BY: TRACY NEARY
Mark Pernice
In Billings, Montana, an urban center of the frontier West, improving the health of those who live there lies not just in health care delivery, but in addressing complex social conditions that have an impact on health. The ability to do so lies in building relationships with people and organizations across multiple sectors of the community.
Recent census figures peg the population of Billings at slightly above 100,000. In 1897, when Sr. Theodora McDonald and Sr. Antoinette Ireton, both Sisters of Charity of Leavenworth, made their first visit, they found a frontier and railroad town of 3,000 that had seen its share of shootings, fights, suicides, murders, despondency and despair. Billings badly needed a hospital. Henry Chapple, MD, the town's doctor and mayor, teamed up with Fr. Clarence Van Clarenbeck, the local Catholic priest, to persuade the Sisters of Charity of Leavenworth to consider opening one there.
The religious community responded to the call by forming relationships with doctors, businessmen, government officials and clergy for funding and support. St. Vincent Healthcare opened in 1899 in Billings, and Chapple, an Episcopalian, was its first physician. He and the sisters served God in their own ways, and they seemed to have the idea everyone was working under the same management, the doctor was said to remark.
Reaching across faiths, backgrounds, business interests and politics to support community health is part of St. Vincent's history and the key to its future. Rooted in sobering health statistics and the call to serve is the desire to make transformational improvements in the community and to navigate the constant tension between where the health care ministry wants to be and the capacity to get there.
In Yellowstone County, where Billings is located, 12 percent of the population lives below 100 percent of the federal poverty guidelines. Of all Yellowstone County residents, 7 out of 10 are overweight, and 1 in 4 is obese.
Three different reservations are in close proximity, and although American Indians make up just under 5 percent of the county population, they have disproportionately high unmet health needs, including diabetes.
Against that backdrop, the major health providers in the Billings area — St. Vincent Healthcare, Billings Clinic (a similarly sized, tertiary-care hospital) and RiverStone Health (the Yellowstone City-County Health Department and federally qualified health center) signed an innovative collaboration agreement in 2001, calling themselves "the Alliance."
Since that time, the trio has moved toward a model of collective impact on community health in Billings. The individual visions may not perfectly match and strategies sometimes may be competitive, but many parts must come together on common ground if members of the Alliance and other partners are to make the sweeping social change necessary to truly improve the health of the area's population.
THE ALLIANCE
In Billings, health care operates in a highly competitive marketplace where the daily headlines and newspaper advertisements demonstrate the battle for market share. Still, "coopetition" among rivals is alive and well. It might be rooted in the interdependence of frontier beginnings, but it is formalized in the Alliance memorandum of agreement that acknowledges missions in close alignment and in a shared vision. "Together we improve the health of our community," the agreement states, "especially for those who are underserved and most vulnerable, in ways that surpass our individual capacity."
The agreement calls for a formal process to assess and plan short- and long-term collaborative opportunities to improve community health, including mental health and substance abuse. It suggests co-location of staff and services in order to increase access to care, shared recruitment and training of practitioners, establishment of new facilities, shared case management and joint education and outreach.
In the winter 2011 issue of the Stanford Social Innovation Review, authors John Kania and Mark Kramer introduced what they named the collective impact framework. The framework suggests five elements that need to be in place in order for successful change to happen amid complex social conditions: a common agenda, shared measurement, mutually reinforcing activities, continuous communication and backbone support.
Though it predates the description, the model created in Billings' Yellowstone County clearly fits that framework.
YELLOWSTONE COUNTY MODEL
Billings' first joint community health needs assessment was conducted in 1994 by St. Vincent, Billings Clinic, the local university and United Way. When access to prescription medication emerged as a gap, collective work began to establish a medication assistance program that helped patients navigate the dozens of different charity applications pharmaceutical manufacturers offered. The hospitals embedded medication assistants in their own facilities and committed to sponsoring assistants at RiverStone Health, the local FQHC. The program quickly grew and now secures millions of dollars' worth of medications for hundreds of patients each year.
This early success set the stage for ongoing needs assessment and action-planning work.
In 2006, the joint community health needs assessment showed health gaps tied to multiple chronic conditions linked to diet and activity patterns. People affected by health disparities more frequently live in environments with inadequate access to affordable, nutritious food or safe places to play and be physically active. The Alliance members — St. Vincent, Billings Clinic and RiverStone Health — agreed to a shared prevention approach to target improvements in physical activity and nutrition.
