BY: EMILY FRIEDMAN
In working to improve community health, health care organizations are obliged to consider partnering with other entities, which is not always a comfortable pursuit. Reaching out to competitors or other organizations in the community can be difficult to contemplate, much less do. But as CHA's Julie Trocchio and Sr. Mary Haddad, RSM, point out on page 28 of their article in this issue, "We know that working with community partners to change conditions that contribute to vulnerability can get at the root cause of many serious health problems. Thus collaborative actions to eliminate poverty, unsafe housing, violence and environmental risks will improve the health of at-risk populations in entire communities."
It is also important to understand that whatever becomes of the Patient Protection and Affordable Care Act in the courts or Congress, many of its provisions have taken on lives of their own and are likely to survive. These include accountable care organizations, bundling of Medicare payments to cover an entire episode of care (with other payers following suit), more consolidation among hospitals, growth in multispecialty medical groups and measurement of provider performance in terms of improvement in population health.
All of these initiatives share at least one characteristic: In order to succeed, providers must join with other health care and social service entities. Hospitals must partner with physician practices, outpatient programs, home- and community-based services and nursing homes. Matters that affect community health, such as violence, nutrition, poverty and lack of preventive care, must be addressed. The results — good or bad — are more than likely going to have broad impact. As the stories here show, creative alliances can bring impressive results.
Detecting Women's Cancers Early
Mercy Hospital and Medical Center in Chicago is the lead agency of the Illinois Breast and Cervical Cancer Program, funded by the Centers for Disease Control, the state of Illinois and the Avon Foundation. The program offers free breast and cervical cancer screening and follow-up care to uninsured women and welcomes those with Medicaid and Medicare coverage. Free transportation is available to any woman who lives within 10 miles of the hospital.
Mercy President and CEO Sr. Sheila Lyne, RSM, said, "This population is under-screened and underserved, and we want to be their medical home, even if no lesions are detected. Some women are frightened [about getting a mammogram] because they don't know what it's going to be like, and some are frightened that they may have a tumor. We used to encounter women in some parts of the city who should have had a mammogram, and we would have a bus there to bring them, and some would not even come then."
More are coming in now. According to Eileen Knightly, director of the hospital's breast center and its women's health center, "We started out in 2001 with about 100-150 women a year, and now we serve around 4,000 annually."
Working WithPublic Schools toCombat Obesity
In 2006, Catholic Healthcare West's Northridge Hospital Medical Center launched the School-Based Obesity and Diabetes Initiative in Northridge, Calif. Bonnie Bailer, director of the hospital's Center for Healthier Communities, said the initiative targets public schools in the district that participate in the federal school lunch program providing free meals to children from low-income families. Many district students qualify, and the vast majority of them are Latino.
The program provides a full-time physical education teacher for each participating school; an obesity clinic; and "Food for Thought" plays that instruct children in better eating habits. Parents are offered healthy cooking workshops, walking groups and weight monitoring. Teachers can take advantage of fitness retreats and stress management programs.
The program is available to more than 30,000 students in 36 schools. Since 2006, the proportion of participating students who engage in an hour of physical activity daily has risen from 16 percent to 22 percent; cardiovascular fitness increased from 33.7 percent to 37.7 percent; and the proportion of students who consume fruits and vegetables two or three times a day has risen from 18 percent to 24.4 percent. The percentage of overweight or obese students in the program has declined from 40 percent to 32 percent.
Bailer said hospital representatives were fortunate to gain the support of a community relations person at the local school district who became an advocate for the program and helped gain cooperation from schools and district leadership.
A Center of Hope for Families
California Hospital Medical Center in Los Angeles, a member of Catholic Healthcare West, has been the core sponsor of the downtown Hope Street Family Center since its 1992 founding. The center was created, said director Vickie Kropenske, "in part to address issues related to access to care. It began as a partnership to predominantly serve families with young children, but because of support from the community, parents and the hospital, the center has developed far beyond that."
Today, the center serves a population that is about 90 percent Latino and 10 percent African-American. On any given day, the center and a satellite site provide home visiting and social services for 2,000 people. There are educational programs for adolescents with learning challenges; after-school programs; family services that specifically target such areas as family communication skills and parenting training for fathers; English as a second language; mental health services for children; and programs for abused children and family reunification. The center also has a targeted program for kids with special needs; "We want to be able to provide services to them early on," said Kropenske.
She said of the center, "This is the vision the hospital had, of going way beyond acute care and providing preventive and social services for its community."
