BY: MICHAEL BILTON, MA
Mr. Bilton is director, Community Health Programs, Health Research and Educational
Trust, Chicago, and executive director of the trust's Association for Community
Health Improvement.
Everybody Wins When Hospitals Collaborate with Others to Serve Their Communities
SUMMARY Community benefit is an opportunity for hospitals and health systems to affirm
their community-focused missions and to ensure implementation of those missions
in their organizations. There are four key themes of community benefit: community
health improvement, underserved populations and unmet needs, collaboration outside
the hospital, and coordination and strategic management inside the hospital.
Together, these constitute a broader perspective, one in which community benefit
is of strategic value to both the community and the hospital, and serves as
a departure point for some of the hospital's most fruitful contributions
to health and well-being. The community benefit function can be organized and managed to achieve specific
priorities with measurable objectives, just like any other hospital activity.
There are innumerable examples of creative and successful models for community
benefit programs that incorporate the principles of community health improvement,
unmet needs, collaboration externally, and strategic management internally.
These are models that hospital leaders should create and pursue, because they
demonstrate the value of a broad view of community benefit that fully realizes
the potential of hospitals' charitable purpose. |
There is much discussion these days of not-for-profit hospitals' community
benefit roles and functions, and the conversations taking place have several
dimensions—consistent with the various perspectives people bring to the
subject.
Conversations with a chief financial officer (CFO), a lawyer, and a hospital
community benefit director are likely to yield very different, if ultimately
compatible, understandings of the concept. A CFO may think of community benefit
as a dollar figure tallied from a wide range of hospital activities, including
charity care. A lawyer may think of community benefit in terms of charitable
purpose and corporate social responsibility. Meanwhile, a community benefit
director may think of health promotion and disease prevention programs, access
to care initiatives, and a web of community relationships. These are, of course,
different views of the same proverbial "elephant," based on the differing
roles of the people involved.
As for the financial and legal perspectives, the Internal Revenue Service's
"community benefit standard" talks about conditions under which a
health care organization is said to be operating "to promote health in
a way that accomplishes a charitable purpose" and "benefits the community
as a whole."1 This is a foundational element of the not-for-profit health
care sector, including hospitals and health care systems.
Community benefit is, on one level, an enumeration and accounting exercise
in which activities can be tallied and dollars totaled for inclusion in voluntary
reports to the community (or, in some states, mandated reports to public agencies).
There are a number of excellent guides and tools to assist hospitals and health
systems with the mechanics of community benefit. However, viewing community
benefit exclusively through the counting and reporting lens risks fostering
an inwardly focused orientation and a compliance mindset.
Such a perspective is a necessary starting point for understanding community
benefit programs, but it may inhibit the conceptualization and achievement of
greater value for both communities and the hospitals that serve them. In this
article, I intend to identify four key components of community benefit that
together constitute a broader perspective, one in which community benefit is
of strategic value to the community and the hospital, and serves as a departure
point for some of the hospital's most fruitful contributions to health
and well-being.
A Broader View
A good place to begin discussing a broader view of community benefit is
with a statement that most Health Progress readers will recognize. The
Catholic Health Association (CHA) and VHA, Inc., define community benefit as
"a planned, managed, organized and measured approach to a health care organization's
participation in meeting identified community health needs. It implies collaboration
with a ‘community' to ‘benefit' its residents—particularly
the poor, minorities and other underserved groups—by improving health status
and quality of life."2
A complementary description of community benefit from the Health Research and
Educational Trust's Association for Community Health Improvement (ACHI)
states, in part, that community benefit activities:
- Relate to accessibility, quality, and cost of the community's health
system, as well as to community health and well being
- Pay specific attention to community collaboration, community capacity building,
and people in the community with unmet health needs
- Build on, and work to expand and align, an organization's ongoing health
improvement and community service initiatives with the organization's
strategic plan and budget3
Both statements contain four important themes that serve as anchors to the
understanding of community benefit's positive effects on communities and
institutions and its role in a larger health system that includes hospitals,
but does not rely exclusively on them:
- Community health improvement
- Underserved populations and unmet needs
- Collaboration outside the hospital
- Coordination and strategic management inside the hospital
But before considering the meaning of each theme and the themes' relationships
to each other, I want to take a brief look at some visible manifestations of
community benefit in hospitals' programs and in the job titles of people
responsible for the programs.
Programs and Job Titles
Community benefit is an opportunity for hospitals and health systems to
affirm their community-focused missions and to ensure implementation of those
missions in their organizations. One does not need to look very far to find
clues to hospitals' practice of community benefit, even without examining
tools, procedures, and case studies.
