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Collaboration Among Missouri Nonprofit Hospitals and LocalHealthDepartments:ContentAnalysisofCommunity Health Needs Assessments Kate E. Beatty, PhD, MPH, Kristin D. Wilson, PhD, MHA, Amanda Ciecior, MPH, and Lisa Stringer, MPH, MSW
The Patient Protection and Affordable Care Act (ACA)1 and the launch of the voluntary national public health department accreditation program,2 emphasize policies that encourage greater collaboration between health care and public health. Existing silos of communication and lack of cooperation between public health and other sectors of health are well documented.3,4 Experts have recommended the removal of these barriers between health care and public health to create improved population health.5 The process of identifying community needs, an essential part of the ACA and the voluntary national public health department accreditation program, has the potential to reduce barriers to communication and collaboration between hospitals and local health departments (LHDs).6 A 2012 Institute of Medicine (IOM) report identified several advantages for LHDs and local health centers (e.g., hospitals) to share resources while fulfilling new government mandates, including cost-savings potential for communities, better coordination of care, and positive environmental changes.5 Per the ACA, nonprofit hospitals must perform a community health needs assessment (CHNA) every 3 years.1 The Internal Revenue Service published subsequent regulations in July 2011 that provided hospitals guidance on conducting the CHNAs.7,8 According to the legislation, the CHNA is intended to be transparent, available to the community,6,9 and includes individuals with expertise in public health to help during the CHNA process.1,10 Any noncompliant hospital may incur a $50 000 excise tax liability as outlined in the legislation.11 In addition to the CHNA, the ACA requires nonprofit hospitals to design an implementation plan, including strategies that address identified community needs from the CHNA.1,7
Objectives. We identified the levels of joint action that led to collaboration between hospitals and local health departments (LHDs) using the hospital’s community health needs assessments (CHNAs). Methods. In 2014, we conducted a content analysis of Missouri nonprofit hospitals (n = 34) CHNAs, and identified hospitals based on previously reported collaboration with LHDs. We coded the content according to the level of joint action. A comparison sample (n = 50) of Missouri nonprofit hospitals provided the basic comparative information on hospital characteristics. Results. Among the hospitals identified by LHDs, 20.6% were “networking,” 20.6% were “coordinating,” 38.2% were “cooperating,” and 2.9% were “collaborating.” Almost 18% of study hospitals had no identifiable level of joint action with LHDs based on their CHNAs. In addition, comparison hospitals were more often part of a larger system (74%) compared with study hospitals (52.9%). Conclusions. The results of our study helped develop a better understanding of levels of joint action from a hospital perspective. Our results might assist hospitals and LHDs in making more informed decisions about efficient deployment of resources for assessment processes and implementation plans. (Am J Public Health. 2015;105: S337–S344. doi:10.2105/AJPH.2014.302488)
LHDs may voluntarily seek accreditation through the Public Health Accreditation Board’s (PHAB) National Public Health Accreditation program. PHAB was incorporated in 2007, with the national public health accreditation program launched in September 2011. Many stakeholders were involved in creating, as well as in studying the desirability and feasibility of a national accreditation program. 2,12,13 In seeking accreditation, LHDs are required to conduct a community health assessment (CHA) and community health improvement plan (CHIP) every 5 years.14 Collaborative community health efforts are cited as beneficial to those who participate. Although achieving a synergistic relationship relies on a number of factors,15 the benefit to the community by combining knowledge, resources, and skills is greater than what can be achieved alone.16---18 Furthermore, recent literature reflects that through collaborative efforts, there is a greater potential for improved community health.3,19 For example, the
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Community Health Governance partnership allowed communities across the United States to use each other’s professional expertise and built upon existing resources to better solve their unique community’s health needs through an expanded resource network.20 As previously mentioned, the CHNA process for nonprofit hospitals states that hospitals are to engage public health professionals and those with a broad stake in the community, emphasizing the importance of collaboration.7 Likewise, in preparation for accreditation, LHDs are strongly encouraged to collaborate with community partners and stakeholders to accomplish the CHA and CHIP. The inherent assumption is that collaboration is better than working independently. The ability to describe, measure, and evaluate collaboration in a way that provides practical translation of the use of resources for both hospitals and LHDs is important for sustainability. The theory of change provides a framework for identifying, measuring, and testing assumptions in collaborations.20 The theory of
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change focuses on how an effort, initiative, or program is successful, and why it was successful. Connell and Kubisch further identified that the theory of change is beneficial when horizontal, vertical, and contextual complexity are present, making traditional forms of measurement and evaluation difficult.21 The CHNAs, CHAs, and CHIPs are such complex efforts. Being able to test or measure underlying assumptions about collaboration may lead to important changes in the community. Capturing the nature and context of collaboration from both the hospital and LHD perspective becomes important for evaluation and resource deployment as an underlying assumption for change. The literature and practice standards reflect the renewed importance of collaboration between hospitals and LHDs to achieve common population-level health improvement.17 The theory of change provides a necessary framework to understand underlying assumptions of collaboration. Despite the affirmation that collaboration may lead to a greater ability to affect community change, understanding the appropriate levels of collaborative effort necessary to achieve common goals is still being researched. Without leveraging resources, efforts to improve population-level health may be hindered. 4 Determining the perspectives of both LHDs and hospitals and how both sides view their current collaborative efforts is an important step toward effectively promoting and engaging the collaborative efforts of both LHDs and hospitals. Our goal was to identify and establish a baseline description of collaboration among nonprofit hospitals and LHDs in Missouri through content analysis of hospital CHNAs. Hospitals previously identified by LHDs as collaborators on community assessments were compared with other nonprofit hospitals in Missouri.
