Community Health Improvement: Social Care Is Healthcare : Frontiers of Health Services Management

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Community Health Improvement: Social Care Is Healthcare

Kryzer, Emily; Nolan, Christopher M. FACHE

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Frontiers of Health Services Management: Winter 2022 - Volume 39 - Issue 2 - p 17-26
doi: 10.1097/HAP.0000000000000160
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Abstract

In St. Louis, Missouri, health is not equally distributed. One of the most-cited findings in describing the health of the St. Louis region is an 18-year gap in life expectancy at birth between people who are born in two zip codes separated by less than 10 miles (Purnell et al. 2014). Place matters in St. Louis, as it does in cities throughout the country (Harper et al. 2014; Holder and Montgomery 2019; King et al. 2022). Place matters because it shapes St. Louisans' access to social and economic resources, including income, education, quality neighborhoods, transportation, and basic social services. The history of a place also matters. In St. Louis, the history of racial segregation—and decades of local, state, and federal policies that reinforced structural racism—has left a mark on the health and well-being of all St. Louisans (Cambria et al. 2018; Gordon 2008; Rothstein 2014). In the two disparate zip codes, the most notable differences are poverty level and racial composition. In one community (78 percent White), the life expectancy is 85 years and only 7 percent of the population lives below the poverty line. In the other community (95 percent Black), the life expectancy is 67 years and more than half (54 percent) of its population lives in poverty.

The link between segregation and health is clear: Concentrating poverty at the neighborhood level limits access to critical resources and opportunities, and the result is poorer health, education, and other life outcomes (Kramer and Hogue 2009).

It Doesn't Have to Be This Way

How can a large healthcare system begin to confront the region's history and create a new narrative in which all can live a long, productive, and healthy life? The answer to this question for BJC HealthCare (BJC), a large nonprofit integrated academic health system, has come down to changing decisions made, leveraging power and resources in new ways, and expanding the role of healthcare providers in addressing the root causes of health inequities. Through an enhanced commitment to community health improvement, BJC is making an intentional change to address disparities inside and outside of its walls. After all, public health research has confirmed that health and well-being, including premature death, are driven predominantly by socioeconomic conditions, not medical care (Braveman and Gottlieb 2014; Schroeder 2007).

As Cambria and colleagues (2018, 12) observe, “Conscious choices created our ‘geography of inequity’ in St. Louis. Conscious choices can also help to reshape it.” The fatal shooting of Michael Brown in Ferguson, Missouri, in August 2014 was a critical inflection point, accelerating the need for the conscious undoing of systemic racism and its effects in St. Louis. This event, and the unrest that followed, brought to light the health and social inequities. Since that time, and especially during the COVID-19 pandemic, community members, organizations, and institutions in St. Louis have worked to confront the role that race plays in shaping unequal outcomes. Organizations in each sector, from education to housing to healthcare, continue to forge new paths for broader racial equity. It is on this foundation that BJC is able to work collaboratively with the community toward a St. Louis where geography and race do not determine outcomes.

A Framework for Addressing Disparities

BJC has a long-standing commitment to improving the health of the communities it serves, and it made an enhanced commitment to address health disparities in 2019 when it articulated a vision for its emergence as a national leader among integrated healthcare delivery organizations (BJC HealthCare 2021). The vision consists of four areas of focus: community health improvement, clinical quality, customer centricity, and financial stability. The launch of BJC's Community Health Improvement Team in 2020 signaled an additional emphasis on being a catalyst for health and well-being. It also presented an opportunity to work at the intersection of healthcare, economics, and social care to address persistent inequities in health.

As the Community Health Improvement Team set out to launch a strategic planning process, it established a framework to illustrate how BJC can promote health equity and have a meaningful impact on community health. This framework includes three pillars:

  • Anchor institution strategy. The first pillar seeks to leverage BJC's role as the largest employer in the St. Louis region and a major purchaser of local goods and services, as well as a major investor.
  • Community partnership and collaboration. The second pillar recognizes BJC's need to partner with community members who are most directly affected by health inequities and the institutions that serve them. Through equitable partnerships and collaboration, BJC can more effectively leverage existing resources and infrastructure and, most importantly, cocreate more impactful solutions with the community.
  • Policy to address social determinants of health. The third pillar supports the role that policy—at all levels—plays in transforming systems and communities. Without policy interventions that bring solutions to scale, it would be difficult for BJC or any single actor to implement the population-level changes needed to eliminate disparities.

