Traditionally, hospitals are thought of as places people go for medical care. But could one imagine a world where hospitals reached out to people in their communities to address the deeply rooted social and environmental factors impacting health? While not widespread, this phenomenon is already in play at some hospitals in New York State and across the country.

Guided by growing evidence that most of one’s health can be attributed to non-medical determinants such as social, behavioral, and environmental factors, some hospitals are taking a broad population health stance. They are defining their target population to include not only their patients but also everyone in their geographic communities, and broadening their scope of action to include impacting non-medical determinants of health.

Through close collaboration with community and government organizations, these hospitals have been successful—even with relatively small financial investments—in creating programs to improve such things as access to housing, availability of healthy food, and improved education in their communities.

At present, these hospitals are exceptions to the norm. In the future, could more hospitals have the incentives and capabilities to develop sustainable programs that address non-medical determinants of population health in their communities?

The Case For Hospitals To Engage In Community Health

Incentives for hospitals to invest in community health improvement are increasing. Nationally, the growth of Accountable Care Organizations (ACOs) and of value-based, risk sharing contracts that make hospitals partly responsible for total patient costs give hospitals an incentive to improve socioeconomic factors that impact the health of people in their community. This is especially true of hospitals with large regional market shares.

In addition, the Accountable Health Communities program recently introduced by the Innovation Center of the Centers for Medicare and Medicaid Services (CMS) will invest $157 million to evaluate whether engaging hospitals and other organizations in targeting social determinants of health will reduce health care utilization and costs for Medicare and Medicaid beneficiaries.

Finally, non-profit hospitals, which receive an estimated $24.6 billion in tax benefits yearly, are required to conduct periodic community health needs assessments and to report their yearly spending on community benefit activities to the Internal Revenue Service (IRS). Traditionally, most of the reported community benefits involve charity care and unreimbursed patient expenses, but recently the IRS has begun to encourage hospitals to report “community building” activities that affect social determinants of health.

Some states, such as New York, have also initiated programs encouraging collaboration between hospitals and community organizations to improve population health. For example, the New York State Health Improvement Plan mandates that hospitals and local health departments collaborate to create community service plans tackling health and health disparities. The state’s Delivery System Reform Incentive Payment (DSRIP) Program will reinvest up to $6.42 billion dollars of Medicaid Redesign Team savings into programs where health care providers and community organizations collaborate to reduce preventable hospitalizations, in part through population health initiatives aimed at multiple health determinants.

Who Is Engaging In Community Population Health, And How Are They Doing It?

We interviewed leaders at 24 hospitals (18 in New York State and six nationally) and leaders of community organizations working with these hospitals, and found that hospitals’ decisions about whether to engage in community health improvement is idiosyncratic. Participating hospitals covered the spectrum, including hospitals of larger or smaller size, urban or rural location, and public or private governance.

Leadership—especially at the CEO level—that is committed to tackling root causes of health is one of the most important factors. Some leaders are willing to take the risk of investing in programs that are not reimbursable under fee-for service because they believe these programs will lead to cost savings in the emerging value-based payment world — and that the programs are the right thing to do.

As noted, hospitals with a large market share in their communities are often interested in improving the non-medical determinants of health, especially if they are located in disadvantaged communities. Hospitals with a deeply rooted community service mission, through philosophical orientation and/or longstanding community ties, also appear more likely to try to improve community health.

Examples of innovative programs that hospitals have implemented include:

  • Improving the built environment of neighborhoods by creating safe parks and revitalizing crime-ridden, abandoned lots;
  • Assisting local residents in completing their GED and getting jobs;
  • Developing local regulations to establish smoke-free public areas;
  • Creating access to healthy foods and produce through community gardens and grocery store partnerships; and,
  • Providing safe and affordable low-income housing.

Resources To Support Community Investment

Many of the hospital leaders we interviewed felt that lack of financial resources was a significant barrier to engaging in community health improvement. They noted lack of both fee-for-service payment and upfront funding for technology and staffing infrastructure. Nevertheless, some hospitals were able to create such programs with relatively small financial investments, using a number of mechanisms.

First, it was imperative that hospitals develop strong partnerships with community organizations so they would not need to “reinvent the wheel” in learning the lay of the land, developing community trust, and building infrastructure. For example, hospitals partnered with schools and grocery stores to improve access to healthy foods, and with community housing organizations to create access to affordable and safe housing. Hospitals also worked with community organizations with expertise in embedding themselves directly into hospitals’ practices — such as organizations providing on-site legal services to help patients remediate substandard housing conditions or obtain health insurance coverage.

Second, funding opportunities such as New York’s DSRIP initiative can help finance these programs. Additionally, DRSIP may enable hospitals to build infrastructure for measurement of health and cost improvements from tackling community-level non-medical health determinants to show return on investment, not only to Medicaid but to payers across the board. To further assess return on investment, some hospitals are enhancing their electronic health records to track social factors and are seeking ways to share such data with community organizations and public health departments.

Looking Forward

Though hospitals’ core mission is to provide medical care, venturing into the uncharted waters of community non-medical health determinants is a challenging, but not impossible, task. Community organizations, foundations, and government agencies providing examples of how hospitals can feasibly engage in this work will promote further hospital participation.

Hospitals can have influence through their roles as respected organizations and large employers within their communities. They can use their leadership expertise, as well as limited investment of financial resources, to act as catalysts, working with community organizations and public health departments to improve the health of their communities. This—not simply providing better medical care for the population of ACO patients “attributed” to a hospital—is population health.

Authors’ Note

Our study was funded by a grant from the New York State Health Foundation. Dr. Unruh reports grants from New York State Health Foundation during the conduct of the study and personal fees from Navihealth, outside of the submitted work. Jacqueline Martinez Garcel was employed by the New York State Health Foundation during the time the study was conducted. Dr. Casalino is an unpaid member of the American Hospital Association Committee on Research and on the Board of Directors of the Healthcare Research and Education Trust.