Tips for Hospitals working with Communities to Address Social Determinants of health and upstream interventions.

1. 1
Why are Hospitals Increasingly Collaborating with
Community Partners?
1) Partnering enables hospitals to be more consumer centric and earn the trust and long-term
engagement of our communities
Fundamentally, people don’t want to be patients. For 99% of a person’s life, they are outside of the
hospital. If we’re going to partner with patients in managing their health, and be at financial risk for the
health of those patients, it’s important to integrate into patient’s daily lives.
 Opportunities to expand the healthcare system’s sphere of influence: schools, Faith-based
organizations, Community-centers
 Need to think more broadly about where patients want to go to access services, and who our
partners could and should be.
2) Community partnerships help bolster hospital efforts to address the social determinants of health
Community partnerships enable us to tackle underlying causes of poor health status which are primarily
nonmedical (social determinants of health, e.g. housing, safety, food, literacy).
3) Community partnerships help hospitals extend their reach and capacity
It can be difficult to ask our clinical teams who are already stretched extremely thin to take on these
additional issues. Often nurses, physicians, and other clinicians don’t have the expertise or influence to
handle these things alone, on top of being strapped for time. We need people that are already connected
to the community to identify needs and connect patients to needed resources. Partners can step in and
fill some of those gaps to make sure critical services don’t fall through the cracks.
Critical benefit: Partners can help us manage total cost of care and succeed under value-based payment
arrangements:
 CMS is committed to having 50% of payments tied to risk by 2018.
 Final MACRA rule was released on Friday, October 14, 2016.
 Population health is here to stay and even if you’re not participating in an ACO, you won’t be able to
avoid these value-based payment reforms in the long-term.
 65+ markets have to work with CMS under bundled payments for orthopedics, they have
cardiovascular bundles, and we expect those types of payment arrangements to expand.
If you don’t have risk-based contracts at your organization, there is STILL benefit in making community
level investments.
 By expanding access, convenience, and experience, you will be a more appealing partner in a
consumer-driven economy, and having that appeal will build the type of loyalty that prevents
network-leakage (which is good under both fee-for-service and value-based payment models).

2. 2
 Understanding the root causes of patient risk and preventable utilization helps ensure you’re
providing solutions that free up hospital beds for the most complex patients, while still serving the
needs of all, but perhaps in a more appropriate setting.
If you do true population health work (work that impacts everyone, not just panel of patients) does that
put us at a competitive advantage or disadvantage?
 Not really, because your competitors are doing the same thing. They are faced with the same issues
and the opportunity to impact avoidable utilization, familiar faces in the Emergency Department and
are also held accountable to total cost of care.
 Not doing it because you don’t want others to benefit is not a sustainable model, especially moving
forward in a value-based world. You will get your return later on. Patience is rewarded.
How do hospitals quantify or show the value of engaging
in these efforts with communities?
1) It’s important to connect your work to larger system priorities (e.g. success under risk-based
contracts or your population health strategy).
For example:
a. Reducing unnecessary utilization – e.g. non-acute ED visits or avoidable readmissions
b. Trading high-cost service for low-cost care – e.g. expanding primary care access, boosting
PCMH enrollment, extending virtual visit capabilities
c. Enhancing patient engagement and care coordination – e.g. using partnerships to bolster
chronic condition management programming
2) Make sure you’re measuring institutional level commitments or inputs as well as population level
outcomes
Population level interventions take a long time to measure and show impact. It’s important to
capture results and get credit for them in the short term.
a. Track service volume and reach – e.g. Number of dollars invested, number of walking trails
put in place, health access, awareness, preventive care utilization, patient satisfaction,
provider satisfaction, etc.
b. Ultimately track changes in individual behaviors, changes in population health or
community-level outcomes.
As hospital assume greater risk for patients it’s important to not only focus on medical care but
on all the factors that influence health outcomes, because that is what contributes to total cost
of care in the long haul.

