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BY: CONNIE EVASHWICK, Sc.D., F.A.C.H.E., C.P.H., C.A.E.

Public health is suddenly a hot topic for clinical and health management professionals. Historically, hospitals always have been involved with their communities, and the formal field of public health is more than 160 years old. So what's different now? This: The Patient Protection and Affordable Care Act (ACA) places a new obligation on nonprofit hospitals to proactively and measurably improve the health of their communities — not just to provide quality care to individual patients — and to document the evidence of their success. That is what's new.

Although no financial or legal penalties have yet been specified, the mere fact of required annual reporting to the Internal Revenue Service (IRS) and to the community indicates the seriousness of this expanded responsibility. Moreover, the evolution of the science of public health makes quantifiable accountability more possible than in the past.

The dictionary defines public health as, "The science and art of preventing disease, prolonging life, and promoting health through organized community efforts. These include sanitation, control of contagious infections, hygiene education, early diagnosis and preventive treatment, and adequate living standards."¹

Thus, reaching out to the community is an element, but public health has much more to offer. As science has evolved, we have become more refined in diagnosing health conditions as they are affected by factors ranging from genetics to society, with the behavior of the individual influenced by both ends of the spectrum. Public health uses a socio-ecological model of health — social and cultural norms as well as environmental conditions and policies all have an impact on an individual's health.

Just as physicians and scientist are exploring how to modify genes to improve the health of individuals, public health experts are working on how to modify policies and societal norms to create healthy communities. We are all familiar with the adage that what the health system does affects only 20 percent of a person's health status; the other 80 percent depends on the actions of the individual and his or her environment. Public health contributes to the broader context of factors that affect an individual's health.

Thanks in part to funding from the federal government and leadership by U.S. universities and research institutes, public health has emerged over the past 60 years as an evidence-based field that rigorously evaluates the effectiveness of clinical and behavioral interventions on the health status of populations and individuals.

According to the Centers for Disease Control and Prevention (CDC), 10 essential services (see box, below) provide "a working definition of public health and a guiding framework for the responsibilities of local public health systems."²

The importance of this classification system is reinforced by the new Public Health Accreditation Board (PHAB) standards that in 2011 began to offer accreditation to all the state and the more than 2,700 local public health departments across the nation.³ Knowing the formal responsibilities of public health helps private health care organizations know what to expect of governmental public health agencies. Beyond this, there are numerous other organizations in the public health field that offer education, service, research and data.

TRENDS IN PUBLIC HEALTH
Public health is relevant to hospitals, physician practices and other health care delivery entities for several compelling reasons. Notably, the top health problems are chronic and preventable. The disease profile of the United States has shifted over the past 60 years from infectious diseases to chronic ones, from curative medicine viewed in isolation to prevention within the context of physical and social environments. The top health problems that cause individuals to need acute care — obesity, diabetes, heart conditions, stroke, cancer and injuries — all can be affected by public health initiatives, from changing the contents of school lunches to creating smoke-free environments to designing healthy neighborhoods.

Every 10 years, the U.S. Department of Health and Human Services (HHS) sets objectives and benchmarks for public health. The Healthy People initiative (www.healthypeople.gov/2020) lays out explicit goals for improving the status of the nation's health, and it offers specific targets that can guide health systems' priorities for achieving positive community health status. Its list of leading health indicators and data collected over the past 30 years gives federal, state and local government and private entities evidence-based resources to use for identifying and addressing high-priority health issues and measuring progress toward improving U.S. population health.

Population-based health care has become a science, and the demand for population-wide approaches is reinforced by the systemic changes health reform brings. Disease management, insurance-member management and employer-based wellness programs, among others, encompass controlling costs and behaviors at the group level.⁴ Management techniques focus on groups rather than on individuals, and performance measures are based on the collective performance of all participants. Health reform initiatives, including pay-for-performance, patient-centered medical homes and accountable care organizations, all involve a population focus. They represent the intersection of public health and individual clinical medical care.

Also, the federal government has become increasingly stringent about requiring nonprofit hospitals to document and report how they contribute to their communities and to measure the results on the community health status. For example, the IRS Schedule H of Form 990 asks hospitals to provide a community health improvement plan based on priorities from the community health needs assessment and to justify various activities based on their contribution to the health of the community. The community benefit report is required to be made publicly available.

The science of public health has developed the measurement tools and data bases hospitals use to meet the data-driven regulations, as well as to achieve the programmatic effect of offering activities that are known to be cost-effective. CHA, in collaboration with the VHA, Inc., network of not-for-profit, community-based hospitals and the Healthy Communities Institute, has a new guide, Assessing and Addressing Community Health Needs, that details the rigorous process for conducting a scientifically valid community health needs assessment.⁵

The public health approach to needs assessments includes an emphasis on involving key community stakeholders in the process, giving attention to underrepresented segments of the community and incorporating social determinants of health and health behaviors in the assessment. For example, MAPP (Mobilizing Action through Planning and Partnerships) is a detailed process for assessing community needs and assets developed in conjunction with the CDC and used by health departments and other public health community organizations throughout the nation.⁶

Taking a public health approach, engaging the local public health department, identifying community coalitions, broadening the focus to include prevention, reviewing the 10 essential public health functions — all contribute to giving the health care organization a list of stakeholders that might be different from a long-standing, existing list centered primarily around clinical care delivery.