Protecting Children from Violence
Recently Catholic Health Initiatives (CHI) decided to make violence prevention a priority. CHI member St. Clare's Health System in Denville, N.J., partnered with the county domestic violence agency and representatives from agencies serving sexual assault victims, at-risk families, youth and family services, school systems, local churches and the county prosecutor's office. Other partners are a community health center, public health officers, county human services, Catholic social services, Head Start, the YMCA and other entities. This very diverse Violence Prevention Initiative Task Force meets approximately once a month.
Cynthia Lyons, director of community relations for St. Clare's, said, "The task force reviewed data on violence in our community — bullying, domestic violence, sexual assault and child abuse. The school representatives said kids were coming into kindergarten with violent tendencies and that they learn it from violence in the home or the community by being exposed at a very young age." As a result, the task force, according to Lyons, "decided to work on primary prevention — stopping violence against children before it starts."
The task force is developing a comprehensive strategy to, according to a St. Clare's summary report, "provide families in our community with the supports needed to ensure safe, stable, and happy environments for raising children." The group plans to launch the program in 2012. "If child mistreatment does not happen," said Lyons, "the child is not exposed to violence and is less likely to get involved in bullying or street violence."
The committee hopes to promote healthy socio-emotional development for children and education for parents so that, in Lyons' words, "they can avoid violence in a proactive manner."
Beefing Up Behavioral Health
SSM Health System, based in St. Louis, has "the largest behavioral health services presence in the state of Missouri," according to former president and CEO and current board chair Sr. Mary Jean Ryan, FSM. She adds that the BJC HealthCare system, also in St. Louis, has a large presence in the field as well.
SSM and BJC — competitors in the St. Louis market — are working together to reopen a 24-hour emergency room for psychiatric cases and a small number of beds for short-term, acute mental health care. Those specialty services were lost in mid-2011 when state budget cutting closed the St. Louis Metropolitan Psychiatric Center and the Southeast Missouri Mental Health Center, leaving other hospitals' emergency departments to treat the mentally ill among their admissions.
"Patients with behavioral health problems coming into our [emergency departments], in several instances, have been violent, and we have had injuries to several employees," Sr. Ryan said.
"An organization has offered significant funding, and both SSM and BJC will provide $500,000 each," she said, noting the new St. Louis Regional Psychiatric Stabilization Center will have a limited number of inpatient beds at first, with more to be added as funding becomes available.
She continued, "Some people have asked if we should be in this line of work at all. But if we don't take care of them, who will? What options do we — and they — have in the long term? The behavioral health issue in this country is a scandal. It doesn't really matter what kinds of problems these people have — alcohol, drugs, suicidal tendencies — they will all end up on our doorsteps. We must take care of them."
New in the Neighborhood
In Boise, Idaho, Saint Alphonsus Medical Center, a member of Trinity Health, has set up a maternal and child health initiative for thousands of refugees who have been resettled in the community.
According to Saint Alphonsus president and CEO Sally Jeffcoat, the refugees have come to Boise from such far-flung countries as Nepal, Bhutan, Somalia, Myanmar (formerly Burma), Uzbekistan, Russia and Thailand. They began arriving in 2004, many with no possessions, and the hospital's annual needs assessment identified them as the most vulnerable population in the area. The medical center's CARE Maternal/Child Health Clinic, founded in 2009, focuses on the expectant mothers among them.
Margie Widener, a certified nurse midwife who is heavily involved in the program, said many of these women have spent years, in some cases decades, in refugee camps. Most have been victims of violence. Their English-language skills are poor or nonexistent, and they commonly have co-morbidities such as malnutrition, tuberculosis, hepatitis B and cardiac problems.
Saint Alphonsus brought together several agencies, including the state refugee office, resettlement agencies and Medicaid representatives, along with the Genesis Clinic, a free health center offering voluntary physician services. "It's a huge community partnership," said Judy Hobbs, manager of the CARE clinic.
CARE offers obstetric and pediatric care, including all necessary pre- and postpartum services. Interpretation is available in 15 languages, and women from the community serve as health advisers, helping these patients learn about government programs, using taxis, picking up prescriptions, being on time for appointments and even how to shop in a grocery store or use an elevator. In the latest fiscal year, CARE served 100 women.
The program expanded in 2009 to include Curbside Care, an RV that is a primary care clinic on wheels. Jeffcoat said it "is bringing culturally informed family medicine to refugee patients where they need it the most — at their homes and other easily accessible community agency sites."