3. 3
Key Lessons for Effectively Working with the Community
1. Ask the community what they want
Often we try to “prethink” what the community needs. The dialogue is critical – in the context of the
dialogue you can identify the social determinant needs that we often medicalize. Hospitals will never be
able to meet the demands of food insecurity, housing, and other elements that impact health, but we
CAN be credible partners in addressing these issues. You often don’t know who your potential partners
are until you’re in that dialogue.
2. Dialogue requires patience
Great ideas start in the community, and there is always the risk of having
the same conversation over and over with different partners. E.g. Durham
has over 1300 nonprofits, many of whom are health related. They are
often looking to Duke Health, the largest healthcare provider in the area,
to be a partner. Patience with the dialogue is critical.
3. Data are important
Don’t get stuck trying to get perfect data and lose sight of what you’re trying to do. Projects do need to
be data-driven to the extent that we can measure outcomes. It is critical to collect data that helps you
figure out how the community-oriented project will address other hospital priorities, for example: data
around clinical outcomes (e.g. improving health of diabetic patients, BMI reduction, etc.) and data
around utilization outcomes (e.g. avoiding ED utilization, readmission reduction).
4. Key is to focus on the workflow and how things are moving in time
There are a lot of great ideas for projects, some with funding, some with good data, but it’s often hard to
figure out how you’re going to do it. If you don’t take time to discuss how that opportunity will be
captured and how you’re going to correct the problem, it can be very frustrating and often cause you to
lose momentum.
 Go Granular – in the absence of knowing how you’re actually going to do things, it can be
frustrating for hospitals to figure out their role in the project. Make sure to talk about the details
of the workflow and clarify roles of each partner moving forward.
When you’re focusing on total cost of care or utilization avoidance, it takes a long time to show
those metrics are working in a direction that you want them to. Patience and due diligence on the
front end will shorten the time period between project and outcomes.
HOW TO SHOW EARLY WINS
1) FIND THE SYNERGY
2) FOCUS ON THE RIGHT
AMOUNT OF DATA
3) START GETTING TO
WORKFLOWS

4. 4
Case Example: BUILD Project
How has being a part of BUILD benefited the hospital?
1. Connecting with the Community
Being a part of the BUILD project has increased the hospitals partnerships and deepened it’s
relationships with the community. The Ontario BUILD Project is a broad-based collaboration - Everyone is
coming to the table as equal partners. Especially important is the increased connection and strong
engagement of the City of Ontario – a key driver in this work.
2. Raising awareness and changing community
perception
A competitor hospital who has been engaged in the city
and has tight ties with the community members (due to
historical demographics and populations served – less
of a medical population). Community looked at this
hospital as less-accessible. Through the BUILD project,
they are now sitting side-by side with CHWs to help
educate them in case management, and with city
partners.
Using data to demonstrate ROI is important
Together, they are building a data-platform: They decided to build it themselves, which brought everyone to
the table to think critically about what they needed from the data platform. They identified needs for both
the clinical teams (lab data), but also data that would be useful for the clinical CHWs to do case management,
record referrals, and capture follow-ups, and incorporated reporting capabilities to capture progress. While
building out the platform, they are exploring ways to match program participants with other measures to see
if they are making an impact on people’s ability to use healthcare appropriately, or are they still just going to
the ER? (E.g. capturing when BUILD program participants are admitted to the ER; working with public safety
to match 911 calls to BUILD program participants). If the hospital can demonstrate that they are having fewer
readmissions, or fewer visits to the ER, they can start quantifying that in dollars saved.
Demonstrating ROI is important for the hospital to not only show that they are investing their dollars in a
community project that will improve community health outcomes, but also to show the decrease in
unnecessary spending by the hospital. They are also trying to capture quality adjusted life years (QALYs) as a
measure to demonstrate the ROI to their city to support their case for continued city contributions.
People within a hospital have different views of Population
health:
 Community Outreach Side of the Hospital – Refers to population health in terms of the social
determinants of health and community health improvements
THE COMMUNITY’S PERCEPTION ABOUT
THE HOSPITAL HAS CHANGED, NOT
ONLY WITH INDIVIDUAL COMMUNITY
MEMBERS, BUT WITH LEADERSHIP IN
THE CITY – AND THAT’S A HUGE WIN.
- BUILD Hospital Representative

