BY: COLETTA C. BARRETT, RN, FACHE
Baton Rouge's Story
East Baton Rouge Parish, home of Louisiana's state capital, has more than 440,000 citizens, two universities and a robust community college system.1 There are five acute care hospitals located in the parish, but no local public health department.
In 2008, the mayor of Baton Rouge commissioned a group to identify ways of making the community healthier. More than 70 local organizations and others got together in the Mayor's Healthy City Initiative to work toward addressing four specific community health challenges: obesity, overuse of hospital emergency departments, mental and behavioral health, and HIV/sexually transmitted infections. "HealthyBR" became the name of a widespread community movement.
In 2010, HealthyBR became a 501(c)(3) not-for-profit under the direction of the Mayor's Healthy City Initiative. This structural change solidified broad-based leadership for HealthyBR that included the CEOs of the area's five competing hospitals, as well as the CEOs of public, private, government and nonprofit organizations committed to collaboration on community health initiatives.2
With the passage that year of the Affordable Care Act, attention turned to the five local competing hospitals — Baton Rouge General Medical Center, Lane Regional Medical Center, Ochsner Medical Center-Baton Rouge, Our Lady of the Lake Regional Medical Center and Woman's Hospital. The new law required them to conduct community health needs assessments and formulate plans to address those health needs. The process repeats at least every three years, and each new cycle also calls for a progress report on meeting previous goals.
The HealthyBR leadership saw that the five area hospitals could make better use of their resources and be more effective if they worked together on the CHNAs. Using collaboration as a framework, the hospitals met on a routine basis to report on progress.
Sharing the common goal of improving health in the community was a step in the right direction, but there was great variation in what the hospitals measured and reported, and each institution implemented its own plan to reach the goal.3
MORE FOCUS ON IMPACT
By 2014, it became evident that the collaborative model needed to adjust its focus more on impact. The Mayor's Healthy City Initiative board asked the hospitals to undertake a joint CHNA and implementation plan. To that end, HealthyBR adopted the Collective Impact framework —
described in the Stanford Social Innovation Review4 — for the 2015 CHNA cycle. The jointly produced assessment and implementation plan spotlighted four of the community's health needs as priorities: obesity, HIV/AIDS, mental health and overuse of the emergency department.5
The Mayor's Healthy City Initiative board and the HealthyBR teams shared a vision of a healthier community, but just as the hospitals' collaborative model had to change, HealthyBR's structure needed adjustment, too. HealthyBR's mission was to communicate, collaborate and coordinate efforts to impact the community's health, and everyone brought his or her own beliefs and ideas regarding the specific goals. Now, the HealthyBR members would agree as a group on mutually reinforcing activities, and they aligned their metrics for reporting progress — a crucial step. Also, the Mayor's office agreed to provide staffing for the Mayor's Healthy City Initiative, which was essential to the work's sustainability.
THE COLLECTIVE IMPACT FRAMEWORK
For the members of HealthyBR, making the mind shift from collaboration to collective impact was as challenging as it was rewarding. Achieving goals and making progress energized the team to continue the hard work of large-scale social change. The key elements were:
Each HealthyBR member had a voice and vote in identifying top priorities and significant community health needs. This approach assured each institution of meeting its business case as well as community commitment aspirations. Meetings with the hospital CEOs prior to the launch of the 2018 CHNA process meant each organization would commit to looking at the issues through a social determinants of health lens as well as a ZIP code disparity lens. Securing commitment to strategies of local and inclusive hiring, purchasing and investment was critical to having further clarity around implementation strategies.
Common Progress Measures
The IRS rules for the CHNA require that progress toward goals set in the previous CHNA be addressed when producing the next community assessment. It is therefore important for participants in the CHNA process to align their community health improvement plan with the necessary steps to collect information they have agreed to measure for reporting purposes. Each organization collects data and reports that data on a quarterly basis. The community health improvement plan is updated and posted on the HealthyBR website for the community to see.8
Mutually Reinforcing Activities
In 2015, to address the issue of overuse of the emergency departments, a communitywide effort to support the Triple Aim's "right care, at the right place, at the right time" was adopted. All institutions communicated this message about appropriate access through their normal distribution channels. Others developed urgent care centers. Many expanded primary care offerings and expanded hours to augment access. Hospitals across the community initiated case management efforts. Their success inspired the team to celebrate the accomplishments of lowering avoidable hospital days from 46 to 33, decreasing uninsured population from 18 percent to 12 percent after Medicaid expansion and achieving the community standard primary care physician to patient ratio of 1 to 1,100.