The needs assessment also showed significant health disparities based on income. The Alliance agreed to focus on policy, system and environmental change strategies in order to better target disparities and to reach more people in a more financially sustainable way.
The Alliance members created a joint community health improvement plan (CHIP) intended to serve as a framework for a community that is healthy by design, that is, to intentionally influence the environment in which people live, work, play and pray such that positive health effects are enhanced and negative health effects are mitigated. The CHIP incorporates a 20-year vision that has remained reasonably stable over the last 10 years and through two subsequent CHNAs. With each cycle of assessment, Alliance members and community partners help design the survey, participate in focus groups, review results, establish priorities, design intervention strategies and work the yearly operations plans. Today, 28 Billings organizations and about 96 individuals are actively engaged in this work.
In addition to goals tied to access to care and mental health, the CHIP lays out 3-year, measurable objectives toward the goal of healthy weight status. These objectives are intentionally tied to federal "Healthy People" goals, state goals, or the U.S. Surgeon General's National Prevention Strategies. Overarching strategies are developed in alignment with Montana's state health improvement plan. Tactics are included in yearly operations plans at the community level and in operations plans at both hospitals and the public health department.
During the last 10 years, the Alliance's biggest accomplishments to support healthy weight have been in the addition of a health section to the city/county growth policy, establishing a gardener's market in a low-income neighborhood on the edge of a food desert and passing a "complete streets" policy for Billings. Each of these accomplishments required a clear objective, multisector stakeholder engagement, and commitment from hospital leaders to invest time in research, planning, relationship building, and direct advocacy.
"Complete streets" are roadways built for all users, including pedestrians and bicyclists. The coalition recognized the need for a complete streets policy to increase safety and overcome a major barrier to outdoor activity, especially in low-income neighborhoods. Therefore, members rallied, combined resources and developed a "complete streets" resolution that the city council passed unanimously in August 2011. The coalition currently is developing a benchmark report to measure policy implementation progress and make sure healthy changes continue.
ALLIANCE STRATEGIES
Before Body Mass Index screening and follow- up were required for patient-centered medical home certification, a team of providers from Alliance organizations established shared healthy weight plans for adults and children. The plans documented weight, offered choices for physical activity and suggested nutrition improvements to guide patients to select their own behavior modification that providers could acknowledge and support. Training in motivational interviewing — provided through shared grant dollars —helped get providers more comfortable with language to engage patients in what is often perceived as a difficult conversation. The training also helped providers understand that looking past the label "noncompliant" often reveals a patient who is struggling to understand what to do or how to do it. Work in the coming year will build on that foundation and focus on helping providers identify how adverse childhood experiences impact patients. This allows the community to build trauma-informed systems of care.
The Alliance adopted a community health message, "5-2-1-0," encouraging people to eat 5 servings of fruits and vegetables, have no more than 2 hours of screen time, engage in one hour of physical activity and consume no sugar-sweetened beverages every day. The message is on billboards, posters in the schools and workplaces, included on healthy weight plans in the offices of primary care providers, and printed on T-shirts, water bottles and stickers.
The message is reinforced on television and movie theater screens, on the radio and through social media. One current gender-tailored campaign built on the 5-2-1-0 message uses images of moms taking walks with their kids and reminding them that being active doesn't mean investing money and time in joining a gym — the health benefits of being active accumulate in small changes made to increase activity in day-to-day moments such as cleaning the house or giving care to others.
The Alliance has not completely abandoned programmatic interventions. Evidence-based chronic disease prevention and management still are core community benefit programs, but Alliance partners continue to move toward better networking of their individual, hospital-branded programs so everyone in the community has access to programs that meet their needs, regardless of whose logo appears on the wall.
The Alliance partners also give special attention to encouraging healthier environments in the community by offering to help with special-event planning and giving support and recognition for thoughtful decision-making about food, physical activity, safety, wellness and environmental stewardship for special events. So, for example, the standard hot dog or hamburger menu at community events may be swapped for low-fat chicken wraps with a side of veggies, and water stations replace soda — minimizing both empty calories and plastic bottle waste.