METHODS Missouri has 115 LHDs operating within the state. A 2012 survey administered by the Missouri Department of Health and Senior Services asked LHDs about their current collaboration efforts with hospitals on a CHA. The survey found 22% (n = 26) were already
collaborating with a hospital, 12% (n = 14) planned to collaborate, 25% (n = 29) were unsure if they would collaborate with a hospital, 8% (n = 9) did not plan to collaborate, and 32% (n = 37) of LHDs reported that there were no hospitals in their jurisdiction.22 We selected Missouri LHDs that reported that they were already collaborating or were unsure if they would collaborate for a follow-up LHD collaboration survey. Approximately 85% of currently collaborating LHDs (n = 22) responded to the LHD collaboration survey.23 In 2013, we asked the currently collaborating LHDs to provide the names of the collaborating hospitals working on any initiative with the LHD. A total of 49 Missouri hospitals were identified by the LHDs. Because we attempted to build upon findings from the LHD collaboration survey, we only included hospitals identified by name by the LHDs in the study sample. We had no expectations of collaboration on CHAs and CHNAs for hospitals that were not identified by an LHD. We included nonprofit hospitals that were required to perform CHNAs and make them publically available in the study. Our exclusion criteria included for-profit hospitals, government- or county-owned hospitals, and certain specialty hospitals that were not required to prepare a CHNA. A hospital could be listed as a collaborator by more than 1 LHD, and we removed duplicate identification of hospitals by LHDs. We were interested in the overall level of joint action between the hospitals and the LHD, regardless of how many times the hospitals were listed as a community partner by the LHD. Including the same CHNA multiple times from the same hospital gave more weight to certain hospitals because of the hospital’s geographic location, which might have included multiple LHDs. There are a total of 167 hospitals in Missouri, of which 105 are nonprofit. After accounting for hospital duplication and exclusion criteria, our final study sample of hospitals to determine levels of joint action was 34, or 32% of all nonprofit hospitals in Missouri. We then used the remaining 71 nonprofit hospitals for the comparison study sample. Of these 71 comparison nonprofit hospitals, 50 (70%) had CHNAs that were publically available. Therefore, our final study
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sample included 34 study sample hospitals and 50 comparison hospitals.
Data Sources Community Health Needs Assessments document review. In 2014, we initially reviewed all publically available hospital documents to determine the best sources for identifying levels of joint action from the hospitals’ perspectives. Our review included a document search for partnerships or collaboration with the LHDs. The documents reviewed included (1) the CHNA, (2) the hospital community benefit implementation plan, (3) the Internal Revenue Service Form 990 Schedule H, (4) the hospital annual report, and (5) the Web site of each hospital. In reviewing these documents, we determined that the only consistent source of information for determining levels of joint actions with the LHDs was the CHNAs. Thus, we chose the CHNAs as the source for content analysis. We selected search terms to identify the varying levels of joint action between the hospital and LHDs. We identified the following search terms: “health dep,” “health agency,” “public health,” “health center,” “collab,” “coop,” and “partner.” We used abbreviated versions of the search terms to capture all forms of the word or phrase. CHNAs were reviewed for any mention of these search terms. Once the search term was identified in the CHNAs, we captured the surrounding text, including the search term, in a database. On the first review of the captured content, we needed further definition of terms to include more specific exclusion criteria of search terms. Our additional exclusion criteria included template language included in the CHNAs by the hospitals that repeated the regulation language from the Internal Revenue Service. In many cases, hospitals defined their community in a way that might have included more than 1 county jurisdiction, whereas the LHDs in Missouri were generally defined by county jurisdiction. Therefore, we included all mentions of health department(s) for each hospital. We reviewed the CHNAs of the comparison hospitals for mention of public health and health departments using the following search terms: “health dep,” “health agency,” “public health,” and “health center.” We had no
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expectations of joint action with the LHDs not previously named; therefore, we did not use the terms “collab,” “coop,” and “partner” used to extract levels of joint action. We used the same methods of language extraction for the study hospitals for the comparison hospitals. Hospital characteristics. The demographic and descriptive characteristics of hospitals included in the analysis of the study and comparison hospitals were (1) member of a health system or an independent hospital as self-reported via the hospital Web site, (2) county-level urban, suburban, and rural classification,24 (3) faith-based designation, and (4) staff- or consultant-led CHNA. Each CHNA indicated whether the assessment was conducted by an internal team or an outside consultant. We based the determination of faith- or not faith-based systems on a review of the hospital mission statement from the hospital Web site. We based the determination of the hospital’s classification on the 2013 National Center for Health Statistics UrbanRural Classification Scheme for Counties using the county in which the hospital resided. 24
Content Analysis We coded each block of captured text based on the levels of joint action defined by National Association of County and City Officials (NACCHO). These levels of joint action included networking, coordination, cooperation, and collaboration. We used the following definitions to identify each level: networking was considered “exchange of information,” coordination was “exchange of information and linking existing activities for mutual benefit,” cooperation was “sharing resources for mutual benefit and to create something new,” and collaboration was considered “working jointly to accomplish shared vision and mission using joint resources.”25 We coded each study hospital based on the blocks of text captured from the CHNA. If blocks of text within a hospital’s CHNA differed based on the level of joint action, we chose the highest level of joint action to define the hospital’s overall level of joint action with LHDs. Hospitals that had no blocks of text that met the criteria for levels of joint action were coded as “none.”
