Summary
Three years ago St. John Hospital and Medical Center, Detroit, made a commitment to strengthen its community relationships and reaffirm its mission of serving those in need by following the Catholic Health Association's Social Accountability Budget. While implementing the program, administrators were surprised to learn the hospital was already participating in many community programs for which it received little or no reimbursement. They also discovered that the hospital had no formal, written charity care policy even though St. John provided more than $14 million in uncompensated care annually.
To learn what the needs of the surrounding community were, the hospital went to the clergy, who overwhelmingly identified the needs of the elderly as the number-one priority. A close second was supporting the basic family unit. Other concerns included basic family needs, safe neighborhoods and schools, and teen pregnancy.
Although the hospital realized it could not do all that was needed, it felt obliged to be a leader in seeing that the needs were met and drew up a community benefit plan that documented the problems and the solutions. The hospital did what it could and worked with other organizations to address needs such as housing for the elderly, affordable and accessible healthcare, neighborhood improvement and safety, and family services.
In the past, hospitals were often the hub of community activity or at least one of the major employers, critical to the community's economic well-being. But the past decade took its toll. Steadily declining reimbursement, expensive technology, a dwindling qualified labor force, deteriorating inner-city neighborhoods, and an expansion into new market areas to attract more affluent patients — all these factors contributed to changes in the relationship hospitals once enjoyed with their surrounding communities.
At St. John Hospital and Medical Center (SJH&MC), on the northeast side of Detroit, a renewed interest in the community took place about three years ago. SJH&MC faces the same dichotomy as many other urban hospitals. It sits between the "haves" and the "have nots" and must serve both. To its immediate north is Grosse Pointe, one of the most affluent areas in Michigan; however, just a few miles south are some of the most impoverished neighborhoods in the country — neighborhoods plagued by gangs, drug wars, and a lack of adequate healthcare services. As a Catholic-sponsored hospital (SJH&MC is part of the Sisters of St. Joseph Health System), SJH&MC always held firmly its commitment to carrying out the mission of the Church; however, the hospital's adoption of the Social Accountability Budget: A Process for Planning and Reporting Community Services in a Time of Fiscal Constraint (SAB) served as a reminder to the administration.
SJH&MC made a commitment to pursue the principles outlined in the SAB, a document the Catholic Health Association developed in 1989 to help Catholic-sponsored healthcare organizations reaffirm their mission to serving those in need and protect their not-for-profit, tax-exempt status. When St. John's senior managers received a copy of the SAB, they immediately put in place a plan to implement the program.
Steps toward Social Accountability
The hospital began by forming a Social Accountability Steering Committee to oversee the project. Included on the committee were representatives from finance, social services, community education, mission effectiveness, hospital operations, planning, and the medical staff.
Taking Inventory The committee's first objective was to inventory charitable services and activities the hospital was currently providing. The inventory showed about half of the departments were participating in some type of community program for which they received little or no reimbursement. As Sr. Suzanne Zieske, SSJ, vice president for mission effectiveness, says, "We have always provided these types of services, but we never gave ourselves credit." The Finance Department estimated the costs of providing these services to be slightly more than $2 million (this number represents only the direct costs of the programs and does not include the amount of charity care provided).
Reviewing Mission and Policy The next step was to review the mission statement and the hospital's charity care policy. The committee was shocked to learn that the hospital did not, in fact, have a formal, written charity care policy in spite of the fact that it provides a large amount of uncompensated care annually. Consequently, the committee asked the Finance Department to develop a charity policy. Now available to patients, physicians, and employees, the policy describes how patients can obtain care even if they have no insurance or financial resources.
In addition, recognizing that all successful organizations are driven by a mission statement that reflects their purpose, the committee rewrote the mission statement. Although the changes were minor, the hospital's mission statement now includes a reference to serving those with special needs, especially the poor.
Involving Medical Staff The group also wanted to involve the medical staff in the process. A questionnaire was distributed to all medical staff members to determine their involvement in community service and their willingness to treat indigent patients. Of the 350 physicians who responded to the survey, more than 70 percent indicated they did some type of community service for which they received no compensation.