First, voluntary, not-for-profit hospitals include community benefit and community
service firmly in their missions. In the most recent annual hospital survey
conducted by the American Hospital Association's Health Forum, 97 percent
of voluntary, not-for-profit respondents report that their "mission statement[s]
include a focus on community benefit."4 This should surprise no one. Given
the origin and evolution of such facilities in the United States—and especially
faith-based ones—the charitable purpose of such hospitals has been present
from their earliest days.
Perhaps more importantly, the vast majority of hospitals in the survey reported
having plans and resources in place that help them carry out their community
benefit-oriented mission. Specifically, 93 percent of hospitals report having
resources for their community benefit activities, and 88 percent have a "long-term
plan for improving the health of (the) community"5 (see Box).
Another quick, albeit informal, way to gain some insight into hospitals' views
on and practice of community benefit is to take a look at the job titles of
people with community benefit functions. Ask for a list of hospital community
benefit directors, and you will likely get a varied list (see Box).
Apart from the variety of these job titles, what is interesting about them is
how closely they reflect the four key community benefit themes extracted from
the CHA/VHA and ACHI community benefit descriptions. Community health is the
dominant theme among these titles, and one could make a case that the titles
that include the words "mission" and "accountability" represent
a commitment to the underserved and people with unmet health needs. Collaboration
with other organizations and the community is explicit in the words "outreach,"
"healthier communities," and "community partnership." And
internal coordination and strategic management is present in the titles that
include the words "integration," "public affairs," and "accountability."
Four Community Benefit Themes
Now let's take a closer look at the four vital community benefit themes
I mentioned earlier.
Community Health Improvement Among some practitioners in the field,
there is such a strong identification of "community health" with "community
benefit" that the terms sometimes seem nearly interchangeable. After all,
what is the community benefit goal of a health care organization if not better
health and health services?
Community benefit, viewed through the community health improvement lens, is
often defined broadly to include physical, mental, emotional, and spiritual
health. It also can encompass education, economic development, and social programs
that strengthen a community's capacity to be healthy. The term also frequently
implies preventive action. Even in the case of charity care, community benefit
is arguably about health improvement. Charity care that is provided in conjunction
with community benefit minimizes or avoids health risks both to the individual
and the community as a whole.
On the other hand, not all community health improvement activities are community
benefits. The primary distinguishing factor is likely to be found in the nature
of the need.
Underserved Populations and Unmet Needs A focus on underserved populations
and unmet health needs is a central theme running through the broad notion of
community benefit. This is where mission statements that contain phrases referring
to "all members of our community" come into play, because doing so
may require special effort, sensitivity, or competence to reach and effectively
serve those who have the needs.
These special populations have no common characteristics. Depending on the
community, unmet needs may exist among people with specific illnesses, or among
those in particular economic segments, or those in particular job classifications.
There may be ethnic or linguistic markers for underserved populations, in certain
instances, and purely geographic criteria in others. Commuity needs and assets
assessments frequently serve as guiding lights to help ensure that community
benefit programs are indeed designed to include those with the greatest needs.
Collaboration Outside the Hospital If we think of community benefit
as unique to and purely in terms of hospitals, we may be more apt to organize
community benefit departments—and their plans and goals—without linkages
to partners outside the hospital who share similar missions and common goals.
While community benefit terminology may be narrowly associated with not-for-profit
hospitals and health care systems, the fact is that hospitals' colleagues
in community health centers, public health departments, community organizations,
and others with a stake in the health of the community all have responsibilities
to the communities they serve—communities that are often the same as those
served by the hospital.
We know that many health issues involving hospitals require engagement with
the community. Among such issues are:
- Access to care for the uninsured and for isolated populations
- Chronic disease prevention and management
- Funding gaps for specific services or populations
- Shifting roles among hospitals and public health departments
None of these is the exclusive domain of the hospital. Each has the potential
to be better managed by a collaborative partnership that includes the
hospital.
Hospitals do not have to go it alone. Indeed, they need to work with organizational
and community partners to get beyond the "language barriers" inherent
in the jargon of each sector. Doing so will better enable hospitals to utilize
their unique skills—while benefiting from their partners' abilities—to
more effectively address the health improvement goals they have in common. Hospitals'
collaboration with other service providers (for example, public health agencies
and free clinics) can yield a continuum of care for vulnerable populations.
Their collaboration with the places where people gather (for example, schools,
workplaces, churches, and parks) can facilitate reaching many more people efficiently
and effectively.