DOES PUBLIC HEALTH HURT BUSINESS?
Does improving the health of the community result in less revenue for health care organizations, whether they are hospitals, physician practices or community service entities? The accounting is complex, but the short answer is no.

In a payment system that is strictly fee-for-service, one might expect that healthier people would use fewer health services, thereby resulting in less income to providers. However, one of the underlying causes of the health reform movement is recognition that future anticipated demand for care in the U.S. far surpasses current capacity. Payment mechanisms aside, unless structural changes are made, the U.S. will not be able to meet the projected increase in demand coming from the explosion in numbers of older adults, increased prevalence of obesity and related health problems, longevity of those with chronic conditions and increase in the number of people living in the U.S., among other factors.

The goals of integrating public health more closely with health care delivery are to minimize illness and to maximize the use of scarce resources, to save high-cost care for those who really need it and to revamp how basic services are delivered and accessed so that more people stay healthier and access to services is attained with lower costs.

Highly successful managed-care organizations such as Kaiser Permanente and population management programs such as employee wellness programs have demonstrated for years that investment in health promotion decreases unnecessary use of scarce resources, yet they cannot prevent illness completely. Rather, some serious conditions might be detected earlier due to preventive techniques and knowledgeable consumers, and high-cost services are not eliminated but rather are targeted at those with the most serious conditions. In short, providers do not need to fear that investing in such public health approaches is going to undercut their business success.

Without delving into detailed financial projections, a simplistic example shows the potential contribution to health care providers. Assume that a hospital faces financial penalties for re-admissions within 30 days. Contrast the likelihood of readmission of two people having knee replacement surgery. One person is obese at the outset, has diabetes and hypertension related to obesity, lives in a low-income building with poorly maintained elevator service and even worse stairs, cannot easily access transportation to go for physical therapy or follow-up visits and has limited access to a healthy diet due to the shortage of full-service grocery stores in the area.

The other person is not obese, does not have hypertension and diabetes, can get a ride to physical therapy and follow-up appointments and enjoys an adequate supply of healthy food.

Both patients have the same surgeon with the same excellent surgery results and the same post-surgery follow-up call from a nurse. Yet, the first patient gets readmitted while the second does not. The cause of the readmission is not the quality of the surgeon or the hospital — it is more attributable to the patient's personal and environmental conditions. But, the hospital nonetheless will likely lose money on the cost of readmission care.

The hospital could improve chances for a positive outcome and reduce the readmission risk by adding social and behavioral factors to the patients' initial assessment, addressing environmental elements in post-surgery discharge plans (for example, giving the first patient information on transportation options for getting to physical therapy) and working with physicians to expand patient eligibility criteria and preparation for knee surgery. This approach isn't new — many hospitals, for example, require candidates for bariatric surgery and their family members to attend pre-surgery weight-loss and diet-change classes, because they recognize that the surgery alone cannot guarantee a positive outcome.

ACTION FOR HEALTH CARE ORGANIZATIONS
How can health care organizations embark upon a public health trajectory or refine public health initiatives that they might already be engaged in? The overarching launch would be a commitment throughout the organization to examine public health and implement activities consistent with goals and resources. Though each organization and each community are different, some actions that have led to success in spanning acute care and public health include:

• Learn what public health is all about. Some staff might already have a background or even formal academic training in public health; others might be learning it as they engage in programs; some might have no familiarity whatsoever. Senior leaders should educate themselves about what public health is and has to offer and then develop a plan to train other staff, as well as physicians and other independent professionals involved with the organization. Education about public health is widely available in all types of formats from a variety of sources. Public health is a very broad field; education should be appropriate to each person's role.
• Embrace public health concepts, methods, and data and inculcate appropriately into organizational operations. The field of public health has developed a wealth of tools, techniques and measures. Health care providers, insurers and community agencies, among other types of health care organizations, will find that many of these can be readily incorporated into program planning and management. In deciding among many outreach projects, for example, public health data bases offer a wealth of information about what community-wide education programs are most effective and what measures are realistic to use to document change. Explore the CDC's Community Guide at www.thecommunityguide.org or the National Repository of Evidence-Based Practices maintained by the federal Substance Abuse and Mental Health Administration at www.nrepp.samhsa.gov/ViewAll.aspx.
• Build public health data and informatics expertise into the organization's data or information technology department. Large health care organizations tend to have staff members who specialize in health care informatics, and even small organizations have someone responsible for data. The information technology department or specialist should be encouraged to become familiar with the contents and use of data pertaining to public health. Information about the field of public health informatics can be found at www.amia.org/applications-informatics/public-health-informatics.
• Inculcate service to the community in institutional culture. A health care organization can make a conscious effort to create a culture of community awareness and service. One guide is the American College of Healthcare Executives policy statement called "Healthcare Executives' Responsibility to Their Communities." Exemplary health care systems have incorporated measures of commitment to the community into their annual performance reviews, asking employees to document the number of hours they have participated in community service events, and by holding managers accountable for positive performance of community-oriented programs.7
• Elevate the importance of the community and reflect this in the organization's structure. Many health care organizations have departments of community outreach. Because of the IRS Form 990 Schedule H requirements, hospitals have now created specific departments of community benefit. Whatever the title or day-to-day responsibilities, including the director among the executive leadership of the organization is an important means of giving visibility to activities within the community and including community issues in decision-making criteria and resource allocation. The hospital's board also should be apprised of and assume responsibility for community-oriented activities. Hospitals have created separate community outreach committees, required board approval of the annual community benefit plan and re-examined board composition to ensure broad representation of critical community segments.
• Take community health needs assessments and community health improvement plans seriously. Even entities that are not required to prepare a formal community health needs assessment (i.e., any entity that is not a non-profit hospital) should be involved in such information gathering anyway. What's more, as the reporting requirement begins to be implemented by hospitals throughout the nation, it's likely that more health needs assessments will be conducted jointly by multiple organizations. Participating in designing the needs assessment can ensure that an organization's target audience and service issues are included and useful information is generated. For example, a home health department could request special sampling of community residents receiving home care; Catholic Charities might request a survey of recent immigrants' health problems, conducted in person and in their native language in order to make sure that the needs of this subset of the population are adequately included in overall descriptions of community health needs.
• Analyze the financial benefits and constraints to a public health approach. The board of a health care organization could well ask the questions, "Why should we invest in public health — isn't this someone else's obligation?" And, "Will investing in public health result in cutting rather than increasing our revenues?" Each organization will need to address these questions based on its unique characteristics and using its own financial, utilization and client data. Some public health activities could be more justifiable than others. If the health care organization proactively examines the data, it will be able to decide and defend its actions. A passive approach to the resource allocation issue could cause anxiety and stall a positive approach for the future.
• Work closely with payers and providers to create movement toward a "healthy community" approach. Many examples exist of community-wide collaboratives and joint projects that have had a measurable impact on community health status.⁸ A hospital or health system need not take on improving the health of the entire community single-handedly. Indeed, quite the reverse will likely be more successful, as a collaborative effort will enable staff to become involved with, learn from and build upon the expertise and relationships of other organizations that represent and work with various subsegments of the community.

For all the uncertainties and imperfections of the ACA, changing structures and processes to focus on keeping people healthy, rather than fixing them up after they become ill, is imperative to ensure the long-term financial viability and outstanding quality of the U.S. health care delivery system. The fear that acute care organizations, by pursuing public health, will lose money and undercut their financial viability is not supported by the data. Public health is the key to creating the foundation of a healthy community that allows each organization to promote health and maximize use of its clinical resources in the most cost-effective way — to the ultimate benefit of individuals and communities alike.

CONNIE EVASHWICK is the author of the forthcoming book The Hospital-Community Imperative, to be published in 2013 by Health Administration Press.

NOTES

1. Merriam-Webster Dictionary, www.merriam-webster.com
2. Centers for Disease Control and Prevention, www.cdc.gov/nphpsp/essentialServices.html.
3. Public Health Accreditation Board. Standards and Measures, www.phaboard.org/standards.
4. Ann McAlearney, Population Health Management (Chicago: Health Administration Press, 2010).
5. Catholic Health Association, Assessing and Addressing Community Health Needs (St. Louis: Catholic Health Association, 2012).
6. National Association of County and City Health Officials, MAPP Project, www.naccho.org/topics/ infrastructure/mapp/framework/index.cfm.
7. American College of Healthcare Executives, "Healthcare Executives' Responsibilities to Their Communities," www.ache/policy/Respons.cfm.
8. American Hospital Association, Community Connections (Chicago: American Hospital Association, 2010), www.caringforcommunities.org.

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CDC HISTORY

In 1946, Congress created the original CDC — the Communicable Disease Center, based in Atlanta. Its original focus on surveillance and understanding of communicable diseases morphed into recognition of the 10 essential services of public health and an emphasis on prevention, according to the agency's history. What is now the Centers for Disease Control and Prevention and other federal agencies have created numerous databases that can be used to assess the health status of a community; developed frameworks and analyses for evaluating interventions, particularly ones related to prevention; and laid the groundwork for a health system that measures performance related to population well-being as well as cure of individual patients.

Thus it is feasible for a hospital to select activities based on expected results and measure outcomes against quantifiable objectives. More powerful than government regulations, the transparency inherent in public reporting creates an expectation among community stakeholders that hospitals will act on evidence and report quantifiable performance with regard to community-oriented initiatives.