The responses to the questionnaire also indicated that most physicians felt patients faced few treatment barriers related to income, race, age, gender, or disability. The comments highlighted, however, that physicians were not familiar with the charity process or the fact that the hospital provided more than $14 million annually in uncompensated care. Consequently, the hospital implemented a communication plan to educate the medical staff about the charity care process and the goals of the SAB. The success of this campaign is currently being evaluated.
Assessing Community Needs Probably the steering committee's most important project was conducting a community needs assessment to determine whether the hospital was providing the programs and services the community needed.
Instead of surveying the community with questionnaires, the hospital decided to tap a knowledgeable community resource: the clergy. Three groups of clergy members representing local churches in the surrounding neighborhoods were invited to attend focus sessions on community needs. To avoid biased responses, participants were not told the sponsor's identity. They were asked to name the three most pressing needs in their congregations and offer possible solutions to those problems. They were also asked what they knew (and thought) about the current community services several local hospitals were offering.
Although the clergy represented very different congregations and neighborhoods, the results of the assessment generally applied to both the wealthy and the impoverished communities.
Overwhelmingly, the clergy identified the needs of the elderly as the number-one concern. They mentioned needs such as suitable, affordable housing; affordable healthcare; and transportation for medical care. The second most pressing concern was assisting the basic family unit, specifically through affordable counseling services addressing divorce, domestic abuse, stress, and all issues affecting youth.
The clergy expressed concern about the need to improve the quality of life on Detroit's east side by making neighborhoods and schools safer and keeping children interested in school and in their future. Other issues included teen pregnancy and the need for youth programs.
Big Order to Fill
With a laundry list of needs long enough to keep the committee busy for years — and to make any chief financial officer cringe — the group began the monstrous task of reviewing and prioritizing. The steering committee recognized that the hospital was obligated neither legally nor ethically to address all the community needs; however, members believed the hospital was obliged to take a leadership role and work with other organizations and community leaders in addressing the problems.
At this point the committee saw a need for a community benefit plan to lay out the identified needs of the community and document how the hospital planned to tackle each problem. The steering committee chairperson drafted one version of the community benefit plan and presented it to the executive management team for review and approval. Once the plan was approved, the hospital attempted to identify possible solutions to many of the problems facing the community, even if the hospital was not directly involved in the solution.
Needs and Solutions
Housing the Elderly
SJH&MC considered housing for the elderly outside the scope of the hospital's primary purpose; still, since the problem was so pressing, the hospital initiated discussions about the possibility of building an additional 144 apartments at its skilled nursing facility, which SJH&MC owns jointly with another local hospital. In addition, the hospital has appointed a director of government relations to serve as a liaison with municipal officials and state legislators in the hospital's service area. The goal is to establish ongoing communication regarding community needs such as senior housing.
Transport to and from Medical Care
Although the hospital recognized that it could not completely meet this need, it planned to upgrade its current transportation services. Free transportation is now provided for patients receiving physical therapy, radiation therapy, and renal dialysis. The hospital contracts with the Community Resource and Assistance Center, Inc., a not-for-profit organization providing nonemergent transportation, to provide transportation for those patients whom the hospital van cannot service. In addition, several hospital departments are authorized to issue cab and bus vouchers for patients who cannot afford to pay the fare.
Social Support for Seniors
Clearly seniors were in need of social support. The hospital lacked a coordinated program for seniors, so it hired a senior services coordinator. The hospital has initiated many projects, some as simple as clarifying signs on the hospital campus to eliminate confusion. The hospital is also considering the development of adult day care and the development of a case management system to coordinate utilization of services such as physician care, rehabilitation therapies, and pharmacy services.
Affordable, Accessible Healthcare For some time, SJH&MC has recognized the need for a primary care site for those unable to pay for basic services. Also, like many other large urban hospitals, SJH&MC's emergency room has become a topic of concern in the board room, in the hallways, and in the community. Because SJH&MC is a trauma center, it receives patients from throughout the metropolitan area. With the trauma cases come gangs and rowdy crowds, particularly during the evening. In addition, the employees, visitors, and patients must put up with overcrowding. The current emergency room was built to accommodate 45,000 annual patient visits. In 1992 it treated more than 63,000 patients.
