Conversations about the Affordable Care Act and its effect on hospitals have often concerned readmissions and the health insurance exchanges. Also important for hospitals and patients, though, is the effect the law has had on population health.
Many institutions devoted significant resources toward improving community health before the law, which has formally required tax-exempt hospitals to produce community health needs assessments and implementation strategies. The ACA qualified work planned or executed by health systems already in tune with community needs.
As more and more organizations have reflected on their level of engagement in community health programs, the ACA has provided significant guidance and motivation, even if the law doesn't survive in its current form as a result of congressional action.
Determinants of health
In addition to providing health care, hospitals offer employment and engagement programs that establish strong connections with community members across generations. The importance of these connections is bolstered by scientific evidence supporting the impact of social and physical determinants of health — conditions, circumstances and behaviors outside the hospital walls that can factor into about 80 percent of total health, according to the University of Wisconsin Population Health Institute's County Health Rankings for that state.
It is imperative to consider the social and economic context of individuals’ situations. For example, advising diabetic patients to eat better while providing them no access to nutritious foods is a problem. Offering important health screenings that a patient can’t take advantage of because of a lack of transportation falls into the same category.
An important first step for improving population health is to understand the social and economic factors that determine a community's health. As providers, we first must be prepared to screen for possible barriers to accessing health care and provide tools to address those barriers. Second, we need to recognize that as individuals, we are patients only a small percentage of the time but community members 100 percent of the time. True delivery of care means going to where members of the community live, play and work.
To accomplish this radical change in health care delivery, health systems need to establish meaningful partnerships with local organizations that know how to engage the community. By combining these organizations’ resources with those of hospitals, we can provide effective, health-empowering tools for patients.
Two patient populations
For many hospitals, especially those in urban centers, improving community health is a necessity due to patient populations with social and economic barriers to health care. Lankenau Medical Center — part of Main Line Health’s five-hospital health system serving portions of Philadelphia and its western suburbs — has a unique situation that requires us to serve the needs of a diverse patient population.
Lankenau sits between west Philadelphia and suburban Montgomery County in Pennsylvania. To put the two different patient populations into context, the Robert Wood Johnson Foundation ranks Montgomery County as the sixth healthiest county of 67 in the state, while Philadelphia County ranks last.
Assessing the best way to meet the health needs of this diverse group of patients has been our focus for well over 50 years, before population health was as prevalent of a concern in the field as it is today. In fact, in 1958, Lankenau’s Katheryn E. Langwill and Edward Hoge Vick discussed the impact population health would have on the community in the American Journal of Public Health. They stated, “A physician must be concerned with more than the care of the sick and injured, he must study health as well as disease, aid in maintaining and supervising health, advise and educate the public by providing the best health and medical care that is available.”
Population health growth
There are four population health initiatives we’ve experienced success with that involve tangible solutions other hospitals might consider:
Education: Health education needs to go beyond pamphlets and brief, in-office doctor visits. It’s important this education begins at school age, especially when your patient population attends schools that might not have the resources to address health needs.
For example, Lankenau’s Health Education Center offers classes and programs related to general health, nutrition, substance abuse and family life to supplement students’ traditional classes. Additionally, our Health Career Academy partners local high school students with medical students for an intensive, interactive program to learn about health careers.
Diversity: As we explore ways to improve health care delivery and delve into a more individualized approach, it’s pivotal to obtain the knowledge, people and resources that can address various facets of patient populations. This includes knowledge of religion and spirituality, sexuality, food restrictions and cultural orientation.
A 2004 report from Georgetown University’s Health Policy Institute states that “patients are at higher risk of having negative health consequences, receiving poor quality care or being dissatisfied with their care” if their doctors and hospitals have low cultural competence ("Cultural Competence in Health Care: Is It Important for People With Chronic Conditions?"). Enhancing cultural competence begins with educating our staff, which can include bringing in members of different patient populations for brown bag lunch sessions to explain subtle cultural requirements.
Diversifying staff to better support your patient population goes a long way toward increasing patient safety and comfort. For example, a prominent Chinese-American cardiologist was recruited to Lankenau with the intention of utilizing her expertise and background to engage a new population of patients by better communicating with and supporting them.
It’s essential to provide tangible signs that you are listening to patient needs. Lankenau established Shabbat Suites a few years ago to accommodate the Orthodox Jewish population that can’t easily travel to and from the hospital on the Sabbath and other holy days.
Nutrition: Addressing patients’ nutritional needs can have positive long-term effects on numerous chronic conditions, including diabetes and heart disease. We’ve learned, however, that educating patients only goes so far, especially when inefficient food access — in terms of both affordability and lack of transportation — is mixed with convenience and habit.
As a result, we’ve focused on making nutrition tangible, as well as bringing it outside the hospital walls, and have found this highly effective in improving patient health outcomes. In partnership with the Food Trust, we provide our patients with Philly Food Bucks — vouchers for fresh fruits and vegetables that can be redeemed at local farmers markets. We’ve also worked with the Food Trust on the Heart Smarts Corner Store Initiative, which aims to convert Philadelphia’s corner stores into healthy community assets by increasing access to healthy food and providing nutrition education.
In 2016, we launched the Delema G. Deaver Wellness Farm to grow organic fruits and vegetables. As a result, hospital representatives were invited to Washington, D.C., in October 2016 for the anniversary of Let’s Move, the program developed by former first lady Michelle Obama to solve the epidemic of childhood obesity. The visit also marked the rededication of the White House Kitchen Garden, during which Obama referenced the farm’s successes.
We’ve even brought Wellness Farm produce to weekly pop-up farmers markets at our doctors offices. Providing this food to patients can make the nutrition conversation more realistic and establish the connection to preventing conditions such as diabetes or hypertension.
Research and learning: The previous three areas can only have long-lasting effects if their successes are effectively measured.
Major third-party organizations such as the Robert Wood Johnson Foundation have released research that supports the impact of population health initiatives. When individual institutions analyze the results of local initiatives and publish those results, however, as Lankenau and Main Line Health are planning through the newly established Center for Population Health Research, it can help make addressing health needs outside the hospital walls the rule rather than the exception.
Reminder for all
We believe the key takeaway for all hospitals is simple. There should be a purposeful flow of information from clinicians and hospital staff members to those in need — and vice versa — to eliminate significant lacks in knowledge and deficiencies in care.
This starts by simply paying attention — watching and listening — to your patients and beginning to understand what their lives are like outside the hospital walls. From there, you will be able to identify barriers in the community to improving residents’ health and can act to overcome them.
Phillip Robinson, FACHE, is the president of Lankenau Medical Center in Wynnewood, Pa. Chinwe Onyekere is the associate administrator at Lankenau Medical Center. Norma A. Padron, Ph.D., M.P.H., M.A. (firstname.lastname@example.org), is the associate director for the Center for Population Health Research at the Lankenau Institute for Medical Research and assistant professor at the Thomas Jefferson University College of Population Health. Lankenau Medical Center is part of Main Line Health.