Sunrise, Philadelphia. Photo by Flickr user Peter Miller, CC BY-NC-ND 2.0
The 2010 Affordable Care Act (ACA) ushered in a new requirement that every three years, nonprofit hospitals must conduct a community health needs assessment (CHNA) or face fines or even loss of their tax-exempt status. The assessment examines and prioritizes health needs in the community the hospital serves and helps guide health systems’ implementation plans for initiatives to improve community health.
CHNAs must include not only quantitative data on actual health conditions, but also qualitative data gathered from stakeholders representing broad and diverse community interests.
Garrett O’Dwyer, health programs and special projects manager for the Philadelphia Association of Community Development Corporations (PACDC), saw in the new mandate a chance to elevate the work his organization’s members were doing locally in housing, economic development, and social services—often addressing social determinants of health (SDOH), those nonmedical factors like economic stability and food security that influence health outcomes.
As O’Dwyer scrutinized Philadelphia area hospitals’ first CHNAs in 2013, he spotted substantial ZIP code repetition across multiple assessments and decided to analyze further.
“I took the ZIP code information and created a map,” he says. “Looking at the map, I saw an intense overlap—hospitals were serving some of the same areas but not coordinating with each other.”
A Pivotal Meeting
Soon after, at a senior services event, O’Dwyer met Dalton Paxman, the regional health administrator for the U.S. Department of Health and Human Services (HHS) Region 3. O’Dwyer chatted with Paxman about an idea: CDCs could play a convening or supporting role in helping hospitals coordinate their services better.
As luck would have it, Paxman was already a key player in convening a working group comprising HHS, local and state public health agencies, and nonprofit social service agencies. The working group had several goals: to see if hospitals could do more to direct their community benefits resources toward addressing social determinants of health, break down silos between hospitals and the CDCs in their communities, and collaborate across neighborhoods.
“For HHS, the highest priority was doing what we could to implement all aspects of the Affordable Care Act,” says Paxman. “The ACA’s language described ‘community health needs assessments,’ but it didn’t define ‘community.’ We thought if we took a broader definition, like southeastern Pennsylvania or the city or county of Philadelphia, it would allow hospitals to work together and still meet the requirements under the law. Individual communities might have as their top health issue diabetes or heart disease or maternal mortality—but working together, we could agree on a set of major issues across the city.”
O’Dwyer kept in touch with Paxman and the working group. In November 2014, when HHS and the Hospital and Healthsystem Association of Pennsylvania (HAP) invited nonprofit hospitals to a meeting to discuss the idea of collaborating on community health needs assessments, PACDC was among the presenters. “I presented to the hospitals on the opportunity to partner with community groups, how CDCs were already working to address social determinants of health, and the overlap we had observed between communities,” says O’Dwyer.
Getting hospitals to come together and truly collaborate, though, was a tall order.
“It was a tremendously complicated effort,” says O’Dwyer. “These are nonprofit hospitals with mission-driven priorities, but they are also multi-billion-dollar institutions with bottom lines and CFOs. There was concern about territoriality, and how this would work in practice.”
Paxman agrees. “Hospitals in Philadelphia are quite competitive,” he says. “They are competing for not only patients, but for resources, and they’re not used to working together. We did have to coax the hospitals to the meeting.”
Leading hospitals toward sharing information and work required acknowledging and cutting through some of that competitiveness. One step was to keep it neutral, on no particular hospital’s turf. “We provided a safe space for them to meet,” Paxman says, “since HHS and HAP weren’t stakeholders.”
James Plumb and Rickie Brawer, co-directors of Jefferson University’s Center for Urban Health, which marshals the resources of Jefferson Hospital to build community relationships and health, were at that 2014 meeting.
“We were all invited to a meeting, and the hospitals couldn’t really say no. We’re part of HAP and we’re part of Region 3, and we’d better show up,” recalls Plumb. He adds, “Philly is probably unique in that the city has so many medical schools and hospitals within its borders, and all are competitors. It took the leadership of HHS and HAP to make this happen.”
For the first round of CHNAs in 2013, hospitals had gone it alone, Brawer says, producing their own assessment or contracting with a consultant. Now the suggestion was that they should combine their efforts. “HHS Region 3 and HAP pulled us all together and said, ‘Next time it would be really nice if you could all work together to do this,’” she says.
Birth of a Collaborative
By many accounts, that 2014 meeting, with seven health systems attending, representing nearly all the area’s nonprofit hospitals, was pivotal. It started the ball rolling toward the creation of the Collaborative Opportunity to Advance Community Health (COACH)—a more formalized group of health systems that grew to include public health, insurance, and community partners—and eventually, to the first joint regional CHNA in 2019.