To address these problems, SJH&MC initiated two major projects: a primary care clinic and a $6 million emergency room expansion. Opened in the summer of 1993 in a neighborhood that lacks adequate primary care, the St. John Detroit Health Clinic should become a viable alternative for many patients who currently seek treatment in the hospital emergency room. To date, the clinic has treated more than 300 patients. The hospital hopes to arrange for its family practice residents to also treat clinic patients, greatly increasing clinic hours. Emergency room renovations are scheduled to begin in the fall of 1994.
Schools and Neighborhoods Several SJH&MC employees participate in the Detroit COMPACT Program, formed to combat the rising school dropout rates and declining confidence in the Detroit Public Schools system. Teaming up with the city's Barbour Magnet Middle School, SJH&MC employees help students explore their interest in healthcare careers. The hospital financially supports student activities such as career days and health screening programs. SJH&MC employees also volunteer to work with the students, helping them develop self-esteem, which contributes to academic success. Two employee volunteers work with a group of Barbour students to publish an edition of the school newspaper each semester. The students complete every step of the process, from writing stories and taking photographs to typesetting and printing.
In 1992 St. John also joined the mission of Cornerstone Schools. Nearly two-thirds of the students at Cornerstone's three campuses come from underprivileged homes. The schools focus on Christ-centered, high-quality education and rely on corporate and community leaders to donate scholarship funds. St. John financially supports the schools and also participates in Partnership Days, where staff get to know one child and encourage him or her.
Meanwhile, the hospital made a new commitment to improve its surrounding neighborhoods. To show residents they were important to the hospital, SJH&MC recently launched its Minority and Community Vendor Task Force, which identifies areas in which the hospital could increase its use of minority and community businesses. So far, the hospital has increased its use of such vendors more than 100 percent over the previous year.
Family Services Another project SJH&MC sponsors is the Joy of Jesus Program, developed to positively influence urban youth, families, and the environment with Christ-centered programs that can be replicated. In 1990 the founder and president of Joy of Jesus, Rev. Eddie Edwards, was honored by former President George Bush as a "Points of Light" recipient for community services. Some of this ministry's major accomplishments in Detroit include rehabbing and providing housing for low-income families and establishing a block organization and neighborhood beautification project. These projects no doubt contributed to the 44 percent decrease in the crime rate in those neighborhoods. In addition, SJH&MC has provided free health lectures, vision and hearing screenings, and physical examinations to children in specific neighborhoods. In 1993 St. John helped sponsor a few of the 600 children who attended summer camp in Kingston, MI, as part of the Joy of Jesus program.
Community Health Historically, Detroit has had one of the highest infant mortality rates in the country and one of the highest incidences of heart disease. As part of the community benefit plan, SJH&MC participates in three programs targeting these problems:
- For several years SJH&MC has participated in the Infant Mortality Project, a program involving several Catholic healthcare systems that supports women and infants by promoting literacy and greater access to job placement services.
- In 1992 SJH&MC joined about 50 other hospitals nationwide in the National Heart Attack Risk Study to educate persons about the risk factors associated with heart disease and to help them make life-style changes to reduce their risk. To date, SJH&MC has enrolled about 5,000 participants in southeastern Michigan.
- More recently, SJH&MC teamed up with the Wayne County Health Department in the Breast and Cervical Cancer Screening Program to offer screening services to women who meet specified criteria, regardless of their ability to pay.
Smart Investments Clearly, insufficient reimbursement is the most common reason for hospitals' lack of community service; however, an outlay of time and energy can purchase a lot. For projects that require substantial financial commitments and clearly benefit more than the hospital, administrators should seek the support of other community organizations. Each community has its own set of problems and should involve many community resources in identifying the needs and setting the priorities.
A hospital's commitment to the community entails long-term strategic planning and ensuring that its goals are reflected in the community benefit plan. The board of trustees, the medical staff, the administration, the employees, and the community must understand why the hospital exists and what it plans to do. Unfortunately, in the next few years communities will continue to be plagued by problems of crime, lack of day care, an increasing elderly population, the need for youth development and education, and inadequate access to affordable healthcare. The good news is that by working with other community groups, hospitals have the opportunity to plan for the future and address the needs of today.
Ms. Brown is an associate administrator of professional services, St. John Hospital and Medical Center, Detroit.