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BY: EILEEN BARSI, M.C.G.

Ms. Barsi is director, community benefit, Catholic Healthcare West, San Francisco.

As health care providers, the hospitals associated with Catholic Healthcare West (CHW), San Francisco, have long applied scientific and analytic rigor to their medical practices, in order to ensure the best possible outcomes for the patients who seek care from them. As a not-for-profit organization, CHW is also responsible for helping to improve the quality of life in the broader community. Yet the results of community benefit activities have been historically difficult to assess, in large part because of a lack of consensus concerning what constitutes effective programming. Because of its commitment to the general welfare of the communities it serves, CHW has been working with its 40 member hospitals in California, Arizona, and Nevada to apply the same level of scientific and analytic rigor to community benefit activities as is applied to clinical practices.

Through strategic, incremental steps, CHW has succeeded in bringing greater precision, effectiveness, and accountability to community benefit programming.

In the first step, taken in July 2002, CHW established a policy that called for a uniform measurement and improvement of community benefit work that would preserve the flexibility of each facility to respond to the needs of its particular community. The goals, set forth in CHW's Community Benefit Policy and its Standards for Mission Integration, were included as part of each hospital president's annual performance evaluation. For example, in the first year of this new approach, each president was urged to:

• Assess the competencies of the facility's current community benefit staff and determine its capacity for implementing CHW's Community Benefit Policy. Plan and budget for any necessary adjustments.
• Establish a baseline by assessing the hospital's current community benefit programs in a way that enables an evaluation of both their effectiveness and their relationship to the hospital's local health priorities.
• Develop a work plan that includes measurements of progress and a budget based on the findings from the above assessments.

In the initiative's second year, CHW facilities were asked to submit two community benefit goals that would be monitored for outcomes over the subsequent two years. The system's corporate office helped staff members at each facility determine the baseline for performance improvement, set realistic goals, establish measurable outcomes, and develop an effective intervention strategy for the health issue being addressed. Besides reporting the number of persons served, community benefit staff were to describe what would change for the community as a result of the program offered.

Three Successful Programs
Three programs represent successful examples of community benefit programs undertaken in this new approach.

St. Elizabeth Community Hospital, Red Bluff, CA
A review of emergency department (ED) use revealed that more than a third of the patients treated there had no primary care physician. Of the average 300 patients being seen in the ED every month, 120 (or 39 percent) were "unassigned."

In response, the hospital conducted a community needs and assets assessment to determine the reason for the high number of unassigned area residents and also to assess other health services being offered in the community. The assessment revealed a significant shortage of primary care physicians for both adults and children in Tehama County. St. Elizabeth's leaders concluded that improved access to primary and pediatric care services, specifically for those county residents who lacked a primary care provider, might result in a decrease in ED use on occasions that were not genuine emergencies. Such a solution would be good for both community residents and the hospital.

The facility launched an aggressive effort to tackle the problem. A rural hospital, St. Elizabeth applied for and was granted recognition as a Health Professional Shortage Area (HPSA), which resulted in increased reimbursement for its Medicaid patients.* The hospital then partnered with local physicians to recruit providers specializing in primary and pediatric care.

*The HPSA program is run by the Health Resources and Services Administration of the U.S. Department of Health and Human Services. For more information, see www.bhpr.hrsa.gov/shortage/.

Over the next two years, six new primary and pediatric physicians were recruited to Tehama County. And, as the result of improved access to primary care services in the community, the need for emergency care by this patient population diminished and the number of unassigned patients admitted to the ED dropped by 16 percent.

Saint Francis Memorial Hospital, San Francisco
In response to a need for more effective post-hospitalization care for seniors, this hospital collaborated in the Homecoming Service Program, a project involving three local organizations — San Francisco Senior Center, Little Brothers/Friends of the Elderly, Project Open Hand — as well as Saint Francis. The goal was to facilitate earlier discharge from the hospital by creating a safe and healthy home environment for isolated, frail, low-income seniors and to minimize the potential for costly readmissions.

The collaborating organizations understood that, for elderly people, addressing such basic post-hospitalization needs as housekeeping, grocery shopping, and meal preparation is critical. Seniors who are unable to take care of themselves, keep physician appointments, and navigate the health care and social service systems often feel so much stress that their health deteriorates as a result and they require readmission to a hospital. On the other hand, community-care management programs such as the Homecoming Service Program have been shown to reduce both hospital admissions and hospital costs by providing care management for elders who might otherwise go to the ED when their health fails.

Discharge planners at Saint Francis identify appropriate frail, low-income patients and refer them to the program. The Senior Center then assesses patient needs and coordinates services, including emergency home care and case management. Project Open Hand provides those who need them with groceries. Little Brothers/Friends of the Elderly provide escorts to medical appointments. The combination of these services ensures a smooth transition from hospitalization to home, which has a positive impact on patients' recovery.

In its first year, the Homecoming Service Program assisted 43 Saint Francis patients. They received an average 67 hours of direct service a month to help them maintain safe and independent living situations following their hospital discharges. If it hadn't been for the program, these patients would have required an extended hospital stay, because they would not have been able to care for themselves at home. And by facilitating follow-up treatment with physicians and therapists, the program also made readmissions unnecessary. The Homecoming Service Program has been cost-effective, saving at least one day of hospitalization per patient. And because its services are provided by a caring community, the elderly involved benefit most of all.

As a result of the program's success, this collaborative approach to assisting frail elders is being considered for adoption in 2006 by all hospitals in the city and county of San Francisco.