In 2001, Lewiston, Maine, became home to a significant number of immigrants from Togo and Somalia. The city had few minority residents, and racial tensions developed.1
The leaders of St. Mary's Regional Medical Center, a member of Covenant Health Systems, formed an advisory group composed of representatives of the Togolese and Somali community. They identified four main objectives: guaranteed access to care, community education about the new groups, a hiring program that included teaching English as a second language and collaborating with other community organizations to promote cultural diversity.
St. Mary's is involved in other outreach activities in Lewiston, including Lots to Gardens, a program that creates community gardens on vacant lots and distributes the produce to food banks and low-income residents.
St. Mary's has also worked with hospitals in Haiti for more than 20 years, including mentoring medical staff, providing preventive care, rehabbing an orphanage and offering free treatment. The hospital was won both the American Hospital Association NOVA Award and the Foster G. McGaw Prize, an annual award recognizing a hospital's efforts to improve the health and well-being of its community.
Serving the Street People
In 2010, Mount Carmel Health System in Columbus, Ohio, part of Trinity Health, worked with a mental health program, a food pantry and a soup kitchen to create the Street Medicine program to seek out and bring services to the homeless. According to Sr. Barbara Hahl, CSC, senior vice president for mission and outreach at Mount Carmel, "There are long-term homeless people living in this city in the bushes, in the woods and in the shadow of two upscale high-rise towers."
The hospital assembled a team consisting of a nurse, a physician or nurse practitioner, an emergency medical technician and a patient advocate. The advocate has extensive experience in working with homeless people in shelters and other locations. He visits the street people and seeks to connect them to services; the clinicians provide ambulatory care. The advocate also has housing contacts and tries to fill clients' requests if they want to get off the street. If they choose to stay outside, he tries to provide them with tents and other supplies.
Nurse practitioner Jackie White told of visiting a homeless camp where one patient was a man diagnosed with colon cancer. He was afraid to undergo chemotherapy. The team convinced him to keep his follow-up appointment for treatment and gave him a bus pass so that he could do so. Another patient was suffering pain from a hand fracture, but, as a former addict, did not want to take any narcotics. They gave him ibuprofen and made an appointment for him to receive care at a nearby clinic.
Eat, Grow, Swim
In 2007, Provena Saint Joseph Medical Center in Joliet, Ill., conducted a community needs assessment and learned that childhood obesity was a particular problem, especially among low-income families. The hospital formed the Joliet Partners for Healthy Families, a coalition including the Harvey Brooks Foundation, a nonprofit organization devoted to community development and opportunities for young people, the city park district, the county health department, the local YMCA and two universities.
Julie Edwards, director of mission services for the medical center, said the partnership works with children in a local school district in which 60 percent of the students have family incomes below the federal poverty level. Third graders participate in the partnership's Healthy Kids Club that makes sure the children receive 20 minutes of nutrition education and 40 minutes of physical activity on a regular basis — and the kids receive free athletic shoes. In fourth grade, the children move into the Kids 'n' Nature program in which they visit a nature center and learn organic gardening. The students receive plants to take home and are given instruction in both English and Spanish about how to grow and care for them.
In fifth grade, the children receive free swimsuits and swimming lessons at the YMCA, as well as more nutrition education and other physical activities.
The Healthy Kids program keeps parents informed about the program and their children's progress through parent-teacher sessions, PTA meetings and a newsletter. "We really want to start targeting families overall," Edwards said.
Making Medical Homes
Every emergency-care professional knows the term "frequent flyers" — patients who come to the emergency department frequently, whether for care, comfort or narcotics. Sometimes they "shop" different emergency departments to try to get what they want. These patients can be very difficult, often suffering from substance abuse or mental health problems. Nonetheless, said Doug Busch, administrative coordinator for the CHOICE Regional Health Network in Washington state, "I believe that no one really wants to come to the emergency department four times a month. That's an indication that there's something wrong in their lives."
CHOICE is a coalition formed 16 years ago in western Washington to help improve the local health care delivery system in a five-county area. CHOICE provides direct health care services, works to improve quality of care and collaborates with many community entities from hospitals to churches to food banks to schools.