Strategic Planning Process

With this framework as its guide, and with support from executive leadership, BJC began a nine-month strategic planning process that engaged more than 200 internal and external stakeholders. The planning process (described later) was informed by both public health and community expertise (BJC HealthCare 2021) gathered through:

  • key informational interviews with BJC leaders, academic and public health partners, community and social service providers, and elected officials (23 interviews);
  • listening and learning sessions with groups of stakeholders within BJC's system who are most heavily engaged in the organization's existing community health efforts, including social workers, nurses, board members, and other health professionals (6 sessions, 120 individuals);
  • steering committee planning sessions with internal and external stakeholders who developed the mission, vision, and guiding principles for the Community Health Improvement Team's efforts (4 sessions, 20 individuals); and
  • working group planning sessions with internal and external content experts, including public policy experts and members of community-based organizations who developed the priorities, goals, and measures of success for each focus area of the strategic plan (5 sessions for each area, 70 individuals).

The mission developed by the steering committee describes the purpose of the Community Health Improvement Team's work as well as whom it serves and how it will execute its purpose:

BJC Community Health Improvement advances health equity for those most impacted by health disparities in the urban and rural communities that BJC serves through authentic and equitable partnerships with community stakeholders and community members.

The group's vision for success—“a thriving bistate region in which all people have an equal opportunity to live their healthiest lives”—underscores that health equity is not just an outcome but rather a process of transforming the social and economic conditions that produce predictable health disparities around race, income, gender, and geography. Steering committee members also identified the following principles to inform how BJC makes decisions, allocates resources, and implements its community health improvement strategy (BJC HealthCare 2021):

  • Center health equity. By centering health equity, BJC will ensure that everything it does is in service of the well-being of communities that have endured disinvestment and discrimination. This work includes providing disproportionate resources to those who have suffered the greatest harm and resolving the root causes and conditions that drive health disparities.
  • Partner authentically and equitably. Recognizing that community health improvement is not the work of a single individual, organization, or system, BJC will reject siloed efforts; listen humbly to, learn from, and value the leadership of impacted communities; work with institutions and individuals who are on the front lines of service; and build bridges with those who do not share BJC's perspective or agenda. Importantly, BJC will also negotiate resource and power imbalances that have contributed to disparities.
  • Focus on the long-term. BJC understands that the transformation it seeks requires a generational approach. To sustain this change, BJC will exercise more creativity and informed risk-taking as well as greater investment in community capacity and infrastructure.
  • Maintain accountability. BJC's accountability to the communities it serves requires that it review important decisions, actions, and impacts with stakeholders, and truthfully report successes and shortcomings. BJC will also act on what it learns, including when it has not operated in alignment with its principles.

Priorities, Partners, and Measures of Success

BJC's strategic planning partners identified areas of opportunity for the Community Health Improvement Team's efforts. Each area was organized around a central aim and its priorities. Priorities were determined collaboratively among working groups. The groups assessed each potential priority to identify the greatest promise for providing the most to those most adversely affected by existing social, economic, and health conditions (equity); transforming conditions for the better (impact); being maintained and escalated over time by BJC or its partners (sustainability); aligning with BJC's expertise, capacity, and resources (capacity); and building on the work of others who are executing effective and coordinated action (existing efforts). Although not described in detail here, specific goals, objectives, and strategies were also established for each focus area of the strategic plan (Exhibit 1).

F1
EXHIBIT 1.:
BJC HealthCare's Community Health Improvement Strategic Plan

BJC HealthCare's community health improvement strategic plan covers each area with two specific priorities and goals:

  • Anchor strategy. BJC aims to close the racial wage and wealth gaps to improve individual and community-level health outcomes. The priorities are workforce development and support (hiring, promoting, and retaining Black employees; creating opportunities through pipeline programs) and supplier diversity, including business development, and impact investing (supporting the growth of Black-owned businesses, investing in local community and economic development).
  • Diabetes and healthy food access. BJC aims to reduce racial disparities in diabetes incidence and prevalence by improving access to healthy food and physical activity. BJC will prioritize efforts that address healthy food access (improving awareness of and access to healthy and affordable food, investing in community food ownership models) and type 2 diabetes in youth (amplifying successful intergenerational nutrition and physical activity programs).
  • Infant and maternal health. BJC aims to improve Black infant and maternal health outcomes by ensuring trust and transparency and providing culturally appropriate, holistic clinical care. Priorities are doula partnerships (supporting the integration of doulas in clinical settings, introducing families to doulas early in their pregnancy, and developing mechanisms to reimburse doulas) and improving trust and transparency in the system of care (growing and retaining Black clinical care team members, collecting and sharing stories of patient experiences, and advocating for community-facing data systems).
  • School health and wellness. BJC aims to advance equitable health and educational outcomes by increasing access to comprehensive wraparound support for children and staff in early learning and K–12 settings and in surrounding communities. Priorities are behavioral health (increasing support for school- and community-based behavioral health programs, increasing the capacity of schools to bill Medicaid for behavioral health services) and equitable and comprehensive support in schools (adopting the Centers for Disease Control and Prevention's Whole School, Whole Community, Whole Child model and increasing knowledge and use of trauma-informed services that are culturally relevant).

