The U.S. health care system continues to grapple with increased chronic disease management, changing demographics, increased responsibility around care coordination and medical homes, and the elimination of disparities in care. Hospitals will play a significant role in creating and implementing new strategies that catalyze meaningful change on all of these issues. As a health care system originally built for illness shifts to one driven by wellness, hospitals will have a unique role to play in making good decisions easier for patients and helping to build community infrastructures that support health and healthy choices. Such engagement also requires:

  • Executives and trustees setting clear expectations and direction based on a mission to improve health.
  • A designated community health director who can be visible, working with internal staff as well as with community partners.
  • A strong connection with front-line staff who may know what gaps exist and already volunteer within the community.

The American Hospital Association's Committee on Research is exploring what the next generation of community health may look like as hospitals redefine themselves to keep pace with the changing health care landscape. This report is intended to encourage activity within the field to improve community health, offer an overview of current strategies as well as provide new ones, and spotlight tools and best practices.

This work aligns very closely with the AHA’s Advancing Health in America initiative, developed to better communicate about the changes underway in the U.S. health care system, enhance awareness and understanding of transformation paths, and underscore the importance of collaboration as well as proactive patient care. The vision that guides both the initiative and the work of this year’s Committee on Research is the same: a society of healthy communities where all individuals reach their highest potential for health. Given that vision, the key components of the initiative are:

  • Access (access to affordable, equitable health, behavioral and social services).
  • Value (the best care that adds value to lives).
  • Partners (embrace diversity of individuals and serve as partners in their health).
  • Well-being (focus on well-being and partnership with community resources).
  • Coordination (seamless care propelled by teams, technology, innovation and data).

Trends driving community health

The forces described here are driving change within the community health realm. They offer an explanation of why hospitals and health systems are looking to evolve in a manner that further expands the care they provide outside of the traditional hospital setting to incorporate community health as a comprehensive part of their mission.

Coverage gaps: While increased access to care has certainly improved health outcomes for many, gaps in coverage still exist. Further, we are learning that people won’t enroll if they don’t know or understand their coverage options. Every day, the caregivers in America’s hospitals see firsthand how these gaps affect people’s ability to access the right care at the right time and in the right place. This is why individual hospitals across the country are working in a variety of ways to enhance access to needed services through community outreach programs, as well as dedicating time and resources to help people understand their options and enroll in affordable health coverage. Access and coverage are essential components of achieving true community health. The AHA has been active at a national level with efforts like Enroll America, and local hospitals are working to do the same.

Holistic focus on health: Extensive research on social determinants of health clearly illustrates that where people live; their age, race and ethnicity; and language preference along with income and education influences have a strong correlation to individual health outcomes. Hospitals are now looking more holistically — beyond single ailments or injuries — at how to improve an individual’s health status, offering a more coordinated and integrated approach to caring for the whole person. A holistic approach to health care accounts for how patients may perceive their health and all factors that influence that: physical, mental, environmental, social and spiritual. Increasingly, care teams are integrating behavioral and emotional health as well as addressing social determinants that can greatly improve an individual’s ability to achieve success in becoming healthy and maintaining a healthy lifestyle. This work can include engaging in activities to build a community infrastructure that allows access to healthy food, transportation to medical appointments, guidance on exercise and fitness regimes, and support for adequate and safe housing options.

Cultural competency must play a key role. Caregivers must understand the beliefs and cultural traditions that may impede a patient’s ability to achieve good health. Enhanced cultural awareness and education can help clinicians move upstream in caring for their patients and in further improving the health infrastructure within a community.

Payment for value: While the health care payment system is undergoing a move toward a value-based reimbursement system, providers have opportunities to deliver higher-quality care for patients at a lower cost and better value. Payment programs are being designed to reward or penalize hospitals for the quality of care they provide and the ability to keep patients healthy and living at home. By learning more about the social determinants of health affecting patients and how those factors influence their ability to achieve good health, hospitals and health systems can be more intentional around decisions affecting how, when and where care is delivered within a community.

Benefit to the community: Benefits to the community vary from hospital to hospital, reflecting the individual needs of specific communities. Activities span from establishing free or mobile health clinics to increasing access to care to offering job training programs for unemployed residents or conducting health education and smoking cessation classes. Some hospitals provide back-to-school immunizations and sponsor literacy programs and housing projects. As the health care systems transform and the needs of communities change, hospitals are creating new, innovative and collaborative partnerships that will allow them to remain a facilitator in building stronger, healthier communities.

Results from a community health focus

The next generation of health care and, by extension, community health, will have the patient at the center of a better coordinated system of care that will be value-driven. With these shifts, hospital leaders and their governing boards will see further alignment between mission and philanthropy and the business imperative to keep patients and communities healthy. As traditional health care evolves and aligns more closely with public health needs, addresses drivers of poor health such as socioeconomic status and social determinants of health, and expands to involve a broad base of community partners, the next generation of community health will be more pervasive, more efficient and more effective in keeping people healthy.

