In the summer 2012 SSIR article “Realigning Health with Care,” Rebecca Onie, Paul Farmer, and Heidi Behforouz state that recent changes in the health care marketplace “create an unprecedented receptiveness to new approaches in care delivery.” They argue that “the inevitable shift away from fee-for-service reimbursement to shared risk between payers and providers” is leading to new approaches that “could significantly improve health outcomes and reduce inefficiencies.” I couldn’t agree more. Hospitals can play and are playing a leadership role in these efforts. Boston Children’s Hospital, where I worked until earlier this year, is one such place.
The 2010 Patient Protection and Affordable Care Act, as well as recent guidance from the US Internal Revenue Service, requires that tax-exempt hospitals assess the health needs in their local communities and develop plans of action. Although community-benefit regulations specify the actions that hospitals must take to achieve compliance, they also leave room to explore ways in which hospitals can contribute to a changing health landscape. It is in this space that Boston Children’s has brought innovation to its work—particularly through a collection of community-focused programs called the Portfolio to Achieve Health and Social Impact.
In the early 1990s, Boston Children’s set out to formalize and expand its commitment to improve the health of the city. Although already a leader in three areas—research, patient care, and teaching— the hospital asked what it would take to become an innovator and a trusted resource for relieving the social stresses that weigh on urban families.
Conversations among hospital and community leaders led Boston Children’s to become one of the first academic health centers in the country to make community a fourth part of its mission. Since then, the hospital has created an Office of Child Advocacy (OCA) to coordinate community benefit efforts throughout the hospital and to manage its Portfolio to Achieve Health and Social Impact. It has also created four programs to bring innovation to some of Boston’s most pressing health issues: child development, mental health, asthma, and obesity. The programs include strategic partnerships—with Boston Public Schools, the Boston Public Health Commission, and the city’s community health centers.
The programs of the Portfolio to Achieve Health and Social Impact demonstrate what hospitals can accomplish by using their community health initiatives to increase their effectiveness in the broader health care ecosystem. For example, since 2005 the Community Asthma Initiative (CAI) has grown into a comprehensive, community-oriented program serving nearly 1,000 families in the Boston area. CAI has demonstrated that participating children experience fewer asthma-related hospitalizations, emergency room visits, and missed school days (and their parents miss fewer days of work). Equally important, the program proved to be cost effective. In the March 2012 issue of Pediatrics, CAI reported that for every $1 spent, the health care system realized $1.46 in savings.
Hospitals can be innovators, conveners, partners, and providers. Their ability to play those roles will be essential to improving health outcomes and reducing inefficiencies.
CAI’s data on its impact, combined with advocacy efforts, have led to recognition and opportunities to spread the program’s model. CAI partnered with the Asthma Regional Council, a coalition of federal and state health, environment, education, and housing agencies, to develop a business case for cost-effective asthma interventions. CAI partnered with another local advocacy coalition that used this business case to advocate policy changes for enhanced asthma care for children in Massachusetts. The efforts persuaded the legislature to earmark funding in the MassHealth (Medicaid) budget to fund and evaluate a demonstration project that would provide case management services for children with poorly controlled asthma. A pilot program is now ready to be launched. In addition, Alabama and Ohio are seeking Boston Children’s technical assistance to replicate the model.
Today, these results are pointing the way toward a reconfiguration of the hospital’s overall approach. Starting with an organizational restructuring in August 2012, which situated the Portfolio to Achieve Health and Social Impact within the hospital’s network development strategy, the hospital seeks to expand and build on programs like CAI to integrate its community mission into its overall approach. Its goal is to serve the Boston community while developing models for reducing health care costs and providing more effective preventive and clinical care.
Beyond Community Benefits
The decision to embed community benefit activities further into Boston Children’s overall strategy reflects a few important lessons.
Programs need a common road map that defines the path toward systemic change. | The OCA found that leaders of its programs had a clear sense of how to carry out their direct service goals, but using their programs to pursue broader change was far more challenging. The development by the hospital, in collaboration with the nonprofit consulting firm Root Cause, of a program evolution framework provided a clear road map, which included a checklist requiring each program to focus on community engagement, evaluation, and cost effectiveness.
Performance measurement provides the key to continuous improvement and external recognition. | In tandem with the program evolution framework, the hospital worked to develop a performance measurement system that would assess the performance and health and social impact of each program. Working with Root Cause, OCA also created a dashboard to measure its own effectiveness in supporting the programs as well as promoting the hospital’s overall community mission.
Substantive, strategic community partnerships are essential. | The hospital cannot achieve maximum impact without partnerships that reach important communities. Community partners provide knowledge about health problems and their most effective interventions, create vital links among the hospital and external stakeholders to leverage resources, and ensure that the health interventions are rooted in community norms.
Hospitals can become drivers of innovation and conveners of community stakeholders to advance public health. | Although the Portfolio to Achieve Health and Social Impact builds on existing best practices at Boston Children’s, the way that it is seeking to achieve broad health and social impact is unique. It demonstrates the role that hospitals can play in driving innovation within communities. In part, this role centers on providing funding as well as managing programs through rigorous measurement tools.
As Boston Children’s builds on these successes, it is entering a new phase of its work: to contribute to health care reform. By using its community-based programs as examples of innovative approaches to care, the hospital will move ahead with that phase. By incorporating its community health programs into its population health and care management initiatives, the hospital will effectively expand the impact of the programs, position the programs to reach tens of thousands of children annually, and decrease unnecessary health care costs throughout its network of relationships. In addition, by taking that step, the hospital will be able to leverage its community needs assessment to prioritize health issues and to identify gaps in community services. All of this will enable the hospital to partner with and encourage community providers to fill certain roles that are ineffectively or incompletely served at the hospital provider level.
A New Role for Hospitals
Boston Children’s is playing a variety of new roles as a result of the work it started in the 1990s. It has become a funder and practitioner of innovation. It has become a community convener that promotes public health. It also increasingly sees itself as part of a health care ecosystem. Other players, including policy makers, funders, community health centers, city and state governments, and nonprofits, are redefining their roles as well. These groups have the ability and knowledge to work together to succeed in health care reform.
Other hospitals are also experimenting with their roles in improving health outcomes and reducing health care costs. For example, Connecticut Children’s Medical Center’s Office for Community Child Health has created an infrastructure to support innovations like the Help Me Grow (HMG) National Center— a program initiated in Connecticut that has been replicated in 17 states with the support of the W. K. Kellogg Foundation and the Commonwealth Fund. HMG assists states in identifying children (from birth through age eight) at risk for developmental or behavioral problems and connects their families to community-based programs and services. Eighty percent of children and families referred to HMG have been successfully connected to programs and services. Based on data from its Orange County (Calif.) program, it’s estimated that the forgone initial costs of medical specialist consultation and diagnostic testing is more than $2,300 per child. The program estimates that the potential nationwide savings of early detection and intervention through the HMG National Center could total more than $54 million per year.
Examples like that one, along with the example of efforts at Boston Children’s, suggest that hospitals can be innovators, conveners, partners, and providers. Their ability to play all of those roles will be essential if hospitals are to contribute fully to the work of improving health outcomes and reducing inefficiencies.