COACH launched in fall 2015, funded by HAP and the seven participating health systems and managed by the nonprofit Health Care Improvement Foundation (HCIF), which responded to HAP’s RFP for a facilitator. By this time, preparation for 2016 CHNAs was already underway and hospitals were still going it alone—but COACH’s work would slowly and surely lay crucial groundwork for the 2019 collaborative effort.
It took a few years to build comfort and willingness to share among the group and to embark on a joint CHNA, says Susan Choi, HCIF senior director of population health, who manages COACH.
“When COACH first formed, it was a bit unclear the extent to which the hospitals would be interested in collaboration,” Choi says. “Folks hadn’t been in that kind of room together talking about their community health work, so there was guardedness in terms of sharing where they were at.”
The slow pace was disappointing to O’Dwyer and his colleagues. “In the broader CDC community, we were really excited that this could lead to some real investment in communities, but that initial excitement waned. It was going to be a much longer process to convince hospitals they wanted to do this,” he says.
Early Pilot Project: Food Insecurity
The COACH group began with baby steps, first identifying a shared pilot project to address food insecurity, a severe local need that was more immediately addressable than, say, housing, and an issue that hospitals could cooperate on with little risk.
“It was a good choice,” Brawer says, “because there’s no competition for patients around food insecurity. Everybody wins if we do this. It’s not like ‘We don’t want you to have our diabetes patients, or our heart disease patients.’”
The COACH hospitals all committed to implementing some type of food security screening, inspired by models like Boston Medical Center’s pioneering work around screening for SDOH in a clinical setting. Then came the next question, Choi says—how to respond when a food need is identified. That led naturally to engaging community-based organizations to be partners hospitals could refer patients to.
By 2017, each COACH member hospital had launched some form of food insecurity screening pilot, “which was an exciting place,” says Choi, “but just a first step.” Over the next year members developed better ways to connect patients to resources and shared best practices with one another. And then it was time to gear up for the 2019 CHNAs. A few hospitals already had hired contractors to do theirs, but most COACH members (and a few hospitals outside COACH) were now ready to work together on the first joint Southeastern Pennsylvania Regional CHNA.
“COACH’s [food insecurity pilot] taught us that a shared model was valuable,” says Heather Klusaritz, director of community health services at Penn Medicine’s Center for Health Equity and Advancement (CHEA) and Penn’s representative in COACH. “Doing this collective work really set the stage to say, ‘It makes sense for us to work on a CHNA together.’”
Gathering Qualitative Data: A Winter Whirlwind of Community Meetings
Even after the desire was established, technical details took time. “The hospitals’ boards all met at different times,” Brawer laments. When they finally solidified the collaboration agreement, it was already December 2018. The data had to be pulled together by April 2019 to publish the CHNA on time. “It was quite a fire drill,” Choi says.
PACDC led the community input segment, where the qualitative data would be gathered. It fell to O’Dwyer to coordinate 19 neighborhood-centered community focus groups drawing some 175 participants over the course of just five weeks in a season of snow, cold, and early nightfall. “It was an incredible amount of work in a short time. That was not a fun time,” he recalls.
His role included delineating which geographies to cover in Philadelphia proper and in neighboring suburbs, selecting centrally located sites with good transit and/or parking access, and doing the legwork to secure refreshments and gift cards to compensate participants. “I will say that one of the benefits of doing 19 groups is you really get to know each area’s pizza,” he jokes.
One of the focus groups was hosted at ACHIEVEability, an anti-poverty organization in what Jamila Harris-Morrison, ACHIEVEability’s executive director, calls “far-west Philadelphia, beyond where the ‘eds and meds’ are situated,” referring to the University City cluster of hospitals and academic institutions in West Philadelphia.
Her staff reached out with flyers and through block captains, social media, and word of mouth to recruit participants. “The message was, ‘We want to hear your voice. Hospitals are planning how they’re going to target resources. This is your chance to let them know what you need,’” says Harris-Morrison. The 15 attendees who came were all Black, as she recalls, and diverse in ages and affiliation, from a 20-something male community college student to a woman who’d lived on the same nearby block for over 40 years, to someone who worked at a hospital and saw the change in neighborhood conditions along her commute from 40th Street to 60th Street.
Residents often are understandably skeptical of large institutions’ intentions in their communities. But at this meeting, people did share thoughts—about youth employment, gun violence, neighborhood conditions, and health issues from diabetes to a dearth of healthy food options. Some lingered afterward and talked with the facilitators—the qualitative data experts from the health systems who posed the questions and listened.
“The fact that PACDC was chosen as the liaison was really smart,” Harris-Morrison says. “If it was a hospital, there might have been less trust. These institutions have such resources and power. And there’s a feeling among residents of not wanting to be studied for the sake of being studied.”
The Joint CHNA is Published
Ultimately, the hectic effort came to fruition. The data was pulled together, the joint CHNA document—representing 18 hospitals from six health systems—was drafted by the Philadelphia Department of Public Health and submitted in time to the boards of each hospital/health system for approval. O’Dwyer was gratified to see a far greater emphasis on and specificity around social determinants of health. The document includes summaries of all the community input and lays out 16 priorities—including substance/opioid use, food access, affordable housing, and racism in health care settings—and potential solutions for each.