Lessons Learned

As BJC deepens its commitment through strategic action and support, the Community Health Improvement Team is learning lessons that other healthcare organizations may apply to their journeys, including recommendations for what not to do.

The first nine months of BJC's community health improvement strategic plan brought to light the importance of partnership and power in creating the kind of deep and trusting relationships needed to do this work; the iterative and collaborative process used to develop initial measures of success; and the opportunities through which connections can be made across the system.

Partnerships, Roles, and Power

Partnership and collaboration are vital to achieving the long-term potential of each of the four community health improvement strategic focus areas. Making the most of existing momentum and infrastructure requires understanding where and when BJC needs to lead versus the need to step back and follow others.

As part of the planning process, BJC identified core roles that it can play during strategy execution (Exhibit 2). Some tasks (e.g., supporting the integration of doulas in clinical settings) require the Community Health Improvement Team to initiate and guide action as the leader. Other tasks (e.g., increasing support for school- and community-based behavioral health programs) are better suited to the roles of investor, champion, and amplifier, in which the team follows the lead of others in the community. Being intentional about the role taken not only extends BJC's capacity but also creates the space to show up in the community in new and more equitable ways.

EXHIBIT 2. - Central Roles in BJC's Community Health Improvement Efforts
Leader Initiates and guides collective action to achieve desired community outcomes
Partner Cocreates initiatives along with a set of strategic partners, sharing resources and capacities for mutual benefit and meaningful impact
Investor Invests money and possibly other needed resources into plans, with the expectation of achieving a significant impact
Champion Listens to, learns from, and actively promotes organizations that are leading impactful work on the priority
Amplifier Increases the power and visibility of efforts so that actions and impacts can be brought to scale
Convener Calls stakeholders together to engage in aligned, coordinated action; provides support to the collective as it works to advance shared interests and agendas
Policy advocate Works to influence the legislative and administrative actions of decision-makers

Equally important is the ability to be nimble. As projects unfold, roles often shift to meet the needs of collaborators and projects. For example, the Community Health Improvement Team first positioned itself internally to lead the development of a regional data hub to increase transparency regarding infant and maternal health outcomes, only to realize that another community partner was getting ready to launch a similar community-facing data initiative. The team's role quickly shifted from setting the table (leader) to bringing other health systems to the table (champion, amplifier).

As the team has learned, the work of community health improvement not only requires leadership but also followership. It is not only impossible to be the leader of every strategy, it is unwarranted. To be successful, health systems must show up in new ways in the community and model the values of those roles, including humility, mutuality, and allyship. When BJC shows up for partnership discussions, it is almost always one of the largest organizations in the room. That does not mean it knows best. Practical steps to achieving more balanced power dynamics start with listening and being open and honest about roles.

The team also acknowledges that some relationships take longer to build than others and need varying levels of attention to maintain and grow, particularly in areas in which there is a history of distrust or reluctance to collaborate with large organizations. Additionally, BJC has an overarching understanding of the activities taking place throughout the region. This allows the team to identify synergy points and serve as a connector between organizations to help accelerate shared goals and maximize impact.

Measures of Success

As noted earlier, BJC focuses on the long term. This requires seemingly paradoxical thinking: Understanding that the transformational change envisioned is generational in scope and scale while acting on present and urgent needs. As an education partner remarked when describing the immediate need for more behavioral health supports, “Our house is on fire, now.”

This challenge comes to the forefront when determining how to measure success. As part of the strategic planning process, each working group identified an initial set of measures, including short-term and long-term outcomes as well as process-related (e.g., quantity of a service delivered) and impact-related (e.g., changes in conditions) outcomes. The working groups consulted public health literature to understand what outcomes were plausible. Engaging community members and organizations throughout the process helped to ensure that selected outcomes reflected what true success looks like to those most affected.

The Community Health Improvement Team continues to evaluate the initial set of measures and has developed dashboards for each of the four strategic focus areas. Each dashboard features two to three indicators with established yearly targets and year-to-date progress in achieving the targets. Policy and partnership milestones, such as advocacy efforts, new community partnerships, and outcomes from coalition meetings, are also detailed on the dashboard.