5. 5
 Business development side of the hospital – Thinks of population health as moving to a risk-based model
with capitated payments and managing that population so they don’t use hospital dollars.
Then what do I tell hospital leadership about population health? It’s one and the same.
Either way, you are still trying to impact and improve the health of individuals and communities and help
individuals manage their own health.
Tips for sharing hospital data with communities
 Clinical data stays in clinical space, doesn’t cross over, and is firewall protected.
 Do share aggregated, de-identified data
 Hospital staff conduct the analytics – look at de-identified clinical data and match it to other data
from the community.
EXAMPLE: In ACOs and hospital population health programs, you can work with claims files and do matching
to inform outreach for care management.
 Use publically available data to create a platform for community to use – e.g. online platform could
allow community members to see the prevalence of diabetes in their neighborhood.
 Analytics are important – the analytics help you put the data together to get a meaningful picture
that you can do something about.
 Make sure the data you have is identifying the problem you’re trying to solve.
Reporting to Health System Boards
10-20% of the impact in health is in healthcare, where 80-90% of the dollars go there. Particularly at the
legislative and policy level, they realize a lot of dollars are going for not as much impact – hopefully this will
support continued investment in social determinants of health work.
EXAMPLE: One site shares their community activities with their board of trustees. Being a community board,
they are interested in the work being done and the impact it’s having. Some board members really like the
storytelling, and others really like the data, so it’s important to have both. They are hoping to have more
quantitative information as the project moves on.
EXAMPLE: Another site reports to the board regularly, but BUILD is part of a larger strategy for their
community health plan. They are very interested in the work being done through BUILD.
“It’s such a challenge when you’re a big hospital system, and you’re fully funding these projects
(that are often pilots) through community benefit, and then you have to tie them to outcomes
and create the will to scale the work and sustain it. We believe that it matters, but it’s so outside
of the norm of a traditional delivery system.” - BUILD hospital partner

6. 6
How do you pick a partner in the community to work
with?
1) Let partner organizations come to the hospital and just see who is interested.
2) Use an RFP process
EXAMPLE: Prometica uses their Community Health Needs Assessment to Identify where support is
needed, then casts a wide net in identifying partners. This helps to identify smaller organizations who
they might not have experience working with, but who are very passionate about the cause to be
addressed.
3) Find organizations with a similar mission
EXAMPLE: As their regions safety-net hospital, this hospital tends to partner with organizations that
share the mission of providing to those who have difficulty providing to themselves. Their strongest
partnerships are with similar organizations (e.g. United Way, Legal Aid Society, local school district).
4) Look for existing services already in place in the community
EXAMPLE: One BUILD hospital just finished the CHNA and developing their implementation strategies
based on that assessment. Based on the identified needs, they look at what resources and services
already exists in the community that could support those needs. Where services already exist, the
hospital then thinks about how they can engage and/or expand those supports into vulnerable
populations or underserved areas.
How do you measure capacity in community partners?
Capacity = resources, materials, knowledge, connections
Often community organizations are small, with 1-2 staff working on their off-time to complete a mission.
With a small amount of increased capacity, the organization is able to expand their reach, impact,
sustainability, etc. If you tie the benefit/dollars with a capacity-building component, that can often be
successful.
EXAMPLE: One BUILD site has engaged partners (and provided them with resources – cash) and required the
community partner to participate in capacity building efforts. They are trying to measure capacity with the
BUILD project to show impact. Most capacity building is related to coalitions who do assessment and planning
in local communities. The hospital has asked those groups to complete assessments with their membership
each year, to inform the action plans.