To assess intercoder reliability on text extraction, 2 researchers (A. C. and L. S.) responsible for data collection selected a random set of 5 study hospitals and 6 comparison hospitals to code a second time, for a total of 22 CHNAs. Percent agreement was calculated at 82% for study hospitals and 83% for comparison hospitals. Areas of disagreement included the following: (1) collaboration: 1 coder included any citation of the word, and 1 coder only included it when it was in relation to another entity (external); (2) “partner”: as a title of an organization (Partnership Council): 1 coder included it in the search and the other coder did not; and (3) “partner” with the consulting group hired to do the CHNA: 1 coder included it in the search and the other coder did not. We further refined any areas of disagreement on coding of levels of joint action, and all CHNAs were recoded. Intercoder reliability on the highest captured level of joint action was performed on study sample CHNAs with 90% agreement. From the 34 CHNAs of the study hospitals, we captured 315 blocks of coded text.
Statistical Analysis We calculated the descriptive statistics for the study and comparison hospitals, and we performed 2 analyses: (1) a test for differences between study and comparison hospitals, and (2) a test for differences in hospital characteristics based on the level of joint action for study hospitals. We used the Pearson v2 analysis to test for differences between study and comparison hospitals, and we used the Fisher exact test to test for differences in hospital characteristics. Because of the small sample sizes for “cooperation” and “collaboration” levels of joint action, we combined these 2 levels for the Fisher exact test analyses. All statistical analyses were performed using SPSS (version 22; IBM, Armonk, NY).26
RESULTS We included 84 (80%) of the 105 Missouri nonprofit hospitals in the analysis of this study. Almost two thirds (65.5%) of all the hospitals reviewed were part of a larger health care system. Study and comparison hospitals differed significantly on membership to
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a health care system, with 74% of comparison hospitals compared with 52.9% of study hospitals belonging to a health system (v2 [1] = 3.97; P < .05). Of all the hospitals reviewed, approximately 58.3% were in urban counties, 17.9% were in suburban counties, and 23.8% were in rural counties. More than three quarter of hospitals (78.6%) completed the CHNA with internal staff, and 21.4% used an outside consultant. In addition, we identified 39.3% as faith-based hospitals. Study and comparison hospitals did not differ based on county-level urban, suburban, and rural classifications; hospital’s faith-based identification; or staff versus consultant-led CHNA (Table 1).
Levels of Joint Action in Study Sample Hospitals The content analysis of the study hospital CHNAs provided insight into how the hospitals documented their relationship with LHDs. Table 2 describes the highest level of joint action between the study hospitals and the LHDs. No significant differences in hospital characteristics were found based on level of joint action using the Fisher exact test. Table 3 provides examples of the CHNA content at each of the levels of joint action. More than one third (38.2%) of CHNAs were coded with “cooperation” as the highest level of joint action. An example of cooperation was working together to identify health professionals in the community to create advisory councils or work groups around a specific health issue. The next most common levels of joint action were networking and coordination, with both at 20.6%. Networking examples included providing completed CHNAs to the LHDs for distribution and the hospital’s use of information provided by the LHD to assist in completing the CHNA. Coordination examples included working together on the CHNA and conducting community focus groups to identify high priority community needs. Only 1 CHNA described a collaboration (2.9%) in which they worked with 2 LHDs to perform a community-wide needs assessment; from those identified needs, they jointly established a federally qualified health center. Approximately 18% of CHNAs in the study sample did not indicate any levels of joint
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Comparison Sample Community Health Needs Assessments Review
TABLE 1—Nonprofit Hospital Characteristics (n = 84): Missouri, 2014 Study (n = 34), No. (%) or %
Comparison (n = 50), No. (%) or %
Total (n = 84), No. (%) or %
Yesa
18 (52.9)
37 (74.0)
55 (65.5)
Noa
16 (47.1)
13 (26.0)
29 (34.5)
Characteristics Member of larger health care system
Faith-based designation Yes No
12 (35.3)
21 (42.0)
33 (39.3)
22 (64.7)
29 (58.0)
51 (60.7)
25 (73.5)
41 (82.0)
66 (78.6)
9 (26.5)
9 (18.0)
18 (21.4)
19 (55.9)
30 (60.0)
49 (58.3)
7 (20.6) 8 (23.5)
8 (16.0) 12 (24.0)
15 (17.9) 20 (23.8)
40.0
60.0
100.0
Completion of CHNA By hospital By consultant Hospital location Urban Suburban Rural Coverage of total population Note. CHNA = community health needs assessment. a 2 v (1) = 3.97; P < .05.
action in relation to LHDs. Examples in the CHNA included collaboration with local school districts or working on “public health”
issues like seat belt initiatives, but none of the 18% indicated working with a LHD on these issues.
Review of comparison hospital CHNAs for key terms showed little mention of specific activities or collaborative efforts with LHDs. Most often, comparison hospital CHNAs referenced health departments in regard to existing personnel working at the health department or community health initiatives which they were leading, with little description of what this meant for the 2 entities on a collaborative level. Another common acknowledgment of LHDs was with regard to the services that were provided by 1 or several of health departments in the area. Content related to the terms public health and health center was general in nature and included public health professionals or public health as an organization or professional title, such as Public Health Department or Master of Public Health and federally qualified health centers. These findings illustrated the differences in describing collaborative action between the comparison group and the study population.