In 2016, Our Lady of the Lake Regional Medical Center was chosen by the Catholic Health Association and the Public Health Foundation to participate in the development and implementation of a population health driver diagram project focusing on early identification of patients with HIV in Baton Rouge.
A driver diagram is a method of showing community stakeholders where and how they can collaborate on interventions to solve a large-scale health problem. The early HIV identification project was such a success that the HealthyBR team voted to use the same approach for all of the 2018 community health improvement plans. The evidence-based approach to program planning and implementation assists the HealthyBR team with a repeatable, reliable process across the community that supports achieving social change.
Each hospital's communications team engages with the CHNA in various ways: Our Lady of the Lake Regional Medical Center provides guidance and alignment with the IRS regulations and reviews compliance; Woman's Hospital edits the document to give it one voice; Baton Rouge General's marketing team typesets the document, etc.
Communication arguably is the most significant element of social change, yet it is one of the most difficult to master. Continuous communication is vital to engaging the community as well as stakeholders in change initiatives.
For HealthyBR, using the project management "RACI" model (responsible, accountable, consulted and informed) to clarify roles helped identify the level of engagement needed and the areas of responsibility during multistakeholder communications planning. This process reduces confusion about expectations, increases efficiency and evenly distributes the workload. It also helps cut through the complexity of messaging and serves as a roadmap for large-scale social impact communications.
The mayor's office in Baton Rouge and the administrative staff assigned to the Mayor's Healthy City Initiative serve as the backbone organization responsible for the day-to-day management of the initiative. Having the mayor's office as the convener brought all five hospitals to the table, insuring that no one institution dominated the work. This was critical to establishing trust. Shared accountability resulted in shared ownership and collective commitment to continue the work.
For the 2018 CHNA and implementation plan, the Healthy City Initiative board identified the need to focus additionally on measures of success related to social determinants and ZIP code disparities. The work of addressing the top four health priorities lies with HealthyBR's MedBR Advisory Board, and the social determinants and disparity work will rest with the Mayor's Healthy City Initiative's board of directors. Having the authority to act, making decisions with respect to resources, convening other multisector stakeholders to address specific issues, and sharing information that may not necessarily be public are all expectations of the board.
PUTTING IT ALL TOGETHER
Building on the collaboration road map and driving toward collective impact, Baton Rouge's efforts through HealthyBR and the Mayor's Healthy City Initiative are structured to achieve a healthier community.
Keeping volunteer leaders at the table can be a challenge, and it requires making and keeping the work meaningful and impactful. A quote from Henry Ford summarizes the journey of the Mayor's Healthy City Initiative on the continuum from collaboration to collective impact: "Coming together is a beginning. Keeping together is progress. Working together is success."
COLETTA C. BARRETT is vice president, mission, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana.
- United States Census Bureau, "QuickFacts: East Baton Rouge Parish," website, www.census.gov/quickfacts/fact/table/eastbatonrougeparishlouisiana/PST045217.
- HealthyBR, "Board of Directors," website, www.healthybr.com/who-we-are/board-of-directors.
- HealthyBR, "Community Health Needs Assessment," website, www.healthybr.com/be-smart/community-health-needs-assessment.
- John Kania and Mark Kramer, "Collective Impact," Stanford Social Innovation Review, (Winter 2011) website, https://ssir.org/articles/entry/collective_impact.
- 2015 Community Health Needs Assessment: East Baton Rouge Parish, www.healthybr.com/assets/uploads/docs/CHNA.FINAL.6.24.16.pdf.
- Community Implementation Strategy, download from link on www.healthybr.com/be-smart/community-health-needs-assessment/ www.healthybr.com.
QUESTIONS FOR DISCUSSION
Coletta Barrett describes the participants and process in a citywide initiative to improve the health of the community of Baton Rouge, Louisiana. Originated by the city government, the Mayor's Healthy City Initiative included participation of public, private and nonprofit organizations, in addition to the five competing hospitals in the area.
1) What collaborative efforts — for example, Community Health Needs Assessment and impact plan, addressing social determinants of health and disparity of care — does your ministry engage in with other, perhaps competing, health systems in the area? Do you think there is a credible and objective person, agency or organization that could organize such an effort, as the mayor's office in Baton Rouge did?
2) What are the successes and/or barriers of these collaborative efforts when it comes to their impact on community health?
3) What advantages and disadvantages do you see in collaboration among competing hospitals and health care systems?
4) Barrett writes that an attitude of collaboration should lead to a commitment to improved outcomes. She lists the key elements for achieving those outcomes as common agenda, common measures of progress, mutually reinforcing activities, frequent and direct communication, and a backbone organization. Do you think these key elements are realistic? Do you think they are sufficient?
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