Hospital-community networks help stretch meager resources
Hospital-community networks help stretch meager resources
Cooperation solves public health issues, fiscal woes
Hospitals are in trouble. Although one-third enjoy fiscal well-being, another third are merely scraping by, and the rest are failing, according to a report, "Health & Health Care 2010: The Forecast, the Challenge," by the Robert Wood Johnson Foundation of Princeton, NJ. (See information box at the end of this article.)
A potential solution for some of the financial troubles may lie in a challenge issued by Carolyn B. Lewis in her acceptance address as chair of the Chicago-based American Hospital Association’s (AHA) board of trustees. She urged hospitals to manage resources ethically and prudently, and warned that could require a shift from competition and expensive advertising toward collaborative solutions to local health problems.
To test the mechanics of such a shift, AHA’s affiliate, the Health Research and Educational Trust (HRET), began in 1994 to nurture models of cooperative partnerships, called Community Care Networks (CCNs). These groups are dedicated to communitywide health improvements. In more prosperous times, the dogged work required for successful coalition building might have discouraged most hospitals and local agencies. But many have learned that with today’s shrinking profit margins and legions of uninsured patients, survival depends on cooperation.
For hospitals, it’s a way to keep pace with the changed focus of medicine, from acute care to preventive and ambulatory care. For many communities, partnerships among hospitals and a cross-section of service agencies are the only viable means of delivering health services to indigent populations.
Health care providers have always known that the hospital addresses only a thin slice of the health continuum. Thus, one of the brightest promises of the CCN is a structure that enables providers and hospitals to move outside hospital walls to serve a wider slice of health needs. "People don’t go into health care to become rich. They go into it to im-prove people’s health, and this project is putting the emphasis where providers want it," says Francie Margolin, director of Community Health Programs for HRET.
The 49 CCNs consist of relationships among community organizations. The membership roster and goals are shaped either by local health needs or by the determination of several organizations to make better use of available resources. Most networks represent the spectrum of community life from health care providers, hospitals, and health departments to government agencies, school districts, and religious organizations. They exist in rural, urban, and suburban settings. Most were up and running before the CCN project was implemented. (For a thumbnail description of changes implemented through community health networks, see box, p. 99.)
Besides local funding, 25 of the CCNs received demonstration grants from a pool contributed by the W. K. Kellogg Foundation of Battle Creek, MI; the Duke Endowment in Charlotte, NC; the California Wellness Foundation in Woodland Hills, CA; the Robert Wood Johnson Foundation; and the U.S. Public Health Service.
The program embodies the AHA’s commitment to foster local reform of health care delivery and finance systems. AHA’s collaborators include the Catholic Health Association of the United States in St. Louis and VHA Inc. in Irving, TX. The CCN mission includes four objectives:
1. community health focus;
2. community accountability;
3. seamless continuum of care;
4. management within limited resources.
As you’ll see later, moving from concept to sustainable community-wide improvements in service delivery and health outcomes can take well over a decade. Phase 1 of the national demonstration involved coalition building and design of service delivery models. Phase 2, currently under way, involves measurement of community health outcomes through the year 2001.
Dramatic changes are already on record:
• Emergency room use by adults age 40-plus in a 12-county region around El Paso, TX, dropped 5% between 1996 and 1998.
• The percentage of low birth weight babies dropped from 4.2% to 1.7% of births in a single year, saving more than $99,000 in Vallejo, CA.
Margolin observes that the CCN project is more than a strategy to further the AHA’s mission to advance health for individuals and communities. She notes, "it brings people back to why they went into health care in the first place." (To learn how CCNs utilize and expand local resources, see "CCN case profile #1," above, and "CCN case profile #2," p. 101.)
Those who commit to delivering services through community networks soon find themselves knee deep in redefining the role of the hospital and its ambulatory clinics. Sometimes the payoffs come slowly — and sometimes they mean organizational survival. "A lot of us have looked at hospital care as primary service. But after we have participated in a partnership, we’ve learned to look at ourselves as partners to other community organizations who could build
prevention initiatives. This stretches hospital resources and doesn’t kill your bottom line because it saves write-offs down the road," says Pat Graham-Casey, executive director of the Cancer Consortium of El Paso (TX) Inc., recipient of a CCN demonstration grant.
The Cancer Consortium’s partnerships with private sector providers transformed services for indigent cancer patients. With a system of "flexible funding," providers receive at least some payment, in a timely fashion, for uninsured patients whose care used to be written off as nonreimbursed. The patients are treated at the more curable stages of cancer.
Sometimes partnerships can eke out support for expensive equipment or services that no single organization could handle. In rural areas, CCNs may help resolve the threat of closure of desperately needed hospitals or ambulatory care clinics.
No matter how substantial the gains, life in a coalition is not for the short-sighted or for the stingy. "The biggest issue is financial," notes Margolin. "Hospitals still have to provide their core services. When budgets are tight, preventive health is often the first thing to go — no margin, no mission." Paradoxically, the strongest hope for sustaining the mission of communitywide service could lie in the tussle of complex partnerships:
• Participation could require a restructuring of your service package. For example, a hospital might support the continued existence of an off-site clinic that duplicates primary care services because the clinic is accessible to the under-served or elderly. In the same vein, a group of hospitals might work with the public health department to devise an efficient method for screenings, immunizations, or sports physicals.
• Expenses of participation might include teaching staff how to relate to various ethnic groups, providing interpreters for non-English-speaking clients, or offering child care. Staff attendance at meetings and the related tasks of partnership building represent significant resource investments.
• Politically sensitive issues often require months of negotiation to resolve.
Although coalitions are cooperative by definition, this is not to say that CCN participants shun competition. Margolin describes two models by which they cooperate and compete:
1. Zones of collaboration and competition. Cooperative programs target a disadvantaged population or pre-natal care. Other services such as coronary artery bypass grafts are fair game for competition.
2. Collaboration among certain hospitals, while others choose not to participate. Some tertiary providers stay outside of partnerships but provide specialty services to partnership affiliates.
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