Comparison of Reported Levels of Joint Action TABLE 2—Study Sample Nonprofit Hospital Characteristics by Level of Joint Action (n = 34): Missouri, 2014 None No. (%) or %
Networking No. (%) or %
Coordination, No. (%) or %
Cooperation or Collaboration, No. (%) or %
Yes
5 (27.8)
3 (16.7)
4 (22.2)
6 (33.3)
No
1 (6.3)
4 (25.0)
3 (18.8)
8 (50.0)
3 (25.0)
2 (16.7)
3 (25.0)
4 (33.3)
3 (13.6)
5 (22.7)
4 (18.2)
10 (45.5)
By hospital
5 (20.0)
3 (12.0)
5 (20.0)
12 (48.0)
By consultant
1 (11.1)
4 (44.4)
2 (22.2)
2 (22.2)
Characteristics Member of larger health care system
Faith-based designation Yes No Completion of CHNA
Hospital location Urban
3 (15.8)
5 (26.3)
5 (26.3)
6 (31.6)
Suburban Rural
2 (28.6) 1 (12.5)
1 (14.3) 1 (12.5)
1 (14.3) 1 (12.5)
3 (42.9) 5 (62.5)
17.6
20.6
20.6
41.2
Coverage of total population
Note. CHNA = community health needs assessment. Levels of joint action as defined by the National Association of County and City Officials. These levels included networking, coordination, cooperation, and collaboration. We used the following definitions to identify each level: networking was considered “exchange of information”; coordination was “exchange of information and linking existing activities for mutual benefit”; cooperation was “sharing resources for mutual benefit and to create something new”; and collaboration was considered “working jointly to accomplish shared vision and mission using joint resources.”25
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Table 4 provides information regarding the hospital and LHD perspectives on the levels of joint action. The hospital perspective was from the content analysis of our study, whereas the LHD perspective came from the LHD collaborative survey. Networking and coordination were fairly congruent between the LHD and hospital perspectives. Notably, there was incongruence between the hospital and LHD perspectives with respect to cooperation and collaboration. This incongruence might be the result of an overestimate of the levels of joint action by the LHDs or an underestimation of the levels of joint action by the hospitals. These results indicated a need for further investigation to more accurately measure both perspectives, because this might prove to be a crucial area of measurement and understanding of the assumptions around collaboration among hospitals and LHDs.
DISCUSSION As mentioned earlier, the LHD collaboration survey identified 32% of the nonprofit hospitals
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TABLE 3—Levels of Joint Action and Examples From Nonprofit Hospital Community Health Needs Assessment Content Analysis (n = 34): Missouri, 2014 Level of Joint Action Networking: exchange information.
Hospital, No. (%) 7 (20.6)
Content Example The local health center offers a number of online resources. Examples of the services available at the health center include immunizations, mental health counseling, women’s health services, and smoking cessation “Quit Kits.”
Coordination: exchange information
7 (20.6)
and link existing activities for mutual benefit.
Hospital system–wide sponsored community roundtable events in both 2010 and 2011. These initial assessments were followed up by meetings with community partners, such as the schools, health department, and regional planning efforts with the partnership council. Continuation of the community roundtable process across the hospital system began in 2013.
Cooperation: share resources for mutual benefit
13 (38.2)
and to create something new.
The hospital clinic provides primary care and is supported by the county 1 and county 2 health department, county regional medical center, and several volunteer health care professionals.
Collaboration: work jointly to accomplish shared vision
1 (2.9)
and mission using joint resources.
On July 1, 2008, the hospital and the county health department began providing a free clinic 1 night per week for the residents of the county who had no insurance, Medicare or Medicaid coverage. Modeled after this clinic, the hospital partnered with the local health departments to open a free clinic in county 1 in 2009 and in county 2 in 2010. The hospital also works with federal, state, and local organizations to improve access to care and the health of the community. Locally, the hospital works with county health departments as they evaluate health needs and work to help meet those needs. The Hospital worked with the county 1 and county 2 health departments to help establish a federally qualified health center in the town.
None
7 (17.7)
Creating healthy communities requires a high level of mutual understanding and collaboration with individuals and organizations in the community.
in Missouri as collaborating with the LHDs on the CHAs. With respect to the hospital characteristics, study and comparison hospitals differed on 1 characteristic—a lower percentage of study sample hospitals were part of a health system than that of the comparison sample. It was possible that without health system resources or support, those hospitals in the sample study were more motivated to seek out the assistance of the LHDs to complete the CHNA. More research is needed to better understand the relationship of a hospital as a member of a system and the impact on likelihood of collaboration with LHDs. For all other characteristics, hospitals in the study sample did not differ from comparison hospitals. Although additional research is needed to examine potential differences, it appeared that, at least through this study, hospitals conducting their CHNA at the local level without health system support were more likely to engage local resources to complete the CHNA. Within the study sample, we found no differences among the hospital characteristics based on the levels of joint
action identified through the CHNA content analysis. Our content analysis of the CHNAs provided important baseline information that described collaboration between hospitals and LHDs from the hospitals’ perspective. Earlier research that described collaboration with hospitals from the LHD perspective provided initial insight and a means to begin quantifying collaboration based on the levels of joint action as described by NACCHO.23 With these 2 studies that examined both LHD and hospital perspectives, initial insight into potential disconnect regarding collaboration was possible. Further research into the differing perspectives and realities of collaboration between hospitals and LHDs might provide a basis for improved or more appropriate collaboration to fulfill policy requirements and goals for improved population-level health. The LHD and hospital perspectives had different leverage points that encouraged collaboration with each other. The goal of public health accreditation is to improve performance and quality of health departments.
