Log in

BY: MICHAEL BILTON, MA

Mr. Bilton is director, Community Health Programs, Health Research and Educational Trust, Chicago, and executive director of the trust's Association for Community Health Improvement.

Everybody Wins When Hospitals Collaborate with Others to Serve Their Communities

There is much discussion these days of not-for-profit hospitals' community benefit roles and functions, and the conversations taking place have several dimensions—consistent with the various perspectives people bring to the subject.

Conversations with a chief financial officer (CFO), a lawyer, and a hospital community benefit director are likely to yield very different, if ultimately compatible, understandings of the concept. A CFO may think of community benefit as a dollar figure tallied from a wide range of hospital activities, including charity care. A lawyer may think of community benefit in terms of charitable purpose and corporate social responsibility. Meanwhile, a community benefit director may think of health promotion and disease prevention programs, access to care initiatives, and a web of community relationships. These are, of course, different views of the same proverbial "elephant," based on the differing roles of the people involved.

As for the financial and legal perspectives, the Internal Revenue Service's "community benefit standard" talks about conditions under which a health care organization is said to be operating "to promote health in a way that accomplishes a charitable purpose" and "benefits the community as a whole."1 This is a foundational element of the not-for-profit health care sector, including hospitals and health care systems.

Community benefit is, on one level, an enumeration and accounting exercise in which activities can be tallied and dollars totaled for inclusion in voluntary reports to the community (or, in some states, mandated reports to public agencies). There are a number of excellent guides and tools to assist hospitals and health systems with the mechanics of community benefit. However, viewing community benefit exclusively through the counting and reporting lens risks fostering an inwardly focused orientation and a compliance mindset.

Such a perspective is a necessary starting point for understanding community benefit programs, but it may inhibit the conceptualization and achievement of greater value for both communities and the hospitals that serve them. In this article, I intend to identify four key components of community benefit that together constitute a broader perspective, one in which community benefit is of strategic value to the community and the hospital, and serves as a departure point for some of the hospital's most fruitful contributions to health and well-being.

A Broader View
A good place to begin discussing a broader view of community benefit is with a statement that most Health Progress readers will recognize. The Catholic Health Association (CHA) and VHA, Inc., define community benefit as "a planned, managed, organized and measured approach to a health care organization's participation in meeting identified community health needs. It implies collaboration with a ‘community' to ‘benefit' its residents—particularly the poor, minorities and other underserved groups—by improving health status and quality of life."2

A complementary description of community benefit from the Health Research and Educational Trust's Association for Community Health Improvement (ACHI) states, in part, that community benefit activities:

• Relate to accessibility, quality, and cost of the community's health system, as well as to community health and well being
• Pay specific attention to community collaboration, community capacity building, and people in the community with unmet health needs
• Build on, and work to expand and align, an organization's ongoing health improvement and community service initiatives with the organization's strategic plan and budget3

Both statements contain four important themes that serve as anchors to the understanding of community benefit's positive effects on communities and institutions and its role in a larger health system that includes hospitals, but does not rely exclusively on them:

• Community health improvement
• Underserved populations and unmet needs
• Collaboration outside the hospital
• Coordination and strategic management inside the hospital

But before considering the meaning of each theme and the themes' relationships to each other, I want to take a brief look at some visible manifestations of community benefit in hospitals' programs and in the job titles of people responsible for the programs.

Programs and Job Titles
Community benefit is an opportunity for hospitals and health systems to affirm their community-focused missions and to ensure implementation of those missions in their organizations. One does not need to look very far to find clues to hospitals' practice of community benefit, even without examining tools, procedures, and case studies.

First, voluntary, not-for-profit hospitals include community benefit and community service firmly in their missions. In the most recent annual hospital survey conducted by the American Hospital Association's Health Forum, 97 percent of voluntary, not-for-profit respondents report that their "mission statement[s] include a focus on community benefit."4 This should surprise no one. Given the origin and evolution of such facilities in the United States—and especially faith-based ones—the charitable purpose of such hospitals has been present from their earliest days.

Perhaps more importantly, the vast majority of hospitals in the survey reported having plans and resources in place that help them carry out their community benefit-oriented mission. Specifically, 93 percent of hospitals report having resources for their community benefit activities, and 88 percent have a "long-term plan for improving the health of (the) community"5 (see Box).

Another quick, albeit informal, way to gain some insight into hospitals' views on and practice of community benefit is to take a look at the job titles of people with community benefit functions. Ask for a list of hospital community benefit directors, and you will likely get a varied list (see Box). Apart from the variety of these job titles, what is interesting about them is how closely they reflect the four key community benefit themes extracted from the CHA/VHA and ACHI community benefit descriptions. Community health is the dominant theme among these titles, and one could make a case that the titles that include the words "mission" and "accountability" represent a commitment to the underserved and people with unmet health needs. Collaboration with other organizations and the community is explicit in the words "outreach," "healthier communities," and "community partnership." And internal coordination and strategic management is present in the titles that include the words "integration," "public affairs," and "accountability."

Four Community Benefit Themes
Now let's take a closer look at the four vital community benefit themes I mentioned earlier.

Community Health Improvement Among some practitioners in the field, there is such a strong identification of "community health" with "community benefit" that the terms sometimes seem nearly interchangeable. After all, what is the community benefit goal of a health care organization if not better health and health services?

Community benefit, viewed through the community health improvement lens, is often defined broadly to include physical, mental, emotional, and spiritual health. It also can encompass education, economic development, and social programs that strengthen a community's capacity to be healthy. The term also frequently implies preventive action. Even in the case of charity care, community benefit is arguably about health improvement. Charity care that is provided in conjunction with community benefit minimizes or avoids health risks both to the individual and the community as a whole.