In 2003, CHOICE and Providence St. Peter Hospital of Olympia, Wash., part of Providence Health and Services, initiated the Emergency Department Consistent Care Program (EDCCP) designed to create medical homes and ensure reliable care for "frequent flyers" who make multiple visits to emergency rooms. The program brought together a collaborative group of hospitals, primary care clinicians and social service providers to get EDCCP patients needed services, coordinate their care, improve their health and cut down on inappropriate trips to emergency rooms.
Kara Elliott, the program's administrative coordinator, said enrolled patients agree to have their medical records added to a unified data base available to providers.
"The primary intervention is to have a plan of care in the ED," Elliott said. "When an enrolled patient goes to one of our EDs, any provider seeing that patient will treat him or her consistently."
"The challenge is seeing to it that these people get established with primary care and maintain that relationship," she added, referring to frequent flyers' characteristically high rate of no-shows at follow-up medical appointments.
Providence St. Peter is tracking more than 700 patients enrolled in the EDCCP program, and their emergency department visits have been reduced by 50 percent. The EDCCP program won the American Hospital Association NOVA Award earlier this year, and CHOICE has expanded the program to more facilities in its region.
Leave No One Behind
Ascension Health, based in St. Louis, decided that by 2020, each of its health ministries around the country would have a plan to ensure everyone in the community has access to high-quality care. The goal was clear: "Seeing to it that all persons, particularly those persons who are poor and vulnerable, can access environments and healthcare that create and support the best journey to improve health status for individuals and communities, and are financed in an adequate and sustainable manner."2
Ascension laid out a five-step program for its hospitals:
- Develop a communitywide infrastructure, including creating coalitions
- Fill gaps in services such as prescription drug availability and dental and mental health
- Create care models that produce better outcomes
- Encourage physicians to create medical homes for uninsured and underinsured patients
- Obtain funding through various public and private sources
Susan Nestor Levy, chief advocacy officer for Ascension, said "one of the priorities of our sponsors and our board was to create a voice nationally, in partnership with others, for those who are most vulnerable. In order to do that most effectively, we needed to play the role of catalyst. This was within the umbrella of our commitment to provide care that leaves no one behind."
In the past 11 years, Ascension has invested $170 million in the effort, after beginning with a modest contribution of $7 million. Once Ascension made the initial investment, the program's leaders sought funding from the federal government, which they received, and then Ascension matched it. In some of the communities that the program serves, including New Orleans and Austin, Texas, local funds were also obtained. Levy said leveraging money from other sources has proven very successful: "We were surprised by the catalytic power of sharing money."
JoAnn Webster, vice president for community health for the system, said the effort must be tailored to the community: "People say that if you've seen one community collaborative, you've seen one community collaborative, and that's true, but there are underlying shared principles."
Among this initiative's success stories is the Milwaukee Health Care Partnership, which was formed in 2006 to address, in the words of Joy Tapper, its executive director, "the growing number of uninsured and underinsured residents here. Also, many community organizations were involved in duplicative efforts."
The CEOs of many organizations, including the hospitals, began to discuss what they could do to improve the situation. Ascension provided resources, and in 2007, the Milwaukee Partnership was born, a coalition comprising hospitals and health systems — Aurora Health Care, Children's, Columbia St. Mary's, Froedtert Health and Wheaton Franciscan — along with four community health centers, the Medical College of Wisconsin and city, county and state agencies. Other collaborating partners include the county medical society and state hospital association.
The partnership works to expand public coverage for low-income people, to enroll those who are eligible for public programs, support Medicaid funding and encourage development of affordable private insurance. It also supports expansion of community health centers and access to all forms of care, including dentistry and behavioral health services. A third priority is coordination of care and assistance to patients in navigating the health care system.
Tapper said leadership is the key to much of the partnership's success. "Early on, the decision was made that the board would be composed of the most senior members of the participating organizations — health system CEOs, directors of community health centers, the dean of the medical school, the state Medicaid director, the state health director, the commissioner of the city health department and the director of the county health department," she said. "They have maintained that commitment, and we have a 90 percent participation rate at every board meeting."
The partnership is also working to eliminate duplication of effort and serves as a clearinghouse for information. "In some cases, we have been able to address overlap," said Tapper. They have also developed a community health improvement plan, an action plan and a commitment to measuring the results of their efforts.
Currently, their ED care coordination initiative links patients with chronic conditions, pregnant women and "frequent flyers" to medical homes. An average of 550 patients annually are referred to community health centers in order to establish medical homes; 44 percent of those who are referred keep their first appointment; of those, 60 percent continue to keep appointments, which is an impressive achievement.
The partnership won the AHA NOVA Award for 2011.