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By meeting the accreditation standards, which include the 10 essential services, health departments might be able to improve population health, provide efficiency (cost
TABLE 4—Comparison of Reported Levels of Joint Action Between Study Nonprofit Hospitals and the Local Health Department Collaborative Survey: Missouri, 2014 Reported Level of Joint Action
Hospital, No. (%)
Local Health Department, No. (%)
Networking
7 (20.6)
6 (27.2)
Coordination Cooperation
7 (20.6) 13 (38.2)
6 (27.2) 0 (0.0)
Collaboration
1 (2.9)
10 (45.5)
None
7 (17.7)
0 (0.0)
Total
34
22
Note. Numbers may not total 100 because of rounding. Source. Wilson et al.23 for local health department information.
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effectiveness) in programs and activities, and do so with equity to all people.27,28 By requiring completion of both the CHA and CHIP before applying for accreditation, LHDs are better situated to provide services and meet the needs of their community. These processes necessitate collaboration with community stakeholders, including hospitals. From the hospital perspective, ACA legislation and regulations require hospitals to “include individuals with expertise in public health.”1 Although the source of expertise is not required to be the LHD, the more accessible public health expertise for many hospitals is likely to be the LHD. Because of the proximity of hospitals and LHDs to one another, continuing to promote these areas of mutual requirements through further integration of services and collaboration might be a promising approach to leverage scarce resources and to improve population health.5,29 The benefits of collaboration as an efficient approach to forming goals and achieving positive population health outcomes compared with individuals or organizations working alone are well documented.15,16,30,31 For example, a recent study of Texas nonprofit hospitals found that the quality of the CHNAs improved significantly when hospitals partnered with LHDs.32 The ability to test the assumption of collaboration within the framework of the theory of change is only possible if the assumptions of collaboration (e.g., through levels of joint action) can be measured.33 The results of both our analysis and previous studies indicated that measuring NACCHO’s levels of joint action might be an approach to better understanding and identifying appropriate levels of collaboration, leading to better use of resources and population-level health changes. The content analysis of the CHNAs we reviewed for this study revealed additional observations. Within the comparison group, key words that represented some type of collaboration reflected relationships outside of the LHD. Many of the comparison hospitals mentioned community partners, but the lack of detail provided in the CHNAs did not allow for any identification of levels of joint action. The CHNAs from the study sample more often had action plans for partnerships in their CHNA.
Our study provided early clues on the identification and use of (or lack thereof) a common language around collaboration. In developing a more widely understood language of collaboration, including measurement, more appropriate levels of action desired or required for a specific set of outcomes might be possible. Working toward a shared language, vision, and common measurement of collaboration for hospitals and LHDs might be important for reducing barriers to collaboration and for appropriate deployment of resources as both work toward improved population-level health. NACCHO’s framing of the levels of joint action provides a starting point for a common language and measurement around collaboration. Once levels of joint action are able to be measured, optimal levels can be determined with a calculated return on investment.
Limitations There were limitations to our study. Content analysis was conducted only using the CHNAs that were publicly available through hospitals Web sites, which represented 80% (n = 84) of nonprofit hospitals in Missouri. In determining our study sample, only 34 Missouri nonprofit hospitals were identified by the LHDs, representing 32% of all nonprofit hospitals in Missouri. In addition, methodological challenges existed because of differing geographical boundaries for LHDs and hospitals. A nationally representative sample is needed to generalize the results There was also an underlying assumption that the CHNA captured the full relationship between the LHDS and the hospitals. It was possible that collaborative efforts between hospitals and LHDs occurred, but were not captured in the CHNAs. Although the CHNA might not have completely captured the collaborative efforts, it provided a baseline for exploration. A longitudinal review of future CHNAs would allow for a review of CHNA changes made over time. Although differences in characteristics between study and comparison hospitals were reported, more information is needed to confirm differences, draw any conclusions related to these differences, or to understand potential implications related to those differences. A more in-depth survey of hospitals, coupled with content analysis, might provide
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a more robust identification of the collaborative relationships. Although a rigorous process for interpreting the content was applied, further analysis that includes direct questions to study sample hospitals is needed to fully develop a collaboration continuum and to begin to test the collaboration assumptions. Finally, our content analysis did not allow for the measurement of the frequency of levels of joint action, but only allowed measurement of the presence or absence of levels of joint action as reported through the CHNAs of the hospitals.
Implications As available resources for both hospitals and LHDs become more scarce, and various health sectors are encouraged to collaborate as a way to break down a “silo” approach to improving population-level health, alignment of various incentives, including policy incentives, becomes important.4 To break down barriers of collaboration and work toward common goals, it is important for these various sectors, including hospitals and LHDs, to identify and measure a common language of collaboration. Where common goals and requirements exist, it may be a more efficient and effective use of resources to determine the most appropriate levels of joint action to achieve goals. Hospitals and LHDs working together on the identification of health needs, determining priorities within their communities, and developing and implementing plans to address the identified priorities are specific approaches that begin to break down the silo approach. To foster a collaborative pathway and to fulfill policy requirements, both sectors should have a congruent perspective on how and why collaboration is of value to both sectors. Although the existing level of collaboration between hospitals and LHDs is varied, LHDs have an important and unique role in facilitating levels of joint action related to health assessments and planning. Assessment is 1 of the core functions of public health.34 Accreditation efforts, including the requirement of CHAs and CHIPs, provide LHDs with the incentive to actively engage hospitals and other stakeholders during the process. In addition, LHDs can actively position themselves as the public health experts in the
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community and engage hospitals as they complete their own CHNAs and implementation plans. LHDs in the past have often waited for the hospital to contact them to collaborate instead of pursuing the collaboration. 2 4 Collaboration requires time and financial resources. Depending on the level of joint action required, the intensity of time and financial resources can vary. Resources are scarce within LHDs and hospitals to carry out the policy requirements around the CHAs and CHNAs. Quantifying the specific levels of action necessary may lead to better understanding as to the most appropriate level of action given the desired outcome. Resources may then be more specifically planned and targeted without incurring possible diminishing returns on investment of time and resources for unnecessary levels of joint action.
