Community Partnerships

By 2006, community organizers in North Carolina's Wake County couldn't deny that their region's waistlines were expanding right along with those of the rest of the nation.

The latest community needs assessment had identified obesity as one of the top health issues for the county, which is home to Raleigh and the Research Triangle. Other data were similarly gloomy. One-third of children ages 2 to 4 and at least 45 percent of older children were either overweight or at high risk of becoming so, according to another survey. Just 13 percent of children ages 5 to 18 reported eating at least five servings of fruits or vegetables daily. One-third of kids watched three-plus hours of television during an average school day.

At a 2007 forum, a cross section of leaders from nonprofit WakeMed Health & Hospitals and other community organizations decided to try a new approach. The county already provided myriad nutrition and other programs, says Laura Aiken, director of the resulting partnership, Advocates for Health in Action.

But teaching nutrition classes does little good if the nearest grocery option is a convenience store lined with sugary products, she says. "Health care providers are putting our patients through these programs," she says. "Then they are dumping them into an environment that doesn't support all of the behavioral changes that they are asking them to make."

So the collaborative, one of many community health partnerships around the country, decided to target policy and environmental changes instead. Advocates for Health in Action, which now numbers some 50 organizations, first compiled a detailed map to identify so-called food deserts—areas where healthy food options are scarce. In the years since, they've begun to attack pieces of the obesity problem, talking to convenience store owners about healthy food placement and pressuring parents to select less sugary food for post-game snacks.

Hospitals are increasingly joining forces with community groups to better address multifaceted health problems such as obesity, says Michael Bilton, executive director of the Association for Community Health Improvement, a personal membership group of the American Hospital Association. Membership in ACHI, formed from three groups in 2002, has steadily increased, reaching 730 members by mid-2010 compared with 345 in late 2003.

Bilton cites a number of potential explanations, including heightened state and national scrutiny involving community benefit expenditures by nonprofit hospitals. Hospital leaders, as they delve into issues such as hospital readmissions, also become more acutely aware of the community environments into which patients are released, he says.

For hospital trustees, combining expertise through a community partnership carries inherent advantages, including the ability to tackle problems that no single organization can handle, according to Bilton and other partnership leaders interviewed. "We are really at the table with an incredible cross section of the community," says Bob Smoot, board chair of Buffalo County Community Partners and vice president of mission and corporate responsibility at Good Samaritan Hospital.

In the process, though, hospital trustees and their partners may face stumbling blocks, depending on the size and the scope of their goals. Sometimes large, sprawling boards have members with differing or even competing priorities. Identifying the best community partners early on is important, so they complement the hospital's resources and interests. The partnership's goals also must be carefully selected and ideally tracked over time to prevent efforts from becoming too scattershot.

At Community Health Enhancement, a division of Memorial Hospital in South Bend, Ind., the partnership regularly evaluates its programs to determine what's working, what's not and why, says Margo DeMont, the partnership's executive director. "We are extremely fluid," she says. Extensive write-ups are included on the hospital's website, detailing frustrations and successes.

DeMont points to the write-up about one of the partnership's most successful initiatives, focused on African-American women and breast health, including access to free mammograms for the uninsured. "You'll see that a group of men tried to get it off the ground, and it failed miserably," she says. Then the women themselves took over, she says, and moved the educational effort into the churches and other community locations.

Combining Forces

Partnerships shouldn't be pursued for partnership's sake, says Bilton, who urges trustees to apply their strategic business skills as they lay the groundwork.

"From a trustee's perspective, put any community health program or community health partnership that you might be considering through the same sort of criteria that you would use to evaluate other hospital programs," he says. "Part of the criticism in the past of some community health engagements is that they haven't been focused on achieving specific results, and they haven't been strategic."

As trustees weigh whether to move forward, Bilton says, they should assess the data available to determine whether the health issue or community need poses a significant problem. Also, they should consider whether the partnership's goals align with the hospital's or health system's own and what resources or expertise they can use to tackle the problem.

In the years ahead, more hospital trustees will be asking these sorts of questions, motivated in part by some elements of the new health reform law, Bilton says. The Patient Protection and Affordable Care Act of 2010 includes new funds tied to prevention and wellness initiatives. It also requires nonprofit hospitals to conduct a community needs assessment every three years and to adopt an implementation plan based on that assessment, along with developing related initiatives.

Like Raleigh's Advocates for Health in Action, community leaders in Buffalo County, Neb., began to discuss forming a partnership in the wake of their own needs assessment of the largely rural community. By 1996, they had developed a mission and board of directors for the nonprofit group, says Denise Zwiener, executive director of the Buffalo County Community Partners. Good Samaritan Hospital, the county's only acute care hospital, holds one of the 25 board seats.

