Nonprofit hospitals can do more to improve community health

In Akron, Ohio, a regional initiative called the Accountable Care Community (ACC) has brought together physicians, health care organizations, elected officials and community groups to reduce the number of people in the community suffering from diabetes and the cost of treating the disease. In just 18 months of work, the ACC has started saving $3,185 per person in annual diabetes-related costs, and has seen diabetes-related emergency room visits drop.

The coalition, which includes three health systems, two universities, and 70 community and social service organizations, is working to change not just the behaviors of those who live and work in the region, but also their community environment. That means adding sidewalks and bike lanes, increasing public transit access to the nearest national park, and setting nutrition standards for food served in vending machines in parks, hospitals, or libraries.

Evidence suggests just treating existing disease explains only a small amount – perhaps 20 percent – of improved health outcomes compared to other factors, including environmental influences and personal behavior. The ACC’s work in Akron and its surrounding communities is one example of what can happen when health care providers go beyond medical care to help prevent disease.

A New Approach for Hospitals

In 2010, the Affordable Care Act expanded what was required of nonprofit hospitals to keep their tax-exempt status. Every three years, hospitals must survey their communities to see what health needs exist, and then put in place a strategy to meet those needs. These requirements are enforced by the IRS and, in some cases, by states that have enacted more stringent provisions than the federal guidelines.

It’s a new approach for many nonprofit health care organizations, but it provides an opportunity for hospitals to build upon their unique expertise to advance strategies that make the communities they serve healthier through what’s called “policy, systems and environmental change.” That means supporting public policies that affect the conditions that drive individual behaviors. For example, that could entail adopting land use and transportation policies that make walking and biking safer and more appealing, creating school wellness policies that require access to drinking water and healthy cafeteria fare, and making public places tobacco-free. The goal of this approach is to make the places where people live, work, and play healthier, which will in turn reduce the rates of chronic diseases. 

Three Steps Hospitals Can Take

Efforts like Akron’s have shown hospitals can be especially effective by using a three-step approach to change:

Step 1: Ensure internal hospital policies serve as a model for healthy choices for patients and staff. Healthy human resources policies might include providing smoke-free campuses, increasing nutritional offerings in cafeterias and vending machines, and ensuring stairwells are open to encourage physical activity. Hospitals can locate their facilities so they’re linked by public transit, or can share space at off-site clinics with other community services, such as schools or recreation centers. They can also host farmers’ markets or community gardens on their property to help increase community access to fresh, healthy food.

Step 2: Partner with community-based networks and organizations to monitor chronic conditions and intervene early. As we’re seeing in Akron, hospitals can make great strides in reducing chronic disease if they find ways to go beyond the traditional hospital setting by partnering with community groups. For example, the ACC worked with a local public housing development to help residents implement sustainable self-management programs to control diabetes.

Step 3: Take advantage of the hospital’s in-house expertise and influence in the community to by tackling the root causes of chronic disease. Hospitals can develop partnerships with community leaders, including government officials, as they assess community health needs, and then can prioritize public policies that can lead to big gains in community health.

This step is key to long-term success, and in Akron, this kind of engagement is central to their work. Hospital partners not only provide health data and medical know-how in fighting disease — they also provide political clout. Whether improving public transit, requiring smoke-free workplaces, changing land-use rules to allow urban agriculture, or improving the nutrition in school lunches, changes to public policy often take political persuasion to be successful. Medical staff can testify at public hearings, serve on public commissions and advisory boards, and recommend policy changes to improve health.

Hospital administrators can use their influence both as medical experts and as large regional employers to hold elected officials accountable to the lowering the incidence and cost of disease. And, hospital community benefit programs can fund grassroots organizations that teach disease prevention strategies and organize community leaders to make health a political priority.

Where Hospitals Can Do More 

Whether they participate directly or work through community-based partners, here are some examples of issues where hospitals can support evidence-based policy change:

Tobacco-free places: Local and state governments from California to Maine are taking steps to protect tenants from secondhand smoke drifting in from neighboring units. Nationwide, more than 230 housing authorities have adopted smoke-free policies for some or all of their units. One of the largest is the Boston Housing Authority, which prohibits smoking in all of its approximately 14,000 housing units. Hospitals could provide data about local chronic disease rates attributed to tobacco use and fund organizations that advocate for smoke-free environments.

Healthy food: Communities have successfully used a combination of proverbial carrots and sticks to encourage greater access to healthy foods and discourage unhealthy foods. Rockford, Ill., used a loan from the U.S. Department of Housing and Urban Development to develop a supermarket in a low-income neighborhood, and Cleveland updated its zoning code to allow urban agriculture (such as community gardens and pocket parks) in residential districts. Hospitals can fund these sorts of community-based efforts to provide healthy food.

Physical activity: In Merced, Calif., schools agreed to open up school fields and certain gymnasiums to be used by the community after school hours. In Minneapolis, the zoning code requires at least one bicycle parking space for every 20 automobile spaces. Kansas City, Kan., adopted a complete streets policy in April 2011 that sets new street design standards including narrower streets, wider sidewalks and bike lanes or shared-use travel lanes, encouraging active transportation. Hospital representatives can sit on or fund coalitions of community-based organizations urging improvements to streetscapes and public transit in their area.

Healthy housing: In addition to living in a healthy community, it is important that individual housing conditions be safe and healthy. A program in Greensboro, N.C., helps low-income homeowners and rental tenants pay for a risk assessment to find out if old lead paint is deteriorating, and offers financial assistance to correct the hazards. Hospitals can make sure their community health needs assessments take housing into account, and can then include prevention-oriented strategies in their implementation plan.

These strategies affect multiple community health needs at once, which also makes them extremely efficient. For example, smoke-free policies curb incidences of lung cancer and reduce asthma rates. Policies that create more bikeable and walkable communities, or policies that increase access to healthy food simultaneously address a broad range of chronic diseases including cancer, heart disease, obesity and diabetes. Such policies can also ameliorate aging in place, social isolation, and climate change.

Photo by USACE via Flickr. 

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