In these deeply uncertain times, marked by a global pandemic and other layered crises that touch every aspect of health and quality of life, it is clear that health care systems must partner in effective community-based approaches in caring for populations. Here are some considerations that can aid hospitals and health systems in making this transformative step.
Evidence from more than four decades of place-based investments shows that comprehensive, multi-dimensional community investment strategies can measurably advance human health and well-being. Measurable progress is more likely when multiple levels of the health care system engage in the work, leaders integrate best practices for delivering "quadruple aim[i]" outcomes, and clinical and non-clinical partners (both internal and based in communities) align with each other in resource allocation and implementation.
Access to quality health care is vital, but that alone cannot significantly improve overall health and well-being. Many complex social, economic, environmental and cultural factors contribute to health outcomes in our communities, including persistent disparities in income, housing, nutrition and environmental safety experienced by racial and ethnic minorities.
We propose seven Standards of Excellence in Community Health Investments for broad consideration by health care systems and partners. We are leaders at Providence, an integrated health system comprising 51 hospitals and more than 1,000 clinics across seven Western states. As our seven standards illustrate, a focus on the profound influence of social factors – better understood as “vital conditions for intergenerational well-being” – must be at the core of health systems’ efforts to deliver measurable outcomes.
Seven Standards of Excellence for Community Health Investments
1. Equitable community development
Equity across your community is essential to improving health. An equity-centric approach helps you acknowledge the profound drivers of race/ethnicity, socioeconomics and language; the need for strong multi-sector partnerships; and identify approaches that connect national and local organizations with shared missions. Models and networks such as Communities of Solutions (outlined in Institute for Healthcare Improvement’s Pathway’s to Population Health[ii]) and Well Being in the Nation (WIN) Network[iii] connect hundreds of national and local organizations in a shared mission and learning. Equitable community development also aligns with the federal Healthy People 2030[iv] consensus standard for well-being measures in the U.S.
2. Data-driven decisions and investments
Triennial Community Health Needs Assessments are required by the U.S. Internal Revenue Service for all nonprofit hospitals and health care systems. The CHNA are valuable tools that can align with and inform a health care system’s overall strategy, incorporating leading health indicators from many sectors, such as health care, public health, transportation and education. The Well Being in the Nation WIN Measures[v] enable quantitative assessment and remind leaders of the indispensable, ongoing process of listening to and engaging the diverse people, assets and gifts within communities.
3. Health care anchor role
Community benefit expenditures of nonprofit health systems represent only one lever – and not the largest – for investing in the health and well-being of communities. By recognizing and applying multiple assets, health care systems can effectively improve outcomes, especially for impoverished and vulnerable populations. The anchor evidence base[vi] calls for optimizing local purchasing and hiring power, catalyzing capital and investment assets, using investment portfolios responsibly and proactively, and aligning an organization’s strategic investments with those of other anchor institutions and investors.
4. Integrated whole-person care[vii]
Health is about how people are doing in terms of their physical and mental health at every age. There is growing attention to training and supporting clinicians to recognize and respond to the whole person. Patients’ physical, emotional, social and spiritual dimensions of experience all contribute to their quality of life. Best practices entail delivering integrated health care services with warm handoffs to social services as a quality standard across all settings. Working with community partners, health care systems can integrate efforts to improve social determinants, such as housing, food security and income, as well as access to legal and financial services.
Further, health care systems can fully integrate behavioral health initiatives, such as suicide prevention and opioid reduction, from the emergency department to primary care and in community settings rooted in the consensus Framework for Excellence in Mental Health and Well-being.[viii] Finally, health care systems and hospitals can use telehealth and other rapidly evolving health information tools to expand interoperability and reach patients with increasing effectiveness, while shifting key roles and tasks to community-based and peer services.
5. Dose sufficiency[ix]
Community health professionals have long acknowledged that most health care system- and grant-funded initiatives lack sufficient focus, reach, intensity and duration to deliver sustained improvement, especially when grant cycles end and priorities shift. Targeted “dose-sufficient” strategies lead to lasting, improved outcomes at the population health level. The number of people reached by the program, the relative strength of its impact on those reached, and the extent to which collaborative planning, implementation and measurement occur in tandem with other place-based initiatives are all critical for enduring change.
6. Accountability for community-level outcomes
Accountability is integral to effective community health improvement plans and system strategy alignment. Governing boards of health care systems should be able to review community health dashboards that incorporate meaningful metrics based on national standards and tailored to local priorities. Governance and executive leaders must develop an understanding of social determinants and be able to align strategic priorities, corporate decisions and investments with community health and well-being goals. In turn, a system’s community health leaders must support governing boards, executives and front-line caregivers, who operate programs and implement improvements required for deep and durable social change.
7. Multi-solver solutions
Multiple stakeholders, perspectives and skillsets working in creative collaborations will be required to concurrently renew economic life, community life and human well-being.[x]
Community partners can collaborate on initiatives that alleviate multiple problems at once. For example, comprehensive housing strategies should address economic, social, cultural and health factors. Exemplars of these multi-solver approaches include improving caregiver and first-responder well-being, both within and outside of health care settings[xi]; increased investment in comprehensive housing with integrated support services based in the vital conditions, and greater reliance on proven models such as including community health workers on care teams.
Health care institutions and systems can elevate their existing good works in realms of community health investments and become more sophisticated, strategic, accountable and measurably effective. The marriage of quality standards and powerful, community-based solutions invites local leadership and broad stakeholder buy-in, while assuring system-level accountability.
The lens of mission, vision, core values and strategic priorities will inform health systems’ choices for structure, process and outcome measures of their population and public health efforts and community health investments. An evaluation infrastructure that includes metrics, data collection and analyses with timely, easily visualized results will enable systems to track their journeys toward better health for all.
Dora Barilla, a doctor of public health, is former group vice president of community health investment for Providence, president of HC2 Strategies Inc. and professor at Loma Linda University School of Public Health.
Ira Byock, M.D., is chief medical officer of the Institute for Human Caring at Providence and active emeritus professor of medicine at the Dartmouth Geisel School of Medicine.
Tyler Norris is chief executive of Well Being Trust, with lived experience serving in more than 500 communities in every state, over a vocation that spans four decades.