Future Research Using CHNAs coupled with CHAs and resulting plans provide new and potentially rich information as to the best collaborative approaches for improved population-level health. Quantifying collaboration through a more in-depth survey similar to our survey that was administered to LHDs would provide more detailed information from the hospital perspective.23 More appropriately categorizing levels of joint action through quantitative and qualitative measurement would also assist in the allocation of appropriate time and financial resources. Comparing the new iterations of the CHNAs with the baseline CHNAs for modification of language and collaborative activity with LHDs might prove useful to identify innovation within communities. Future research considerations should also include the impact of policies on the assumptions of collaboration with respect to desired outcomes, and the discovery and impact of the most appropriate levels of joint action coupled with the impact of strategies and intended population-level outcomes. j
About the Authors Kate E. Beatty is with the Department of Health Services Management & Policy, College of Public Health, East Tennessee State University, Johnson City. Kristin D. Wilson is with the Health Management and Policy Masters in Public Health Program, Department of Health Management and Policy, Saint Louis University College for Public Health
and Social Justice, St. Louis, MO. Amanda Ciecior is with the Department of Vermont Health Access, Vermont Agency of Human Services, Winooski. Lisa Stringer is with the Department of Health Management and Policy, Saint Louis University College for Public Health and Social Justice, St. Louis. Correspondence should be sent to Kate E. Beatty, Assistant Professor, Department of Health Services Management & Policy, College of Public Health, East Tennessee State University, Box 70264, Johnson City, TN 37614 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted November 23, 2014.
Contributors K. E. Beatty and K. D. Wilson originated and supervised the study, and contributed to the writing of the article. A. Ciecior and L. Stringer completed the content analysis and assisted in completing the article.
Acknowledgments We thank Lisa Buettner-Mohr for her work on the LHD collaboration survey study, and Olivia Peavler and Tyler Carpenter for reviewing later drafts of this article.
health needs assessments. 2012. Available at: http:// ascendient.com/2011/06/the-patient-protectionand-affordable-care-act-newly-required-communityhealth-needs-assessments-2. Accessed September 8, 2014. 10. Folkemer DC, Spicer LA, Mueller CH, et al. Hospital Community Benefits After the ACA: The Emerging Federal Framework. Baltimore, MD: Hilltop Institute; 2011. 11. Somerville MH, Nolin MA, Mueller CH, et al. Hospital Community Benefits After the ACA: Building on State Experience. 2011. Available at: http://www.hilltopinstitute.org/publications/ HospitalCommunityBenefitsAfterTheACAHCBPIssueBrief2-April2011.pdf. Accessed September 8, 2014. 12. Beitsch LM, Thielen L, Mays G, et al. The multistate learning collaborative, states as laboratories: informing the national public health accreditation dialogue. J Public Health Manag Pract. 2006;12(3):217---231.
Human Participant Protection
13. Bender K, Benjamin G, Carden J, et al. Final recommendations for a voluntary national accreditation program for state and local health departments: steering committee report. J Public Health Manag Pract. 2007;13(4):342---348.
This study did not require institutional review board approval, as our study was a review of publically available documents that did not meet the threshold of human participant research.
14. National Public Health Department. National Public Health Department Accreditation Readiness Checklists Version 1.0. Alexandria, VA: Public Health Accreditation Board; 2011.
References
15. Lasker RD, Weiss ES. Broadening participation in community problem solving: a multidisciplinary model to support collaborative practice and research. J Urban Health. 2003;80(1):14---47.
