financial support, technical assistance,
    in-kind support, advocacy

Build a Seamless Continuum of Care
  • ID links between community health improvement
    activities and medical care service utilization.
  • ID measures for CHI activities that validate
    progress towards improved health status and
    quality of life.
  • Engage providers and develop expanded protocols
    that make optimal use of community resources to
    manage chronic disease and minimize future
    medical care service utilization.

Collaborative Governance
  • Breadth of competencies and diversity are needed
    for informed decision making.
  • Shared accountability with diverse community
    stakeholders for the design, implementation, and
    refinement of community health initiatives.
  • Diverse community stakeholders have role in ID of
    measurable objectives, data collection, and the
    interpretation of findings.

Programmatic Measures and Major Goals
ID communities with DUHN CB activities ensure
access for communities with DUHN Reduction in
preventable utilization Measurable impacts for
primary prevention activities Increased
engagement of clinicians Increased engagement of
diverse community stakeholders Evidence of
increased community capacity Cost savings
produced by capacity building
Reduce Health Disparities
Reduce Health Care Costs
Enhance Community Problem-Solving Capacity
Disproportionate Unmet Health-related Needs
Institutional Policy Standards
  • Establish board level oversight committee
  • Trustees
  • Senior leadership/staff
  • Community members
  • Develop formal committee charter
  • Specific roles and responsibilities
  • Criteria and process for recruitment
  • Criteria and process for priority setting

Institutional Policy Standards
  • Organizational Support
  • Integrate CB and organizational strategic
  • Align priorities of managers and supervisors
  • Expectations of departments
  • Dedicated time for quality improvement
  • Competencies
  • Outline scope of job responsibilities
  • ID and develop necessary skills
  • Engage external assets

Institutional Standards and Major Goals
Governance / Decision-Making Clear delineation
of responsibilities Explicit criteria for
decision-making Core Principle guidelines for
recruitment Formal reporting on program
progress Mechanisms for program continuity Senior
leadership accountability
Accountability Transparency Objectivity Diversity
Quality Measurability Competence Capacity
Management Clear delineation of
responsibilities Necessary competencies for
position Program design reporting
discretion Access to and support from
leadership Mechanisms for internal engagement
Sustainability Commitment Humility
Operations Develop multi-year plans Leverage
external expertise Ongoing engagement of community
A Sampling of Accomplishments to Date
All Partners - Leadership/Governance
  • CEOs and other senior leaders directly
    accountable for community benefit performance
  • CBC serves as extension of trustees to provide
    direct oversight for all charitable activities
    and ensure alignment with ASACB Core Principles.
  • Trustee members on CBC serve as board level
    champions to keep CB planning on board of
    trustees agenda.

All Partners Management Reforms
  • Increased investment in data collection, tracking
    tools and evaluation.
  • Increased coordination with clinical departments
    to reduce preventable hospitalizations and ER
  • Increased capacity of department
    directors/managers to advocate for CB to senior
  • Increased coordination between CB and finance
    departments on reporting and planning.

Sampling of Hospital Initiatives
  • Technical assistance to establish 501(c)3 status
    for community stakeholder groups Lucile Packard
    Childrens Hospital, St. Jude Medical Center
  • Established referral and funding system with CHCs
    for homeless persons to provide case mgmt and
    transitional housing St. Francis Memorial
  • Technical assistance and leadership influence to
    help community obesity collaborative secure
    grants St. Jude Medical Center

Hospital Initiatives, contd.
  • Work with govt. officials and housing authority
    to develop housing and social services for
    homeless St. Bernardine Medical Center
  • Apply ASACB core principles for community grants
    and participation in health fairs Presbyterian
    Hospital of Dallas, St. Bernardine Medical
    Center, St. Francis Memorial Hospital
  • Reduction in preventable hospitalizations and ER
    use for diabetes and fever-related illnesses
    St. Jude Medical Center, Catholic Healthcare West
    Kern Region

Next Steps
  • National Rollout of ASACB Uniform Standards

National Implementation Strategy
  • With support from the WK Kellogg Foundation, the
    CDC, and other funders
  • Engage leading edge hospitals and health systems
  • Engage key organizations that can serve as
    conveners at the state and national level (e.g.,
    NNPHI members)
  • Engage state and regional foundations as partners
    in the implementation of collaborative
  • San Francisco
  • Minneapolis/St. Paul
  • Dallas/Fort Worth
  • Detroit
  • Massachusetts
  • Florida
  • Oklahoma

Q and A / Discussion
Can you describe examples of practices and
policies undertaken by hospitals in your state /
region that are aligned with the ASACB
standards? Based upon your experience to date
with hospitals in your state/region, what would
you identify as specific standards or elements
that may be viewed as most in line with the
direction and interests of key leaders? Which
do you believe may be most problematic? Given
current priorities of state and regional funders,
what kinds of ASACB-related activities may be of
greatest interest?
Contact Information
  • Kevin Barnett, Dr.P.H., M.C.P.
  • Public Health Institute
  • 555 12th Street, 10th Floor
  • Oakland, CA 94607
  • Tel 925-939-3417 Mobile 510-917-0820
  • Email
  • ASACB standards, tools, and model programs
    available on website _at_