Paxman considers the effort a success that was by no means guaranteed. “Philadelphia’s health care system is about as competitive as a city’s can be. Around the time of our first meeting, we kept hearing that the hospitals wouldn’t come, it would be a failure, they wouldn’t work together. And we proved them wrong. We pulled them in, and they did work together.”
Reflections and Words of Wisdom
A collaborative CHNA is just one step, and it remains to be seen what concrete changes will come of it. O’Dwyer notes that the COVID-19 pandemic dominated hospitals’ attention in 2020, but some promising initiatives have been informed by the joint CHNA, including a Children’s Hospital of Philadelphia program for home repairs to address asthma and Jefferson Health’s community grant program to support organizations addressing health disparities in North Philadelphia.
Here’s a sample of lessons learned so far and advice for other regions seeking to catalyze collaboration among hospitals.
The good and the bad—There are pros and cons to collaborative CHNA work, says Penn Medicine’s Klusaritz. Clearly, it’s good for patients to have hospitals focus on communities together.
“Knowing that our patients are using different health care systems was one impetus for doing this together. If we’re all caring for the same population, shouldn’t we be working together to address their needs?” For Klusaritz and her counterparts, collaborative work also brings important opportunities to share learning. And she emphasizes an important and less obvious benefit: reducing the burden on community organizations, which often are bombarded with multiple calls for data and stakeholder contacts. “That was a key priority, recognizing the demand on our [community-based] partners when so many health systems in a region are doing CHNAs.”
On the other hand, she says, “A regional CHNA is a behemoth of a document. It can easily run 200-plus pages. And it’s not as personalized. Your institution may seem less salient. But we still all do individual implementation plans. That’s where you can highlight the work your individual organization is doing to address those needs.”
Leadership/management—Paxman says a push from an outside or neutral convener is key, and it doesn’t have to be the federal government. “Oftentimes in communities, there are battles and baggage that keep entities from working together. So whether it’s HHS or another entity—a foundation, a philanthropic organization, a professional association—someone has to create that environment for them to come together. It could be a governor or a mayor. Federal Reserve Banks are often great conveners, and they’ve done work in this space,” he says.
With COACH, too, Klusaritz says, “Having an external organization serve [in] that facilitator role was critical. It helped to not let one health system dominate the process. I would certainly recommend that if another geography was considering this route.”
The role of community organizations—Brawer says it was important that HHS brought in community-based organizations. “Their bringing us all together got us to focus on other things we might be able to do together,” she says. “We don’t need to duplicate, we don’t need to do it for them. We need to help each other do it better.”
PACDC’s part, O’Dwyer says, was showing how hospitals could address SDOH by highlighting what CDCs were already doing. “Our role was not playing broker or convener, but representing the community development sector, talking about how we could help break down silos between CDCs and hospitals.”
He adds, “No one group pulled it all together. There was a confluence of interests, and it worked out. The ingredients were there. Lightning struck, and life was formed.”
Logistics and time—“We started too late, and that caused things to be very hectic,” Brawer says. “This time we’re starting much earlier. Hopefully in 2022, we won’t end up trying to run this by everyone’s boards at the last minute.”
O’Dwyer says, “I definitely underestimated the time it takes to get 20 people together in a room to talk about the issues facing them. It was challenging all around,” he says. “But in a way, that turned out to be a good thing—when we only drew 10 people, we realized that was a good size! Anything more than that can be difficult.”
Collaborative Relationships Aided Pandemic Response
One outcome of strengthened partnerships came into the spotlight last year: When the pandemic hit, hospitals and community organizations were better equipped to step up together.
“COVID has put an even greater spotlight on disparities and why they exist,” Brawer says. “What was really successful was [that] we had systems in place to work on food insecurity. We spent a lot of time working with food distribution sites; PACDC helped organize that. We were seeing pictures daily of people in food lines, no social distancing—and then there was the issue of people who couldn’t even get to a food line. The fact that we were somewhat organized to begin with was really key.”
Choi says, “The groundwork has been laid that allowed them to do that in an emergency situation like the pandemic. We’re now in a space where we’re thinking a lot more about those sorts of systemic solutions that could be possible if the health systems are engaged. So, more to come on that.”
Progress
COACH continues to meet regularly and has added trauma-informed practices as a priority focus.
O’Dwyer is gratified to see the needle move on addressing social determinants of health, however incrementally. “The impressive thing is, when we started back in 2012, hospitals really didn’t think they should be involved in social determinants of health. [In 2019], all the entities agreed that they want to address SDOH, including things like housing. Health systems are like big ships that turn slowly. But that arc is happening. There is real payoff.”
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