What do you get when you join three local health departments and four local non-profit hospitals together to complete a regional community health assessment and community health improvement plan? To find out, just talk to Anne Barna, Health Analyst II, Barry-Eaton District Health Department and Brian Brown, Director, Planning & Marketing, McLaren Greater Lansing Medical Center. Barna and Brown are just two representatives from the Healthy! Capital Counties coalition, who have been working over the last two years to complete a comprehensive community health (needs) assessment (CHA/CHNA) and community health improvement plan (CHIP) for the region surrounding and including Lansing, Michigan's capital city. The coalition felt it was important to complete a CH(N)A and CHIP in a way in which those who work, live, learn, and play in the area do: as a region. To do this, three local health departments, working across jurisdictional lines and four hospital systems serving the region forged a new collaborative relationship for the CH(N)A and CHIP work.
Although there is a long history of health department and hospital partnerships on a lot of projects, as a region all involved had not previously worked together. "There were doors open already, but each hospital was at a different place in this work and this work sat in different places in each of the area hospitals," explained Brown. Although all the leaders were on board, "At the beginning of 2011, the question was, 'how do you all want to make this happen?'", said Barna. A few months later, the three health departments involved decided that they could conduct the work, but they lacked the financial resources to provide the staff time needed. The departments collectively wrote a proposal to conduct the work in partnership with the hospitals and submitted it to the hospitals for funding support. The hospitals agreed and the work was quickly underway. A Core Committee comprised of the health officers and project lead staff from the health departments and a representative from each of the involved health systems met regularly and also worked with the Community Advisory Committee, comprised of the Core Committee plus a broad array of local partners representing other organizations.
In addition to their regional focus, Healthy! Capital Counties was committed to using a health equity and social determinants model of health as the basis of their CH(N)A and CHIP work. "We were clear about the model for how health happens," said Barna. "We incorporated health equity concepts in the selection of indicators and social determinants of health were built into the process. We carefully crafted interpretation and incorporation [of these factors] based on the expertise and experience of health department staff and leaders who were capable of translating social justice and health equity concepts." "When we selected the strategic priorities, we used selection criteria that lent to selecting social determinants...," explained Barna. She added, "It is quite exciting to look at the social determinants [of health] model and integrate it into assessment work." Although there was the history of health equity and social justice work within the health departments, with one department being a national leader in this area, the hospitals were not as experienced in this type of work. Brown explained, "Upstream work is more uncomfortable for the hospitals. 'Safety and Social Connection' as a priority and then thinking the hospitals might support a crime watch, for example, requires hospitals to leave their comfort zone." Brown thinks that there are specific things hospitals and hospital partnerships can do to move their work into this realm that helped Healthy! Capital Counties partner hospitals: "Integrating [upstream issues] into the hospital plan, at the board-level and at the physicians' level, is helpful. Putting the pieces of that out there in each organization [hospital] as there are different processes for this [is key]." Although Healthy! Capital Counties feels confident they were successful in examining these issues and concepts in their assessment work, whether or not and how social determinants of health or health equity are truly addressed in health improvement action will be seen as the group continues forward in finalizing the details of their CHIP and begin putting it into action. "The proof is in the pudding," said Barna. When asked what advice they have for other health departments and hospitals working together in an attempt to examine and address social determinants of health and work towards achieving health equity, Barna recommended that they, "Start as you mean to go on." For example, Healthy! Capital Counties asked lead organizations that were aware of and could champion social determinants work, such as health departments, community mental health, housing sector, etc., to participate on its Community Advisory Committee to help position them for success.
Although they set their sights high in working to complete a regional CHA/CHNA and CHIP and one that specifically considers the social determinants of health and health equity, Barna and Brown both feel as though they've been successful thus far."Not duplicating things has been a benefit. [Working together] eases the burden of doing these [CHAs/CHNAs] three different times for each area. From a time perspective, this is valuable," said Brown. "From the outlying county perspective, the health department has a strong relationship with our county hospital, but wasn't known to the big hospitals [in the area]," said Barna. "There is no way we could have done the quality of the CHA for Eaton County without partnering with other health departments," explained Barna.
Now the Healthy! Capital Counties partners are focused on turning their CHIP into action. The group is currently working to identify which organization in the community will lead and sustain CHIP implementation efforts and this work in the future. "The coalition structure we created [for the purposes of completing the CHA/CHNA and CHIP] was not necessarily sustainable or the best fit for the community and we pushed worrying about it until later," explained Barna. It is likely that the CHIP implementation efforts will be sustained by an organization other than the health departments or hospitals. If that's the case, health departments and "The hospitals would need to provide leadership and participate in the implementation efforts at some level," explained Brown. All four hospitals have developed their implementation strategies for the IRS based in some way on the CHIP and the health departments are working to complete and update agency strategic plans that do this as well. Brown explained that, "Having community health needs assessment findings to back-up the contents of the CHIP is important;" as this can be the rationale behind discussions and decisions about which CHIP strategies different partner can engage in.
Although they feel good about their work, Barna and Brown acknowledge the tremendous amount of work that went into their process and the challenges that arose in their efforts to ensure that four hospital systems meet the IRS requirements to complete a CHNA and implementation strategy and that each of the three health departments are positioned to fulfill PHAB's related standards. "The timing of everything was slightly off," said Brown. He adds, "Luckily everything that has been done meets the IRS rules. The challenge has been finding a sustainable model for conducting the CHA and CHIP work [in the future] because the hospitals and health departments need to conduct the work on an ongoing basis." Both also agree that the regional CHA/CHNA and CHIP work will likely be easier in the future given that this was the first iteration of working together and with the organizations' respective requirements in place. Both Barna and Brown also mentioned the differences between hospitals and health departments that they have learned along the way: "Hospital culture is different and they have different ways of going about things. This is true of health departments also, but I think health departments are more alike than hospitals. Various hospitals have various priorities. It's difficult, from a health department perspective, to know a hospital's priorities," explained Barna. Brown also shared, "Hospitals also get very focused on who's walking in our doors. Hospitals tend to think that 'X number of people need one service'. Hospitals are transitioning to thinking upstream and to a population focus. There are different cultures." In addition, differences between the composition of hospital boards versus health department boards of health also have implications and should be considered. Recognizing that this type of work and the way in which it is completed together is new, it is important to recognize there will be lessons and challenges along the way. For example, the Healthy! Capital Counties group worked hard to embody true community engagement and ownership of the community health improvement process. I think that this "'Lack of control' over the CHA/CHNA and CHIP process was likely more comfortable for the participating health departments than the hospitals," said Barna.
There do seem to be specific keys to success in assuring that a regional and collaborative process between hospitals and health departments is successful. "Make sure you're clear early-on with timeframes and deliverables. It will help each side navigate better. Discuss this earlier and you can get specifics known upfront and you're better off down the road," said Brown. Knowing each others' processes was also cited as something really important in health department-hospital partnerships. All in all it seems there is no clear-cut recipe for a multiple health department and multiple hospital-led community health improvement process partnership, but there are key ingredients that when combined pave the way for success and hopefully for health equity and improved public health.
For more information, please refer to the Q&A with Barna and Brown.