Hospitals and health systems play a critical role in improving the health of their entire communities. However, that was not always the case.
A variety of factors, including concern for the communities they serve, scientific evidence pointing out the importance of social determinants of health and the dramatically changing economics of healthcare, have come together to make community health a strategic objective for many health systems. As Joanne Conroy, MD, CEO, Dartmouth Health, says, “We believe a community’s health demands the engagement of the community … By addressing barriers to social determinants of health, like access to nutrition, housing and income, we’re promoting the long-term health of our communities.”
The long history of hospitals is the history of society’s response to poverty and migration. London’s St. Bartholomew’s and Paris’s Hotel-Dieu began as charitable organizations to care for the poor, migrants and those with serious contagious diseases. While doing good work, they were at least partially motivated by the desire to keep the sick and impoverished away from the community. What we now think of as “public health” was primarily the responsibility of city governments and boards of health and included a focus on sanitation, clean water and responding to epidemics.
It wasn’t until the mid-19th century that we saw significant involvement of hospitals in what we would now call public health via public education campaigns focusing on hygiene and visiting nurse programs. By the mid-20th century, hospitals provided a variety of services focused on community health such as tuberculosis control programs, immunization drives and early cancer screenings. From the 1970s through the 1990s, many hospitals established community health departments and worked closely with public agencies.
In 2010, the Affordable Care Act required nonprofit hospitals to conduct Community Health Needs Assessments every three years and develop plans for improving public health. Hospitals began addressing the social determinants of health as part of their community benefit work. In the past few years, we have seen public health concerns and initiatives become more integral to the healthcare work of hospitals and hospital systems.
The move toward more public health partnerships has emerged from a long journey defining the role of hospitals in the larger social environment. We are now in the era of hospital/community organization partnerships in service of public health. Three examples illustrate this.
CommonSpirit Health partners with community organizations on such efforts as the Community Investment Program, providing grants and loans to local organizations, and the Connected Community Networks. With these initiatives, they aim to affect housing, food security and care access through the provision of a technology platform and “trusted community conveners” to coordinate services. Services might include housing assistance, nutrition programs or mental health counseling.
These are joined by strategic partnerships with academic institutions to expand educational programs and training in primary care and maternal health, for example. CommonSpirit uses the Pathway Community Hubs model to provide infrastructure for community-based care coordination and certification of community health workers.
Dartmouth Health has a history of involvement with community organizations as well as providing direct services and programs. They address the social determinants of health through their social care navigators, who connect patients with resources such as food banks and housing support, and through partnerships with local organizations focused on food security, substance use and mental wellness.
The social care navigators are employees of the health system who leverage relationships in the network of agencies, food banks and financial assistance programs, including Healthy Monadnock Alliance, the Manchester Food Collaborative and New Hampshire Hunger Solutions. Dartmouth Health’s ConnectShareCare also offers a platform in which patients and caregivers can connect and provide support.
While less engaged with external community organizations, University of Chicago Health co-leads the South Side Healthy Community Organization, a coalition of 13 healthcare providers focused on coordinating planning, research and services on Chicago’s South Side. This work is focused on high community engagement as is the Graduate Medical Education Community Champions program.
In conjunction with the Urban Health Initiative, this initiative addresses the community’s health needs to improve health equity for residents on the South Side and in the southern suburbs. These are supplemented by the Chicagoland Free Clinic Consortium where local medical schools support a network of student-run free clinics.
What are the lessons from these initiatives?
- The social ecology of health demands an acknowledgment that well-being is almost never solely an individual issue and hospitals must play a key role in community approaches.
- Medical professionals can never completely know the circumstances and the impact of healthcare on a community. Therefore, we must rely on creative ways of involving the community in shaping what is required and building mutual trust.
- The size and economic impact of healthcare systems (often the largest employer in a region) mean they can have significant impact on a community’s well-being. Many health systems see this reality as both a practical and moral obligation they hold.
The rise of healthcare systems as community hubs and strategic partners with communities is reshaping health in the United States. Hospital boards and healthcare systems would do well to immerse themselves in developing democratic approaches to community public health, creating structures and processes in partnership with local organizations to shape investment and participation.
Douglas Riddle, PhD, DMin, FAPA, is curriculum director, The Carol Emmott Foundation.