By JOSEPH BEDNAR
It’s a simple word — one that brings many other words to mind. Like hospital, doctor, or nurse. Or a specific disease. Or a specific medication.
But what about … poverty? Or transportation? Or racism, violence, or literacy?
As part of a broad category known as ‘social determinants of health,’ those concepts do, indeed, fit neatly under the health umbrella, because the way people experience them often have an impact on how healthy they are.
This philosophy is at the heart of the Community Health Needs Assessment (CHNA) recently prepared by the Public Health Institute of Western Massachusetts, in partnership with the Collaborative for Educational Services, the Franklin Regional Council on Governments, the Pioneer Valley Planning Commission, and, perhaps most surprisingly, seven regional hospitals and Health New England.
“When you think of a health needs assessment, you might think of healthcare itself and what goes on inside the four walls of the hospital when you’re sick or need surgery,” said Annamarie Golden, director of Community Relations at Baystate Health. “But we’re getting people to think more broadly about health. It’s bigger than those things. It’s education, employment, environment, housing.”
The surprising part is that the hospitals, which have partnered on these studies for most of the past decade, are working together at all. Hospitals across the U.S. are required by law to produce a CHNA every three years, but rarely do they collaborate.
“This kind of coming together of hospitals is quite innovative and new, and it started here in Western Mass.,” said Jessica Collins, executive director of the Public Health Institute. “We came together nine years ago and pooled resources. Boston hospitals caught wind of that, and a couple of them got together to do the same thing. For a sector that is insanely competitive, the fact that we had the forethought and recognition that we’re all actually treating the same people — and got out of the patient mindset and into a geographic population mindset — was actually quite shocking.”
Kim Gilhuly, Research and Population Health manager at the Public Health Institute, noted that the Affordable Care Act requires nonprofit hospitals and healthcare organizations, because they don’t pay taxes, to prove they benefit the community. “The first step is to see what the community health needs are. The CHNA is a step in the process. Then we have to create a strategic implementation plan and show how we’re addressing those needs.”
The physical report resulting from all this data collection is almost 100 pages long, but at its heart is a rundown of prioritized needs and issues, which break down into four key categories:
• Social and economic determinants that impact health, which include factors like housing affordability and quality (and homelessness); lack of access to transportation and healthy food; poverty, unemployment, and workplace environment; financial health and financial literacy; barriers to educational success; violence and trauma; and environmental factors like air quality and lead exposures.
• Barriers to accessing quality healthcare, including insurance challenges, limited availability of providers, need for culturally sensitive care, need for transportation, lack of care coordination, health literacy, and language barriers.
• Health conditions and behaviors, which include mental health and substance use; chronic conditions like obesity, cardiovascular disease, diabetes, asthma, and cancer; infant and perinatal health; and sexual health, including teen pregnancy and sexually transmitted diseases.
• Priority populations of concern. For example, available data indicate that children and youth, older adults, Latinos, and African-Americans experience disproportionally high rates of some health conditions when compared to the general population. Meanwhile, LGBTQ youth are at higher risk of depression and suicide, and black and Latino populations face inequities — such as poverty, unemployment, institutional racism, lack of affordable and safe housing, and lack of access to transportation and healthy food — that impact overall health.
“It’s so clear that some of us are doing better healthwise than others,” Collins said, “and it’s hard for the healthcare sector not to pay attention to that.”
Among the factors noted in the CHNA, behavioral health particularly stood out, she noted. For example, the report notes, 17% of Springfield adults report poor mental health on 14 or more days a month, compared to the statewide average of four days. And the suicide rate in Hampden County is higher than the statewide rate, which has also risen over the past decade.
Unlike asthma, obesity, and cardiovascular disease, which are serious but tend to fluctuate by region, she noted, “behavioral health is different — it cuts across class, it cuts across race. Everyone is suffering.”
Collins said the CHNA partnership has evolved significantly over the years, especially when it comes to community engagement. “This group has said, ‘we need to put residents at the center of this,’ which then adds a ton of work and engagement. It was a huge commitment.”
“It’s so clear that some of us are doing better healthwise than others, and it’s hard for the healthcare sector not to pay attention to that.”
The current report was developed with the input of 230 people in focus groups; more than 50 ‘key informant’ interviews with healthcare leaders, administrators, and providers, as well as local leaders; and more than 800 people who attended about 40 ‘community chats.’
“The idea was to go out where people are instead of having them come to us, although we did that, too,” Gilhuly said.
As a community resource, however, these conversations don’t amount to anything if they’re not followed up with action, and the hospitals have been busy strategizing for next steps, Golden said.
“Hospitals are required to develop an implementation strategy,” she noted, adding that each Baystate hospital comes up with its own set of priorities and will issue requests for proposals to invest money in the community around those priorities. At Baystate Medical Center, education has been targeted as the priority determinant of health in the current report.
“We can’t address all the needs, but we decide which ones to take on,” she said. “We have conversations internally, and really work with our Community Benefits Advisory Council to move the needle.”
Those conversations demonstrate how broad the needs actually are, Golden added. “We went around the room and asked, ‘how do you define education?’ Some people said, ‘I think of education as Springfield public schools and graduation rates and increasing those rates.’ Another said, ‘I think of the high school to community college to employment pipeine.’ Another said, ‘I think of chronic disease management, as we have a high asthma rate.’”
Baystate’s Community Benefits team treats the CHNA as a living document, she added, and priorities or strategies may shift year to year based on what’s going on in the community and environment.
Collins said she hopes the CHNA will guide a hospital’s overall strategic plan, not just its community-benefits arm — and she believes the trend is moving that way as administrators increasingly understand how a host of socioeconomic and environmental factors affect how healthy the people they serve are, which also affects the bottom line.
Gilhuly added that community organizations, many of whom served on a regional advisory council during the CHNA process, often use the results to apply for funding for programs that meet what is now a documented, data-driven need. Collins, meanwhile, would like to see the CHNA partnership lead to more policy and advocacy work on the state level, with organizations raising awareness about program needs in a unified way.
Keep the Ball Rolling
Whatever happens in the future, Collins said the role of the CHNA has come a long way in the past decade. “I think hospitals, historically, have been known for saying, ‘oh, we put our report on our website.’ But this added effort of going back and communicating with the community, I think, is extremely important.”
Gilhuly agreed. “Even though it’s mandatory, a lot of hospitals have just checked the box and said, ‘oh we did the CHNA; we gathered our data and looked at health outcomes — oh, look, there’s a lot of asthma, so we’re going to spend a little money on community education for asthma.’ But the power of it is, it can guide where hospitals go. If we talk about transportation or inequity or policy, this document has the ability to guide a hospital, which is a huge anchor institution in a community, to do its work a little differently.”
Golden said she’s proud to be part of an effort that requires so much collaboration across, again, a very competitive local sector.
“Western Mass. is a large geographic region with multiple counties — rural, urban, and suburban — that are really unique, and each brings its own set of challenges and rewards,” she told HCN. “Each time we do this, we bring in more partners and invite more of the community to the table.”
That said, “just as important is going back to those individuals to share with them our report — ‘this is what we learned from you, and this is what we’re doing to take action,’” she went on. “So we’re getting ready to go back to those groups and getting ready to engage with new groups and new individuals. It’s an ongoing engagement, and not just something we start and stop every three years. It’s a labor of love.”