The team prioritized each indicator through a process that included evaluating whether the data for the indicator existed, whether the indicator supported equity (i.e., aimed at a population or region that has been disproportionately affected by health disparities), and whether the work would move the needle toward the target. In some instances, data for the indicator were not available. When acceptable proxies were available, they were used; when they were not, the creation of the indicator became the indicator itself.

Some of the short-term indicators for each focus area include

  • total spend with minority- and women-owned businesses in priority zip codes in the St. Louis region (anchor strategy);
  • average change in A1c among patients with uncontrolled diabetes who are food insecure and receive culturally and medically appropriate meals (diabetes and healthy food access);
  • development of a plan for an electronic health record–integrated data system to monitor the use of doulas across BJC facilities (infant and maternal health);
  • number of community wellness hubs operating in partnership with community organizations (school health and wellness); and
  • total community financial investments in each area.

Creating meaningful measurements for this work requires iteration, trusting relationships with partners, and an adaptive mindset. The indicators will likely change as knowledge increases and the work unfolds. Getting to the right measures takes time.

A recommendation for what not to do is simple: Don't go at it alone. All the work involves some level of partnership. For some strategic focus areas, BJC is building on years of work, which allows teams to leverage measures that are known and accepted by the stakeholders. Other focus areas are forging entirely new bodies of work or requiring a new lens on existing work. Making the case for why progress needs to be presented in a new way—even if that means stepping outside traditional reporting structures—can be achieved over time through early and ongoing engagement with partners.

Opportunities to Improve Connections

In reflecting on BJC's efforts to build the community health improvement strategy, several factors enable a systemwide approach. Some factors, such as BJC's governance structure, are already helping to create alignment. Others, like community health needs assessments (CHNAs) and the St. Louis Community Information Exchange (CIE), represent opportunities that can be further leveraged in the future.

Governance structures at multiple levels enable BJC to execute on the guiding principle of maintaining accountability to the communities it serves. Because community health improvement is a focus area for BJC, the work has greater visibility among the board and senior leadership. This facilitates integration with internal partners, including human resources; diversity, equity, and inclusion; supply chain; and patient experience teams (to name a few). In addition, each strategic focus area has a steering committee, with members representing various departments and facilities across BJC's system. These committees then report to BJC's executive leadership. Each committee's knowledge and connections help guide the work, clear roadblocks, and expand community networks. In short, the approach to governance has been to leverage what exists to build stronger connections across the system. This model can be applied in other scenarios.

One example is the CHNAs that are completed every three years for each of BJC's 12 hospitals. These assessments offer data insights into community need, and since 2016 have helped BJC build its muscle for collaborative action on community health priorities. BJC's community health improvement strategic plan was created with the understanding that each hospital identifies and commits to its own priorities through its CHNAs. The system efforts are not intended to replace the work outlined by hospital efforts; rather, BJC promotes complementary processes in which the system's priorities are informed by what is learned from staff on the front lines of local community health efforts, and their approach is informed by the capacities, resources, and partnerships the Community Health Improvement Team develops through its work.

The CIE is another way to create stronger system and region connections. Launched in 2020 in response to the COVID-19 pandemic, the CIE facilitates a regional coordinated entry system that connects client data across health and social service providers. With leadership and backbone support from the United Way of Greater St. Louis, the CIE and the broader Unite Missouri network connect partners through a shared technology platform that enables them to send and receive electronic referrals. BJC has been a lead partner in the development and implementation of this network and looks forward to understanding its impact, not only in terms of the extent to which it enhances BJC providers' understanding of patients' social needs and allows them to respond in real time, but also in facilitating more integrated social care systems across the region to address health equity.

Conclusion

To improve the health of our communities locally, regionally, and nationally, health systems must adopt intentional change to move from what was and is to what could be. Addressing social standards for the delivery of care both inside and outside of hospital walls involves making a new or renewed commitment to community health improvement and taking the appropriate actions to address the root causes of health inequity, many of which include social conditions. BJC believes that all people can have an equal opportunity to live their healthiest lives. The vision requires that the institution change how it thinks about healthcare, move to a model that addresses the whole person, and affirm that social care is in fact healthcare.

Acknowledgments

The authors thank BJC HealthCare's Community Health Improvement Team leadership members Jason Q. Purnell, PhD, vice president of community health improvement; Karlos Bledsoe, Sr., director of strategy and operations; and Doneisha Bohannon, director of community health partnerships and collaboration for their contributions. The authors also thank Rebeccah L. Bennett; Jessica Perkins; Natalie Parks, PhD; and Chelsey Carter, PhD, of Emerging Wisdom LLC, and Jacqueline Ferman-Grothe, director of media and public relations at BJC HealthCare.

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