On the other hand, not all community health improvement activities are community benefits. The primary distinguishing factor is likely to be found in the nature of the need.

Underserved Populations and Unmet Needs A focus on underserved populations and unmet health needs is a central theme running through the broad notion of community benefit. This is where mission statements that contain phrases referring to "all members of our community" come into play, because doing so may require special effort, sensitivity, or competence to reach and effectively serve those who have the needs.

These special populations have no common characteristics. Depending on the community, unmet needs may exist among people with specific illnesses, or among those in particular economic segments, or those in particular job classifications. There may be ethnic or linguistic markers for underserved populations, in certain instances, and purely geographic criteria in others. Commuity needs and assets assessments frequently serve as guiding lights to help ensure that community benefit programs are indeed designed to include those with the greatest needs.

Collaboration Outside the Hospital If we think of community benefit as unique to and purely in terms of hospitals, we may be more apt to organize community benefit departments—and their plans and goals—without linkages to partners outside the hospital who share similar missions and common goals.

While community benefit terminology may be narrowly associated with not-for-profit hospitals and health care systems, the fact is that hospitals' colleagues in community health centers, public health departments, community organizations, and others with a stake in the health of the community all have responsibilities to the communities they serve—communities that are often the same as those served by the hospital.

We know that many health issues involving hospitals require engagement with the community. Among such issues are:

• Access to care for the uninsured and for isolated populations
• Chronic disease prevention and management
• Funding gaps for specific services or populations
• Shifting roles among hospitals and public health departments

None of these is the exclusive domain of the hospital. Each has the potential to be better managed by a collaborative partnership that includes the hospital.

Hospitals do not have to go it alone. Indeed, they need to work with organizational and community partners to get beyond the "language barriers" inherent in the jargon of each sector. Doing so will better enable hospitals to utilize their unique skills—while benefiting from their partners' abilities—to more effectively address the health improvement goals they have in common. Hospitals' collaboration with other service providers (for example, public health agencies and free clinics) can yield a continuum of care for vulnerable populations. Their collaboration with the places where people gather (for example, schools, workplaces, churches, and parks) can facilitate reaching many more people efficiently and effectively.

Coordination and Strategic Management Inside the Hospital This community benefit theme may be the most important, from a hospital's operational perspective. This is where the themes of community health, unmet needs, and collaboration can, if linked astutely, pay off for the community and the hospital.

The community benefit function can be organized and managed to achieve specific priorities with measurable objectives, just like any other hospital activity. A hospital need not engage in unrelated, stand-alone community programs when it can link an assessment of community health improvement opportunities with organizational strategic priorities and the coordination of relevant hospital departments.6 Nearly every community health issue has some implication for the patient, the hospital, and other community stakeholders. Finding creative solutions that engage and benefit all three is the ultimate goal of community benefit in this broad view.

For example, when an uninsured child is brought repeatedly to the Emergency Department with asthma, the situation is not optimal for anyone, the child least of all. Finding ways to help kids and their parents better manage the asthma, while also working to connect them with appropriate primary care and secure insurance coverage, keeps children healthier, their parents and teachers more productive, and the Emergency Department better able to serve people with nonpreventable illnesses and injuries. Schools, parks, and recreation departments often can be enlisted to share the work by playing a role in education or disease management, because children's asthma affects them, too. With collaboration like this, everyone wins.

Models to Be Pursued
There are myriad other examples of creative and successful models for community benefit programs that incorporate the principles of community health improvement, unmet needs, collaboration externally, and strategic management internally. These are models that hospital leaders should create and pursue, because they demonstrate the value of a broad view of community benefit that fully realizes the potential of hospitals' charitable purpose.

The author expresses warm appreciation to his mentors on the Association for Community Health Improvement's Community Benefit Advisory Committee for crafting the Community Benefit Description and, more importantly, for helping to illuminate the community benefit field for him and many others.

NOTES

1. Janet E. Gitterman and Marvin Friedlander, Health Care Provider Reference Guide, Internal Revenue Service, Washington, DC, 2004, p. 9, available at www.irs.gov/pub/irs-tege/eotopicc04.pdf.
2. Catholic Health Association, VHA, Inc., and Lyon Software, Community Benefit Reporting: Guidelines and Standard Definitions for the Community Benefit Inventory for Social Accountability, St. Louis, 2005, p. 7, available at www.chausa.org/sab/commbenguidelines.pdf.
3. Association for Community Health Improvement, "Community Benefit Description," Chicago, available at www.communityhlth.org/communityhlth/files/files_intgrps/CB_Description.pdf.
4. Health Forum, 2003 AHA Annual Survey Database, American Hospital Association, Chicago, 2003.
5. Health Forum.
6. Alice Yoder, "Improving Community Health Initiatives," Health Forum Journal, vol. 45, no. 6, 2002, pp. 18-23.

Sample Titles of Hospital and System Positions with Community Benefit Responsibilities

• Director, community benefit
• Director, community benefit/outreach
• System manager, community benefits
• Community benefit outreach manager
• Vice president, mission integration
• Vice president, mission services
• Vice president, mission and community health
• System director, community ministry advocacy
• Vice president, community health
• Vice president, community health and public policy
• Executive director, community health promotion
• Director, community health
• Director, community health integration
• Director, community health and wellness
• Vice president, community services
• Vice president, community outreach
• Vice president, hospital and community development
• Director, community outreach
• Associate vice president, government and community affairs
• Director, government and public affairs
• Director, marketing and public relations
• Health and accountability specialist
• Social accountability analyst
• Manager, healthier communities
• Manager, community partnership

Source: Association for Community Health Improvement, May 2005

Source: 2003 AHA Annual Survey Database, Health Forum, an affiliate of the American Hospital Association.

Copyright © 2005 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.