Is comprehensive community-based population health the future of healthcare?
As hospitals have embraced value-based healthcare over the past several years, many observers have noticed that quality outcomes depend not only on medical treatment, but also on positive socioeconomic factors. A patient with stable housing and employment as well as access to healthy food is more likely to be in better overall health and comply with treatment guidelines and is less likely to develop certain chronic conditions. Many health providers have taken steps to improve patients’ lives outside the clinical setting, but whether they represent an effective strategy for all hospitals remains to be seen. Certain key areas affecting a patient’s health, such as employment, lie almost entirely beyond a hospital’s control or influence.
Though some hospitals accustomed to working with poor or vulnerable populations are probably used to connecting patients with local support resources, the idea is still relatively new and there is no widely accepted community health strategy. CMS has begun exploring the concept through the launch of its Accountable Health Communities model, first announced in January 2016. The program will consist of about 50 health providers who will select one of three tracks that require increasingly greater coordination between providers and community health and social service groups. A recent article in Health Affairs also describes two models that have seen some use, one that depends on health providers to organize and promote community health, and one that treats them as an equal participant in a broad public health initiative. According to the article, the provider-centric model will likely prevail because healthcare providers already have the funding and contracting experience needed to manage populations.
The easiest (and cheapest) way hospitals can encourage better community health is to simply connect patients with local government agencies that provide assistance, whether it’s subsidized housing, welfare benefits, or job training or placement. All it takes is a referral, and many hospitals already have a department of social services designed to support patients with mental illness, substance abuse problems, or extreme poverty. The obvious limitation of the approach is that it is usually confined to work with agencies that tackle the most serious community problems, rather than more prevalent and less immediately damaging health issues such as obesity or health-depreciating factors like unemployment.
Given the role of obesity in many serious health conditions, hospitals have begun to take a more proactive approach to promoting healthy lifestyles. In addition to healthier dining options at the hospital, some organizations have started working with local food providers to expand access to nutritious food. In 2015, Presbyterian Health System, an eight-hospital system operating out of New Mexico, launched the Healthy Here Mobile Farmer’s Market in partnership with a local health council, other community providers, and schools. The market travels to several locations to sell fresh produce and offers classes on healthy cooking and overall nutrition. Coupons for healthy food are also a common nutrition outreach strategy. In 2014, for instance, New York Health and Hospitals Corporation offered discounts to specific patients for vegetables at farmer’s markets, printing roughly $560,000 worth of coupons. Of course, nutrition and eating patterns do not change overnight, and neither do diet changes lead to immediate health benefits, so nutrition education and expanded access to better food are long-term community health strategies.
Least Healthy Counties and Their Hospitals in the Top 10 Least Healthy States in US, 2015*
|Rank||State-County||Unemploy-ment Rate||Obesity Rate||Hospital||Readmission Rate||Readmission Rate Percentile||Payor Mix: Medicaid|
|1||LA-Madison||11%||43%||Madison Parish Hospital||NA||NA||3%|
|2||MS-Holmes||16%||47%||Holmes County Hospital||16.2%||20||8%|
|3||AR-Phillips||10%||42%||Helena Regional Medical Center||17.1%||5||16%|
|4||WV-McDowell||12%||27%||Welch Community Hospital||15.6%||48||32%|
|5||AL-Wilcox||17%||44%||J Paul Jones Hospital||15.5%||55||13%|
|6||OK-Adair||8%||38%||Stilwell Memorial Hospital||13.9%||98||23%|
|7||KY-Harlan||14%||37%||Harlan ARH Hospital||18.9%||1||6%|
|8||TN-Lauderdale||10%||38%||Lauderdale Community Hospital||15.5%||55||4%|
|10||IN-Scott||7%||29%||Scott Memorial Hospital||16.1%||24||24%|
**Top 10 States and least healthy counties list from America’s Health Rankings, other data from Definitive Healthcare
When it comes to other community concerns, such as affordable housing or employment, hospitals have few options, even though the absence of either is associated with worse overall health. All of the counties listed above have unemployment and child poverty rates higher than the national average. Hospitals can refer patients to job training or housing agencies, but their success requires that the agencies have adequate funding (if they even exist) and that communities have jobs or housing available. An economically depressed area will push the tax base and hospital revenues down and the population will tend to put off healthcare consumption, causing negative financial pressure at both private and government-owned facilities. As a result, the communities with the most need often are the least prepared to address the fundamental problems, and the only realistic option for hospitals is to use any existing resources as efficiently as possible. Even in more prosperous areas where employment and housing resources can be readily available, a hospital can do little more than make referrals and hope that patients have the motivation and commitment to make proper use of them.
At the moment, a comprehensive community health strategy that goes beyond direct medical needs and addresses social concerns is little more than an idea at most hospitals. Even if an organization is ready for an expanded population health initiative, the program must have committed partners in the community, either among the local government, businesses, or nonprofit agencies in order to be successful. Much like other value-driven healthcare efforts, it will take time and experimentation to see how effective a hospital-driven, proactive approach to community health can be.
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