Reducing disparities in care: The collection of race, ethnicity and language preference data combined with information gathered through the community needs assessment process can equip providers to ensure equity of care when treating patients. Hospitals and health systems are working more closely with patients upon admission to address disparities in care and understand how external challenges that a patient may face will impact care, recovery and possible readmission.

Ensuring equity in the care provided should be the lens through which all clinical advancements are made, as well as community outreach strategies. The AHA and other partner organizations have prioritized the elimination of disparities and are continuing to advance the work within the field through Equity of Care and #123forEquity efforts.

Addressing social determinants of care and health: Social determinants of health are the personal, social, economic and environmental factors or conditions with which a person is born, lives or works and that influence a wide range of health issues and, ultimately, quality of life. More so, socioeconomic factors can astutely shape an individual’s health, access to health care services and ability to achieve positive health outcomes. For instance, poverty may negatively affect an individual’s ability to access healthy foods; higher levels of crime, violence and trauma are linked to increased use of drugs, alcohol and tobacco; and a poor education system directly influences health literacy and employment opportunities. The connection between these factors is what impacts both an individual’s health as well as the health of a certain population.

Where patients go when they are discharged from the hospital plays a vital role in whether they end up being rehospitalized. For this reason, it is becoming more commonplace for health care facilities to dedicate staff resources to social workers, patient navigators and discharge planners. These individuals are part of the care team, working one on one with patients while they are in the hospital to identify potential barriers for improvement and overall health and resources needed at home upon the patient’s discharge. The care team can follow up and provide assistance to patients by coordinating further treatment, transportation assistance, rehabilitation, social services support and health behavioral coaching.

First-generation strategies

Improving community health reflects invaluable aspects such as creating high-functioning patient and community advisory boards, inviting patients and families to participate in community conversations to identify and prioritize community needs, and ensuring that the patient and family perspective is reflected and communicated at the board level. The boards should truly reflect the community served both in terms of gender and ethnicity but also in terms of profession or “community standing.”

Numerous strategies are currently being used to promote health and well-being. These first-generation strategies will serve as the building blocks for further work in providing high-quality, high-value care not only when patients are admitted to a hospital but also as they travel through the continuum of other care settings, including home.

Community health needs assessment: Tax-exempt hospitals are required to conduct community health needs assessments, and the value can be immense when prioritizing the outreach work being done. The knowledge and partnerships that come from this process help identify strengths and health weaknesses within a community and help direct community benefit activities. A collaborative needs assessment will be instrumental in developing a health improvement plan that is sustainable and that identifies specific areas of expertise among community partners that complement one another and allow for shared deployment of resources.

Incorporating a research approach — robust data collection, monitoring and analysis — into the CHNA process can strengthen the process and hone the direction and action steps that come out of the needs assessment. Research can also be key to identifying and developing strategic partnerships that broaden the scope of outreach. Linking with other organizations may enable a sole hospital to dive deeper into existing research, accessing resources and information to which a partner organization may have access.

Essential community partnerships: Creating a true community health infrastructure requires stakeholders beyond the care continuum — including but not limited to providers, public health departments, social service organizations, law enforcement, education, the business community, insurers and policymakers — to identify and commit to joint priorities.

Hospitals are not always best suited to take on a particular community health need, but they should serve as conveners and collaborate with other community service organizations, coordinating efforts rather than duplicating services. Additionally, through partnerships with public health departments, health centers and other social service organizations, data collection can become more robust, which ultimately can allow for more targeted outreach.

Organizational assessments and checklists: Continuous improvement is possible only if leaders are willing to take a close look at the reality of the care and services they provide and to assess where opportunities for improvement exist. Putting a mirror to current practices can be a valuable tool. Continuous improvement is pursuant to continuous evaluation, and organizational checklists can do just that.

AHA’s Community Connections initiative, along with other efforts, have offered anchoring themes for community outreach work. As a result, building the next generation of community health strategies and weaving them strongly throughout the fabric of an organization will be vitally important to a hospital’s success moving ahead.

Hot-spotting: Hot-spotting, first used by Jeffrey Brenner, M.D., in Camden, N.J., is the ability to strategically focus on a patient population by specific neighborhoods or ZIP codes and then identify associated relationships between geography and health outcomes. Some researchers believe that looking at a patient’s ZIP code can be a strong indicator of the person’s health, even more so than his or her genetics.

The use of hot-spotting has proved to be extremely helpful when refining broad community health and wellness goals that develop more targeted strategies to address the patients who are often admitted repeatedly to the hospital. Hospitals can combine the patient data they collect as well as real-time data, when available, with other public sources of data to refine the work they are doing. Data for hot-spotting can be sourced from public health data, census data and data collected during a hospital’s community health needs assessment and from community partners.