They quickly reached consensus on one of the first community problems they wanted to address: transportation difficulties. Without any bus route or other public transportation, some residents struggled not only to reach medical appointments, but also to get food and other necessities.

Several groups were already providing rides for specific populations, such as schoolchildren or people with health care needs, Zwiener says. They realized that the community would benefit more from one central pool of vehicles with a coordinator or dispatcher. "So all of the vehicles are operating all the time, and we don't have idle vehicles sitting around and being unused," she says.

About a dozen vehicles were contributed to the motor pool, and the program quickly took off. From 2001 to 2009, the number of rides provided annually by R.Y.D.E. (Reach Your Destination Easily) Transit increased from 55,280 to nearly 91,000, according to data from Buffalo County Community Partners. These days an elderly resident can count on a lift to the grocery store and someone to help carry the groceries to her door. The cost each way: $1.50.

In Fargo, N.D., MeritCare Health System has been serving residents facing similar rural challenges, with limited transportation and an aging population. To provide broader educational programs and support, MeritCare leaders decided to expand their ties to local religious and faith organizations, creating the Faith Communities Advisory Group. Formed in 2005, it now numbers about 60 members representing Jewish, Muslim, Catholic, Protestant and other faiths.

Along with providing ongoing community education on issues ranging from advance directives to nutrition, the religious organizations have enabled MeritCare officials to quickly reach out to local residents, says Evelyn Quigley, vice president of mission and community benefit. When floodwaters threatened Fargo in recent years, the faith organizations assisted MeritCare in notifying residents about resources, including mental health services, that were provided by MeritCare and other groups.

The advisory group is a bit in transition. MeritCare merged with Sanford Health in late 2009, and the advisory group's role is being assessed in the context of the larger nonprofit system, Quigley said this summer. The new expanded system, operating under the Sanford Health name, encompasses six states, including 30 hospitals.

Navigating Challenges

Community partnerships can take numerous forms, ranging from outreach education to broad-ranging coalitions with multiple projects. Linking up with several organizations can provide partnerships with significant expertise and resources. But it also can create logistical and management challenges.

At Advocates for Health in Action, Aiken strives to keep the interests of all 50-some participating organizations in mind as they select goals and projects. "If they feel like they are coming to meetings and there is really nothing that applies to them, or nothing they can do, then you are going to lose them," she says. "And you might need them down the road for something else."

With so many voices at the table, conflicting agendas can occasionally develop, she says. "And that can get a little tricky."

Aiken described how the group was looking at ways to fill convenience-store shelves with more fresh produce. One potential strategy: to convince local farmers' markets to sell leftover produce at a reduced rate to the convenience stores. But some concerns have been raised that this might compete with groups that already supply donated produce to needy residents, she says. "If we offered for them to sell it, then it might be more appealing for the farmer to sell it than to donate it."

As of midsummer, that potential conflict needed to be researched further, Aiken says. "There are definitely walking- away points," she stresses. "If anything that we do is truly going to damage a partner's ability to do their work, we would never do that."

Not surprisingly, addressing one community need can reveal other issues. Once R.Y.D.E. was launched, organizers discovered that the transportation service was being used by some kids to get home from school in areas where there was no bus service, and "we were dropping off kids at homes where parents weren't there," Zwiener says.

So Buffalo County leaders made a number of changes in their policy, including a requirement that an adult be onsite when a child is dropped off. But they also delved further, looking at ways children could more safely walk to school, Zwiener says. As a result, some traffic lights have been changed to incorporate a countdown mechanism, so children know how many seconds are remaining for them to cross the street.

Broadening Access

Working in a larger group helps hospital officials address issues that they might not be able to shoulder themselves, says Smoot, the board chair in Buffalo County, Neb. The group is developing a plan to better address the health needs of Nebraska's growing Hispanic population, including diabetes and related nutritional education. "It's a population that is challenged in regard to access," he says.

In South Bend, Memorial Hospital's Community Health Enhancement division even set aside competitive instincts to work with another local hospital to improve medical services on the city's west side. Officials at the other hospital, Saint Joseph Regional Medical Center, had first raised concerns about the dearth of medical services on that side of the city following a 2007 community needs assessment, DeMont says.

Saint Joseph officials donated a vacant medical office building to the project. And the two hospitals, along with the city of South Bend, teamed up to renovate and staff the new facility. Slightly more than $1 million was raised to renovate the building, which opened to patients in 2009, DeMont says. The physician practice serves a critical need in a very poor area of town, she says; nearly all of the children are enrolled in the federal school lunch program.

Officials at both hospitals are interested in whether the benefits of better primary care in the community will become visible in their own emergency departments, DeMont says. They've started tracking admissions by ZIP code, in the hope that expanded medical access will improve community health and reduce the number of patients flowing through the ED doors of the hospital partners.

Charlotte Huff is a writer in Fort Worth, Texas.