The Alliance is in the first of a three-year demonstration project with the local economic development authority, working with a handful of small- to medium-sized businesses to measure health improvement and economic impact from making policy, system and environmental changes to the workplace. Technical assistants (TAs), including staff from the Alliance organizations and community partners, conduct baseline environmental assessments using evidence-based tools, and they provide support to worksites in making make no- or low-cost changes.
Interventions like promoting use of stairs, offering appropriate space to breast-feeding moms, healthier catering options and keeping refrigerators working and clean are relatively simple projects with health benefits. However offering health-risk assessments and biometric screenings may be more costly to the employer — and they move into competitive territory. Because each hospital has business strategy tied to working with employers, TAs are coached to offer all options to the businesses they serve when the intervention strategy may fall into the competitive space.
The project has brought the coalition to its most competitive space so far, but the vision of making the healthy choice the easy choice at work is a powerful motivator to keep pushing forward.
COMMUNICATION AND FUNDING
With its broad agenda and diverse stakeholder group, the Alliance has found communication to be a top challenge. Five year ago, the group's primary strategy rested on sporadic emails and monthly face-to-face coalition meetings. When Alliance partners agreed to commit funds necessary for website development, communication improved dramatically. The website, healthybydesignyellowstone.org, is home to needs assessment and action plans, history of the work and practical tools to support healthy environments for worksites, teachers, health care providers and the broader community. Six-month progress reports outline specific activities with timelines, outcomes, responsible teams or individuals and progress to date tied to each CHIP strategy.
Leaders remain in close communication as well, with quarterly face-to-face meetings for Alliance partner CEOs and time set aside every other week for the next layer of leadership team members to work with the jointly funded community health improvement coordinator. The leadership team navigates the constant stream of barriers to making the coalition work at the appropriate pace to achieve results.
A patchwork of cash and in-kind time investments funds the work, mixed with grant support and, most recently, a small amount of for-profit business investment. In-kind time by hospital community benefit staff members and leadership team members has been essential when there were no grants and no dedicated coalition staff. Now, the hospitals and health department have funded the website and the hiring of dedicated coalition staff.
Grant funds have propelled project-specific work, including the development and dissemination of the "5-2-1-0" community health message, training for health impact assessments, community education supports for "complete streets," and training and tool development to support providers in engaging patients regarding healthy weight. Efforts have focused on securing capacity building grants, rather than programmatic grants to stay aligned with the Alliance members' desire for sustainable change.
Because the coalition is not a 501(c)(3), foundations of the Alliance institutions all look for grant opportunities and work together to submit applications. The process means negotiating everything — from who will be the official applicant to detailing deliverables and discerning who will receive what funds for what scope of work. In the last 10 years, grants to the Alliance institutions to support coalition work has neared $3 million. Funders have moved away from grants to individual institutions for programmatic health interventions to investments in multi-sector collaboration.
STUMBLING BLOCKS
- In the immediacy of reducing 30-day readmissions now, health care administrators may not universally embrace community benefit investments focused on 20-year plans to reduce obesity rates.
- It may be a change of both practice and mindset to build and follow a true community-based plan as opposed to one that is hospital-based and hospital-focused.
- Giving up organizational brand identity for coalition work can challenge competitive ideology and can mean less support from marketing teams focused on documenting return on investment.
- Changing faces in leadership means efforts to build trusting relationships must always be part of the agenda.
THE FUTURE
Based, as it is, in a strong partnership between public health and hospitals, the Yellowstone County model is positioned to achieve measurable, population-level, community-level health improvement.
While rates of overweight and obesity have not shown a significant drop, comparison of the past two community health assessments found a 15 percent increase in residents meeting physical activity recommendations and a 24 percent increase in residents eating fruits and vegetables. Further, Billings now has a physical environment that actively promotes health, providing benefits for years to come. Alliance members believe they will see a reduction in the rates of heart disease, diabetes and cancer in the community as they work to move the population to a healthy weight.
To improve population health, Alliance members hold no illusion of going it alone. Instead, they rely on an interdependence with our community partners, confident in knowing, as Dr. Chapple described it so long ago, that everyone is working under the same management.
TRACY NEARY is director of mission outreach and community benefit, St. Vincent Healthcare, Billings, Montana.