IntroductionAmerica’s health care system is undergoing significant transformation, and the myriad of changes occurring will continue to evolve quickly. Many current reforms are driven by the Triple Aim, which will necessitate that hospitals and health systems move away from a volume-driven, fee-for-service model. Instead, new payment and delivery systems will focus on providing high-quality care, improving the patient experience of care, improving the health of populations and reducing the per capita cost of health care. Hospitals are looking at ways to further enhance the community outreach and community benefit activities they provide through integrating activities with public health, collaborating with community partners along a full continuum of care and building a community health infrastructure that is stronger, more targeted and more effective. In short, through focusing on community health, the hospital field is devising new ways to improve the physical, emotional, mental and spiritual well-being of people and communities. The next generation of community health will be integrally aligned with this care evolution and will serve as the foundation for total population health. It will connect population health management or managing the health of a specific patient or clinical population to the broader intersection of population health. Doing so brings together multiple sectors including public health departments and other community organizations. This new version of community health recognizes that investing in ameliorating the social and economic determinants of health will be as important as delivering high-quality medical services.
Community Health, Population Health and Population Health Management: The Differences
The concepts of population health and community health are often used interchangeably, and though related, they do have different definitions with significantly different implications.
- Community health – Communities can be defined as towns, cities, counties or service areas. The health of a particular community can be measured in many different ways. Generally, community health initiatives tend to be directed at the cumulative impact of social determinants of health, especially behavioral or environmental determinants. Outreach efforts are applied broadly and to people who may or may not be receiving health care services at a specific hospital.
- Population health – Population health involves the accountability for health care outcomes and costs of caring for a defined population of people. The accountability results from the incentives and penalties are both associated with caring for the population as determined by a value-based arrangement.
- Population health management – Population health management speaks to the use of data and the analysis of data, resources and other relevant information to manage clinical health decisions.
Success in population health provides credibility to hospitals for further community health efforts through investment, partnerships and advocacy. Population health contributes to community health. As a general rule, about 10 percent of a community’s health status is determined through the access to care and services provided by local health care providers. Efforts around community health should be directed at mitigating the health risks identified in population health efforts.
*** Definitions adapted from St. Luke’s Health System, Boise, Idaho
A moment of opportunity exists for health care leaders as they consider how to be the strongest partners possible in looking to solve for discreet challenges, address broader determinants of health and ultimately leverage best practices and evidence-based interventions to accelerate improving community health. The underpinning of effective community health is the development of strategic and meaningful collaborations that will allow for sustainability and success.
Hospitals have long been committed to providing high-quality care. That mission will not change, but it will evolve. As hospitals look to adopt “second generation” strategies and move toward integrating community health and wellness into all they do, hospital leaders should consider three key elements:
- Spectrum of services offered by the hospital or health care system
- Locations where care will be provided
- Partnerships through which that care is facilitated
Care will become better coordinated and more comprehensive and will increasingly take place outside hospital walls. Traditional inpatient hospital care has already begun this transformation by intersecting with public and community health to reduce readmission rates. The U.S. health care system continues to grapple with increased chronic disease management, changing national demographics, increased responsibility around care coordination and medical homes, and the elimination of disparities in care. It is essential that health policy addresses and patients, caregivers and community leaders recognize how social determinants of health can greatly impact a patient’s ability to achieve good health. Hospitals will play a significant role in creating and implementing new strategies that catalyze meaningful change on all of these issues. As a health care system originally built for illness shifts to one driven by wellness, hospitals will have a unique role to play in making good decisions easier for patients and helping to build community infrastructures that support health and healthy choices. Engaging in community health must be done in a thoughtful and strategic manner. Such engagement also requires:
- Executives and trustees setting clear expectations and direction based on a mission to improve health
- A designated community health director who can be visible, working with internal staff as well as with community partners
- A strong connection with front-line staff who may know what gaps exist and already volunteer within the community
The AHA’s Committee on Research (COR) is exploring what the next generation of community health may look like as hospitals redefine themselves to keep pace with the changing health care landscape. There will be different paths of transformation and different approaches taken to improve community health status. This report is intended to encourage activity within the field to improve community health, offer an overview of current strategies as well as provide new ones, and spotlight tools and best practices. It is organized into three sections: Trends Driving Community Health, Results from a Community Health Focus and Benefiting the Community Beyond the Four Walls of the Hospital (First and Second Generation Strategies).
This work aligns very closely with the AHA’s Advancing Health in America initiative (AHIA), developed to better communicate about the changes underway in the U.S. health care system, enhance awareness and understanding of transformation paths, and underscore the importance of collaboration as well as proactive patient care. The vision that guides both the AHIA strategy and the work of this year’s Committee on Research are the same: a society of healthy communities where all individuals reach their highest potential for health. Given that vision, the key components of AHIA are:
- Access (access to affordable, equitable health, behavioral and social services)
- Value (the best care that adds value to lives)
- Partners (embrace diversity of individuals and serve as partners in their health)
- Well-being (focus on well-being and partnership with community resources)
- Coordination (seamless care propelled by teams, technology, innovation and data)
Again, this strategy is forward thinking in terms of the role that hospitals, health systems and health care organizations will play in the future, and doing so identifies multiple audiences including patients, clinicians, family caregivers, policymakers and community thought-leaders who must be engaged. Together, this work will further identify and spotlight tools and resources that hospitals can use to advance health and move toward the second generation of community health.
All hospitals and all communities are at different points on their transformation journeys. Similarly, the path toward all individuals recognizing their full potential for health and well-being will have many approaches. While working to improve community health, hospitals should collaborate with other community organizations to identify specific community health needs but also employ a metric or gauge to determine the possible “appearance” of good health. Although strategies and interventions will differ from community to community, there are some common, generally agreed upon indexes for good health.
Sample Community Health Dashboard
Live Healthy Fairfax is a web-based resource that allows people and organizations in the community to access data on topics like health, economy, education, environment, government and politics, public safety, social environment and transportation. www.livehealthyfairfax.org. The website also offers a number of other dashboards, including a disparities dashboard. Equitable growth profile and community health improvement indicators include items like:
- Healthy and safe physical environment (physical environment ranking, recreation and fitness facilities, access to exercise opportunities)
- Active living (adults engaging in physical activities, adults who are overweight or obese, low-income preschool obesity, workers who walk to work, adults 20+ who are sedentary)
- Healthy eating (farmers market density, SNAP certified stores, food insecurity rate, children with low access to a grocery store, food environment index)
- Tobacco-free living (adults who smoke, age-adjusted hospitalization rate due to asthma, death rate due to chronic lower respiratory disease, hospitalization rate due to COPD, lung and bronchus cancer incidence rate
- Health workforce (clinical care ranking, primary care provider rate, non-primary care provider rate)
- Access to health services (adults with health insurance, age-adjusted death rate due to suicide, frequent mental distress, preventable hospital stays, children with health insurance)
Whether developing a new dashboard or tapping into existing electronic platforms, hospitals and other community partners should be cognizant of what factors correspond to a healthy community. These factors will guide and inform the need for action and activities to improve health status.