1. Patient Protection and Affordable Care Act, 42, §18001 et seq. 2010. 2. Bender K, Kronstadt J, Wilcox R, Lee TP. Overview of the Public Health Accreditation Board. J Public Health Manag Pract. 2014;20(1):4---6. 3. Dearinger AT, Howard A, Ingram R, et al. Communication efforts among local health departments and health care professionals during the 2009 H1N1 outbreak. J Public Health Manag Pract. 2011;17(1):45---51. 4. Scutchfield FD, Michener JL, Thacker SB. Are we there yet? Seizing the moment to integrate medicine and public health. Am J Public Health. 2012;102(suppl 3): S312---S316. 5. Institute of Medicine. Primary Care and Public Health: Exploring Integration. Washington, DC: Institute of Medicine; 2012. 6. Rosenbaum S, Byrnes M, Rieke AM. Hospital tax-exempt policy: a comparison of schedule H and state community benefit reporting systems. Frontiers Public Health Serv Syst Res. 2013;2(1):Article 3. 7. Internal Revenue Service. Persons Representing the Broad Interests of the Community. July 2011. Available at: http://www.irs.gov/irb/2011-30_IRB/ar08.html. Accessed September 15, 2014. 8. Internal Revenue Service. New Requirements for 501(c)(3) Hospitals Under the Affordable Care Act 2014. Available at: http://www.irs.gov/Charities-&-NonProfits/Charitable-Organizations/New-Requirementsfor-501%28c%29%283%29-Hospitals-Under-theAffordable-Care-Act. Accessed September 8, 2014. 9. Ackerman B, Van Ochten K. The Patient Protection and Affordable Care Act: newly required community
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16. Lasker RD, Weiss ES, Miller R. Partnership synergy: a practical framework for studying and strengthening the collaborative advantage. Milbank Q. 2001;79(2):179---205. 17. Mays GP, Scutchfield FD. Improving public health system performance through multiorganizational partnerships. Prev Chronic Dis. 2010;7(6):A116. 18. Roussos ST, Fawcett SB. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health. 2000;21(1):369---402. 19. Jarris PE, Monroe JA, Pestronk RM. Better health requires partnerships and a systems approach. Am J Public Health. 2012;102(11):e4. 20. Connell JP. New Approaches to Evaluating Community Initiatives: Concepts, Methods, and Contexts. Roundtable on Comprehensive Community Initiatives for Children and Families. Vol. 1. Washington, DC: Aspen Institute; 1995. 21. Connell JP, Kubisch AC. Applying a theory of change approach to the evaluation of comprehensive community initiatives: progress, prospects, and problems. In: New Approaches to Evaluating Community Initiatives. Vol. 2. Washington, DC: Aspen Institute; 1998;15---44. 22. Missouri Department of Health and Senior Services. Infrastructure and Needs Survey. Jefferson City, MO: Missouri Department of Health and Senior Services; 2012. 23. Wilson KD, Mohr LB, Beatty KE, Ciecior A. Describing the continuum of collaboration among local
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health departments with hospitals around the community health assessments. J Public Health Manag Pract. 2014;20 (6):617---625. 24. Ingram DD, Franco SJ. 2013 NCHS Urban-Rural Classification Scheme for Counties. Vital Health Stat 2. 2014;Apr (166):1---73. 25. National Association of County & City Health Officials. Pulling Together 5, Section Two: Building Collaboration. Available at: http://www.naccho.org/ topics/environmental/pullingtogether/sectiontwo.cfm. Accessed June 13, 2013. 26. SPSS for Windows [computer program]. Version 22.0. Armonk, NY: IBM; 2013. 27. Joly BM, Polyak G, Davis MV, et al. Linking accreditation and public health outcomes: a logic model approach. J Public Health Manag Pract. 2007;13(4):349---356. 28. Handler A, Issel M, Turnock B. A conceptual framework to measure performance of the public health system. Am J Public Health. 2001;91(8):1235---1239. 29. Hardcastle LE, Record KL, Jacobson PD, Gostin LO. Improving the population’s health: the Affordable Care Act and the importance of integration. J Law Med Ethics. 2011;39(3):317---327. 30. Butterfoss FD. Coalitions and Partnerships in Community Health. Hoboken, NJ: John Wiley & Sons; 2007. 31. McLeroy KR, Norton BL, Kegler MC, Burdine JN, Sumaya CV. Community-based interventions. Am J Public Health. 2003;93(4):529---533. 32. Pennel CL, McLeroy KR, Burdine JN, MatarritaCastante D. Nonprofit hospitals’ approach to community health needs assessment. Am J Public Health. 2015;105 (3):103---113. 33. Annie E. Casey Foundation. Theory of Change: A Practical Tool for Action. Results and Learning. Seattle, WA: Organizational Resource Services; 2004. 34. Turnock BJ, Handler AS. From measuring to improving public health practice. Annu Rev Public Health. 1997;18(1):261---282.
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American Journal of Public Health | Supplement 2, 2015, Vol 105, No. S2
Collaboration Among Missouri Nonprofit Hospitals and LocalHealthDepartments:ContentAnalysisofCommunity Health Needs Assessments Kate E. Beatty, PhD, MPH, Kristin D. Wilson, PhD, MHA, Amanda Ciecior, MPH, and Lisa Stringer, MPH, MSW
The Patient Protection and Affordable Care Act (ACA)1 and the launch of the voluntary national public health department accreditation program,2 emphasize policies that encourage greater collaboration between health care and public health. Existing silos of communication and lack of cooperation between public health and other sectors of health are well documented.3,4 Experts have recommended the removal of these barriers between health care and public health to create improved population health.5 The process of identifying community needs, an essential part of the ACA and the voluntary national public health department accreditation program, has the potential to reduce barriers to communication and collaboration between hospitals and local health departments (LHDs).6 A 2012 Institute of Medicine (IOM) report identified several advantages for LHDs and local health centers (e.g., hospitals) to share resources while fulfilling new government mandates, including cost-savings potential for communities, better coordination of care, and positive environmental changes.5 Per the ACA, nonprofit hospitals must perform a community health needs assessment (CHNA) every 3 years.1 The Internal Revenue Service published subsequent regulations in July 2011 that provided hospitals guidance on conducting the CHNAs.7,8 According to the legislation, the CHNA is intended to be transparent, available to the community,6,9 and includes individuals with expertise in public health to help during the CHNA process.1,10 Any noncompliant hospital may incur a $50 000 excise tax liability as outlined in the legislation.11 In addition to the CHNA, the ACA requires nonprofit hospitals to design an implementation plan, including strategies that address identified community needs from the CHNA.1,7