California Hospital Medical Center, Los Angeles
This facility has adopted a Chronic Disease Self-Management Program (CDSMP) to improve the health status of (and reduce health care use among) patients with chronic disease.*

*The Chronic Disease Self-Management Program was designed by K. R. Lorig, DrPH, and her colleagues at the Stanford Patient Education Research Center. For more information, go to http://patienteducation.stanford.edu/programs.cdsmp.html.

The CDSMP accomplishes its goal by helping patients effectively manage their medical care and by addressing the fear and depression that often accompany chronic disease. CDSMPs show patients how to manage their diseases and enhance their life skills; by doing that, they instill confidence in patients as well. Self-management also empowers patients to more fully collaborate with their physicians and successfully navigate the health care system.

Because chronic disease has such a great impact on health status and health care expenditures, society has increasingly become interested in self-management programs that emphasize the patient's central role in managing his or her illness. The CDSMP is a well-tested, cost-effective, six-week series of small group sessions attended by from eight to 20 people with various chronic conditions. Family members are also encouraged to attend. Each session lasts two and a half hours. In them, a pair of instructors (at least one of whom has a chronic disease) teach from a highly structured manual. The program is based on self-efficacy theory and emphasizes problem solving, decision making, and confidence building. Self-management education complements traditional patient education in supporting patients to achieve the best quality of life possible with their chronic conditions.

Prior to the coming of self-management programs, patients diagnosed with chronic illnesses — such as cancer or diabetes — were simply provided by their physicians with medication, diets, or exercise recommendations to relieve symptoms and help them manage the disease. Patients were then left to integrate those recommendations into their lives as best they could, while coping with the emotional impact of their diagnoses. Self-management education supplements the traditional patient education provided by physicians with effective problem-solving skills.Â

In establishing its self-management program, California Hospital Medical Center reached out to the community's churches, schools, senior centers, and community clinics, inviting people living with chronic illnesses to participate in the program. About 1,000 people with heart disease, lung disease, stroke, or arthritis participated in a randomized, controlled trial of the CDSMP and were followed for three years after completing the program.

When compared with people with similar problems who did not participate in the program, those who did demonstrated significant improvements in exercise, cognitive symptom management, communication with physicians, self-reported general health, health distress, fatigue, disability, and social/role activities limitations. They also spent fewer days in the hospital and had fewer outpatient visits and hospitalizations. In fact, they showed a cost-to-savings ratio of approximately 1 to 10. In many cases, this relatively good health lasted for as long as three years.

Goals Are Achievable
The programs described here, as well as many others like them, show that health care organizations can successfully reach more stringent, rigorous community benefit goals by improving their planning and monitoring strategies. At the end of the third year of CHW's effort to apply greater scientific rigor to community benefit programming, more than 85 percent of its hospitals met or exceeded their stated goals. The improvement program's success can be directly attributed to focused efforts to ensure that quality is CHW's hallmark.

GOALS, STRATEGIES, AND OBJECTIVES

In trying to make its community benefit programs more effective, CHW discovered that one barrier was a lack of understanding of goals, strategies, and objectives. The system provided staff members with the following definitions and examples:

• A goal is a future event toward which a committed endeavor is directed. Goals should have numeric targets. Program goals should be simple and concise and include two basic components: who will be affected, and what will change as a result of the program.

  Example: Decrease the number of visits to the emergency department by elementary school-age children for asthma-related conditions by 10 percent.

• Strategies are the steps to be taken to achieve goals. They are more specific and consist of steps used to reach the goals.

  Examples:

  • Conduct three independent asthma-education classes with school nurses and/or teachers.
  • Share class information and schedules with local pediatricians.
  • Conduct 12 (monthly) education classes with parents and children identified by school nurses or teachers and local pediatricians.
  • Conduct a "Breathe Easy" health fair or run a hospital-sponsored booth offering information about asthma (and classes offered in managing it) at this year's 4th of July, Memorial Day, and Labor Day events in the community.
• The objectives of the strategies are aimed at changes in health status, social benefits, or quality of life. They represent incremental steps taken to reach the goal. Assuming the right strategies and objectives have been chosen, the program goal will be achieved. Objectives are commonly written in terms of reduction of risk, physiologic indicators, signs and symptoms, morbidity, disability, mortality, or quality of life measures. At a minimum, an objective should include the following elements: a stated outcome (what), conditions under which the outcome will be observed (when), a criterion for considering the outcome has been achieved (how much), and a description of the target population (who).*
  
  Example: Within two years, improved management of asthma in elementary school- age children will be demonstrated by a 10 percent (30 children) decrease in the number of emergency department visits by this patient population. Baseline utilization is 300.

  *James F. McKenzie and Jan L. Smeltzer, Planning, Implementing, and Evaluating Health Promotion Programs, Allyn and Bacon, Boston, 2001, p. 128.

ABOUT CATHOLIC HEALTHCARE WEST

CHW, headquartered in San Francisco, is a system of 40 hospitals and medical centers in California, Arizona, and Nevada. Founded in 1986, it is the eighth largest hospital system in the nation and the largest not-for-profit provider in California. CHW is committed to delivering compassionate, high-quality, affordable health care services with special attention to the poor and underserved.

CHW's network of more than 7,500 physicians and approximately 40,000 employees provides health care services to more than 4,000,000 people annually. In 2005, CHW provided $623 million in charity care and unsponsored community benefit. For more information, please visit the system's website at www.chwHEALTH.org.