Coordination and Strategic Management Inside the Hospital This community
benefit theme may be the most important, from a hospital's operational
perspective. This is where the themes of community health, unmet needs, and
collaboration can, if linked astutely, pay off for the community and the hospital.
The community benefit function can be organized and managed to achieve specific
priorities with measurable objectives, just like any other hospital activity.
A hospital need not engage in unrelated, stand-alone community programs when
it can link an assessment of community health improvement opportunities with
organizational strategic priorities and the coordination of relevant hospital
departments.6 Nearly every community health issue has some implication for the
patient, the hospital, and other community stakeholders. Finding creative solutions
that engage and benefit all three is the ultimate goal of community benefit
in this broad view.
For example, when an uninsured child is brought repeatedly to the Emergency
Department with asthma, the situation is not optimal for anyone, the child least
of all. Finding ways to help kids and their parents better manage the asthma,
while also working to connect them with appropriate primary care and secure
insurance coverage, keeps children healthier, their parents and teachers more
productive, and the Emergency Department better able to serve people with nonpreventable
illnesses and injuries. Schools, parks, and recreation departments often can
be enlisted to share the work by playing a role in education or disease management,
because children's asthma affects them, too. With collaboration like this,
everyone wins.
Models to Be Pursued
There are myriad other examples of creative and successful models for community
benefit programs that incorporate the principles of community health improvement,
unmet needs, collaboration externally, and strategic management internally.
These are models that hospital leaders should create and pursue, because they
demonstrate the value of a broad view of community benefit that fully realizes
the potential of hospitals' charitable purpose.
The author expresses warm appreciation to his mentors on the Association
for Community Health Improvement's Community Benefit Advisory Committee
for crafting the Community Benefit Description and, more importantly, for helping
to illuminate the community benefit field for him and many others.
NOTES
- Janet E. Gitterman and Marvin Friedlander, Health Care Provider Reference
Guide, Internal Revenue Service, Washington, DC, 2004, p. 9, available
at www.irs.gov/pub/irs-tege/eotopicc04.pdf.
- Catholic Health Association, VHA, Inc., and Lyon Software, Community
Benefit Reporting: Guidelines and Standard Definitions for the Community Benefit
Inventory for Social Accountability, St. Louis, 2005, p. 7, available
at www.chausa.org/sab/commbenguidelines.pdf.
- Association for Community Health Improvement, "Community Benefit Description,"
Chicago, available at www.communityhlth.org/communityhlth/files/files_intgrps/CB_Description.pdf.
- Health Forum, 2003 AHA Annual Survey Database, American Hospital
Association, Chicago, 2003.
- Health Forum.
- Alice Yoder, "Improving Community Health Initiatives," Health
Forum Journal, vol. 45, no. 6, 2002, pp. 18-23.
Sample Titles of Hospital and System Positions
with Community Benefit Responsibilities
- Director, community benefit
- Director, community benefit/outreach
- System manager, community benefits
- Community benefit outreach manager
- Vice president, mission integration
- Vice president, mission services
- Vice president, mission and community health
- System director, community ministry advocacy
- Vice president, community health
- Vice president, community health and public policy
- Executive director, community health promotion
- Director, community health
- Director, community health integration
- Director, community health and wellness
- Vice president, community services
- Vice president, community outreach
- Vice president, hospital and community development
- Director, community outreach
- Associate vice president, government and community affairs
- Director, government and public affairs
- Director, marketing and public relations
- Health and accountability specialist
- Social accountability analyst
- Manager, healthier communities
- Manager, community partnership
Source: Association for Community
Health Improvement, May 2005
| Hospitals' Community Orientation |
| Survey Question | Percentage of "Yes" Responses |
| Does this hospital's mission statement include a focus on
community benefit? | 97% |
| Does the hospital have a long-term plan for improving the
health of its community? | 88% |
| Does the hospital have resources for its community benefit
activities? | 93% |
| Does the hospital work with other providers, public agencies
or community representatives to conduct a health status assessment of
the community? | 88% |
| Does your hospital use health status indicators to design
new services or modify existing services? | 88% |
| Does your hospital work with other local providers, public
agencies, or community representatives to develop a written assessment
of the appropriate capacity for health services in the community? | 79% |
| If yes, has the hospital used the assessment to identify
unmet health needs, excess capacity, or duplicative services in the community? | 81% |
Source: 2003 AHA Annual Survey
Database, Health Forum, an affiliate of the American Hospital Association.