EMILY FRIEDMAN is an independent health policy and ethics analyst based in Chicago.
- American Hospital Association, "Eliminating Racial and Ethnic Disparities Case Example: St. Mary's Regional Medical Center," Executive summary, March 2005.
- Laurie E. Felland et al. "Improving Health Care Access for Low-income People: Lessons from Ascension Health's Community Collaboratives," Health Affairs, 30, no. 7 (July 2011): 1290-97.
PARTNERING TIPS AND TECHNIQUES
Catholic health care leaders who have achieved partnership with other entities have advice to share regarding how to do it right. Here are some of their lessons:
Don't ignore history, but don't be bound by it. Sr. Mary Jean Ryan, FSM, of SSM Health Care jokes about an old saying: "What separates Catholic organizations is that they are divided by a common religion." Cultural pieces from long ago get passed down from generation to generation and may pose problems for the present, she said. "There are always opportunities for working together, but it's clear there has to be a measure of trust among the parties. If that isn't there, no one should waste time trying."
Trust is undoubtedly key; in many of these initiatives, providers and others who have competed for years have been willing to lay down their arms for the betterment of the community. History should not be forgotten, but it should not control the future.
Ideas can come from anywhere. In the small community of Maryville, Mo., Debra Hull is a nurse and the order management computer coordinator for SSM's Saint Francis Hospital. She is also a diabetic, and one day her son's second-grade teacher asked her to speak to the class about diabetes. Hull said, "My question was, how do you make this interesting for second graders?"
With construction paper and office supplies, she created "Joe," a life-sized exhibit that demonstrates what happens to the body when it gets diabetes. Joe was a success, and other schools started asking Hull to speak. She created a DVD, "A Journey with Joe into Diabetes," which has been widely distributed. She also came up with a unique teaching tool: a sweater to which she attached large numbers of refined-sugar bags, so the kids could see how much sucrose they are consuming if they drink a lot of soda.
The hospital supports Hull's diabetes education work, and she has been invited to schools as far away as Kansas City to make presentations.
Know what you have in common. Vickie Kropenske of the Hope Street Clinic stresses that "you need a common vision." Things go much more smoothly when everyone is on the same page. Kara Elliott of the Emergency Department Consistent Care Plan in Washington state believes the same: "The hospitals and clinics share a common need to manage this population. What I try to do is bring people together to fulfill the common objective, which is to help these people be healthier. It's a win-win; we all have the same objective."
JoAnn Webster from Ascension Health adds, "Look around in the community. See who has something to contribute to the effort, and who has something to gain." Also, "identify a problem in the community that will touch everyone, that everyone is willing to solve. As you sort through the hundred things that people might want to work on, find one that touches most people," she advises. That way, she says, more people will commit to the project.
Outreach is essential, whether that means meeting with Somali elders in Maine, as St. Mary's Regional Medical Center in Lewiston, Maine, has done, or offering transportation to homeless people so that they can keep appointments. Barbara Townsend, vice president for business development and community affairs at Mercy Hospital and Medical Center in Chicago, says, "You have to be inside the community; you can't wait for the community to come to you."
Mercy's president and CEO, Sr. Sheila Lyne, RSM, once served as Chicago's health commissioner and she tells of a city program that sent community health workers door to door to get pregnant women and children into care. "If you make enough connections, then that spreads. Eventually, we were able to get pregnant women into our clinics," she said. "And if some of the local dangerous guys made any threats, they were told, 'Leave them alone — they're taking care of our kids.'"
Part of outreach is sharing what has been learned — resources are too scarce, and needs too great, to waste time reinventing the wheel. If there has been a success — or a failure — the information should be shared with others.
Embrace the unknown. It can be scary to initiate collaborative activities. Potential partners might turn you down, meetings can get feisty, and things can fall apart. As Sr. Ryan says, "Conflict is never pleasant, and I don't enjoy it, but we just keep trying to do the right thing."
That right thing might be teaming up with schools to fight obesity, or welcoming new folks in town that others are shunning, or saying to competitors, "In this case, let's work together."
Perhaps the advice from St. Mary's in Lewiston regarding their partnership with African refugees says it best: "Form an advisory group with the culture you want to work with, and take the time to become their friends. Eat with them, invite them into your homes, be a part of their lives, and let them become part of your life. This relationship should go beyond work, and must be a true commitment to become involved with their needs and wants."
Copyright © 2012 by the Catholic Health Association of the United States
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