Using hot-spotting initiatives, health care organizations have been able to be more strategic and focus initiatives and interventions on neighborhoods with social, economic and environmental barriers that lead to poor health outcomes and health disparities. Identifying and focusing on these specific patients and communities can be an effective strategy to reduce readmissions and decrease inappropriate emergency department utilization, while improving the overall health and wellness of a community.

Second-generation strategies

The strategies outlined previously — first-generation strategies — have brought great success and insight to the community health work done by hospitals and have improved population health. Second-generation strategies will build on what is already being done by many hospitals to take community health to the next level. Following are some innovative ways to enhance current efforts, evolve relationships and build upon the existing outreach base.

Collaboration with other hospitals: Great success has resulted when hospitals collaborate — hospitals working together with other hospitals, with public health departments and with social service organizations. A collaborative community health needs assessment can be instrumental in developing a health plan that is sustainable and that identifies specific areas of expertise among community partners to complement one another and allow for shared deployment of resources.

Partnering with hospitals and other health care organizations deepens the roots of access and understanding of community needs. It broadens the scope of activities in which a hospital can engage and strengthens the ability to sustain work in priority areas. An individual hospital may become overwhelmed when faced with redefining itself in a manner that continues to provide care and keeps needed services within the community, while still meeting community benefit standards designed to address community needs. Partnering, not competing, with other health care organizations is how many hospitals are improving traditional medical care while simultaneously integrating care coordination techniques into sustainable models of improvement.

Community visioning: One new approach to community health incorporates innovative thinking about how hospital campuses as well as broader communities can be redesigned to promote better health. This approach, called community visioning, begins with community stakeholders sharing a vision of health and then building a true infrastructure for health where, neighborhood by neighborhood, access to care is available. In addition, access to healthy food options, adoption of healthy behaviors, exercise and disease prevention, combating and changing negative environmental factors are obtainable. Community visioning takes planning and coordination among town and city governments, urban planning and transportation departments, health departments, health care organizations, community partners and many others to produce growth and create redesign that is smart, purposeful and done with health in mind.

Predictive analytics and use of big data: Incorporating data analysis into strategic planning and community health work does not need to mean high dollar expenditures; opportunities exist to hone and inform efforts to tap into existing data. The promise of data can also be further recognized and strengthened through partnerships. Hospitals should first look to see what community data assets already exist and whether there may be unique partnerships with insurers to use payer data to target community health strategies. Hospitals then collaborate with public health departments and other community organizations to collect relevant data or engage with universities or other educational partners who can augment work around research, data analysis and even technology infrastructure.

National collaboratives: Achieving a population in which every individual has access to needed health care services, access to environmental and social needs that affect health, and access to care without inequity or disparities is the ultimate goal all hospitals are working toward, but it is a tall order. While the hospital field itself offers a strong network for collaboration, many other entities are also working to improve health status. Even beyond the value found in community collaborations, there are organizations, foundations and insurers that are national in scope and that can provide cohesiveness to existing efforts, offer resources for expansion, and broaden the scope and infrastructure for success.

Excerpted, with permission, from “Next Generation of Community Health,” a report from the American Hospital Association 2016 Committee on Research, Eugene A. Woods, FACHE, chair. 

Baptist Memorial Health Care — Memphis, Tenn.

Baptist Operation Outreach is a mobile health care clinic for the homeless and the result of a partnership between Baptist Memorial Health Care and Christ Community Health Services. The van provides free acute and primary health care, information on disease prevention and guidance, and a medical home to thousands of area residents without permanent housing. Patients have direct and immediate access to medical examinations, health information, illness prevention and medications as well as vision, dental and referral services. A certified nurse practitioner delivers screenings, health and developmental assessments for children, immunizations and other preventive care, diagnosis of medical problems, and treatment and management of specific disease problems and minor injuries.

About 3,000 patients visit the mobile clinic each year, making Baptist Operation Outreach one of Memphis’ largest health care providers for the homeless.

Contact: Jason Little, president and chief executive officer

Winona Health — Winona, Minn.

Winona Health’s Community Care Network was developed to improve individual health and quality of life, prevent hospitalization and emergency department visits, and avoid unnecessary health care costs. In partnership with Winona State University, CCN trains students to become health coaches. CCN helps people struggling with chronic health conditions that may have a negative impact on all areas of their lives. Health coaches meet with clients in their homes and become nonclinical members of the individual’s care team.

Health coaches are familiar faces who can help residents grasp the big picture of their overall health. CCN supports and empowers clients to take ownership of their health and to make positive changes. Through the program, 42 trained health coaches have made more than 6,000 visits to 103 clients. Emergency department visits and hospitalizations for CCN clients have declined by more than 85 percent.

Contact: Betsy Midthun, vice president, community engagement