Objectives. We identified the levels of joint action that led to collaboration between hospitals and local health departments (LHDs) using the hospital’s community health needs assessments (CHNAs). Methods. In 2014, we conducted a content analysis of Missouri nonprofit hospitals (n = 34) CHNAs, and identified hospitals based on previously reported collaboration with LHDs. We coded the content according to the level of joint action. A comparison sample (n = 50) of Missouri nonprofit hospitals provided the basic comparative information on hospital characteristics. Results. Among the hospitals identified by LHDs, 20.6% were “networking,” 20.6% were “coordinating,” 38.2% were “cooperating,” and 2.9% were “collaborating.” Almost 18% of study hospitals had no identifiable level of joint action with LHDs based on their CHNAs. In addition, comparison hospitals were more often part of a larger system (74%) compared with study hospitals (52.9%). Conclusions. The results of our study helped develop a better understanding of levels of joint action from a hospital perspective. Our results might assist hospitals and LHDs in making more informed decisions about efficient deployment of resources for assessment processes and implementation plans. (Am J Public Health. 2015;105: S337–S344. doi:10.2105/AJPH.2014.302488)
LHDs may voluntarily seek accreditation through the Public Health Accreditation Board’s (PHAB) National Public Health Accreditation program. PHAB was incorporated in 2007, with the national public health accreditation program launched in September 2011. Many stakeholders were involved in creating, as well as in studying the desirability and feasibility of a national accreditation program. 2,12,13 In seeking accreditation, LHDs are required to conduct a community health assessment (CHA) and community health improvement plan (CHIP) every 5 years.14 Collaborative community health efforts are cited as beneficial to those who participate. Although achieving a synergistic relationship relies on a number of factors,15 the benefit to the community by combining knowledge, resources, and skills is greater than what can be achieved alone.16---18 Furthermore, recent literature reflects that through collaborative efforts, there is a greater potential for improved community health.3,19 For example, the
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Community Health Governance partnership allowed communities across the United States to use each other’s professional expertise and built upon existing resources to better solve their unique community’s health needs through an expanded resource network.20 As previously mentioned, the CHNA process for nonprofit hospitals states that hospitals are to engage public health professionals and those with a broad stake in the community, emphasizing the importance of collaboration.7 Likewise, in preparation for accreditation, LHDs are strongly encouraged to collaborate with community partners and stakeholders to accomplish the CHA and CHIP. The inherent assumption is that collaboration is better than working independently. The ability to describe, measure, and evaluate collaboration in a way that provides practical translation of the use of resources for both hospitals and LHDs is important for sustainability. The theory of change provides a framework for identifying, measuring, and testing assumptions in collaborations.20 The theory of
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change focuses on how an effort, initiative, or program is successful, and why it was successful. Connell and Kubisch further identified that the theory of change is beneficial when horizontal, vertical, and contextual complexity are present, making traditional forms of measurement and evaluation difficult.21 The CHNAs, CHAs, and CHIPs are such complex efforts. Being able to test or measure underlying assumptions about collaboration may lead to important changes in the community. Capturing the nature and context of collaboration from both the hospital and LHD perspective becomes important for evaluation and resource deployment as an underlying assumption for change. The literature and practice standards reflect the renewed importance of collaboration between hospitals and LHDs to achieve common population-level health improvement.17 The theory of change provides a necessary framework to understand underlying assumptions of collaboration. Despite the affirmation that collaboration may lead to a greater ability to affect community change, understanding the appropriate levels of collaborative effort necessary to achieve common goals is still being researched. Without leveraging resources, efforts to improve population-level health may be hindered. 4 Determining the perspectives of both LHDs and hospitals and how both sides view their current collaborative efforts is an important step toward effectively promoting and engaging the collaborative efforts of both LHDs and hospitals. Our goal was to identify and establish a baseline description of collaboration among nonprofit hospitals and LHDs in Missouri through content analysis of hospital CHNAs. Hospitals previously identified by LHDs as collaborators on community assessments were compared with other nonprofit hospitals in Missouri.
METHODS Missouri has 115 LHDs operating within the state. A 2012 survey administered by the Missouri Department of Health and Senior Services asked LHDs about their current collaboration efforts with hospitals on a CHA. The survey found 22% (n = 26) were already
collaborating with a hospital, 12% (n = 14) planned to collaborate, 25% (n = 29) were unsure if they would collaborate with a hospital, 8% (n = 9) did not plan to collaborate, and 32% (n = 37) of LHDs reported that there were no hospitals in their jurisdiction.22 We selected Missouri LHDs that reported that they were already collaborating or were unsure if they would collaborate for a follow-up LHD collaboration survey. Approximately 85% of currently collaborating LHDs (n = 22) responded to the LHD collaboration survey.23 In 2013, we asked the currently collaborating LHDs to provide the names of the collaborating hospitals working on any initiative with the LHD. A total of 49 Missouri hospitals were identified by the LHDs. Because we attempted to build upon findings from the LHD collaboration survey, we only included hospitals identified by name by the LHDs in the study sample. We had no expectations of collaboration on CHAs and CHNAs for hospitals that were not identified by an LHD. We included nonprofit hospitals that were required to perform CHNAs and make them publically available in the study. Our exclusion criteria included for-profit hospitals, government- or county-owned hospitals, and certain specialty hospitals that were not required to prepare a CHNA. A hospital could be listed as a collaborator by more than 1 LHD, and we removed duplicate identification of hospitals by LHDs. We were interested in the overall level of joint action between the hospitals and the LHD, regardless of how many times the hospitals were listed as a community partner by the LHD. Including the same CHNA multiple times from the same hospital gave more weight to certain hospitals because of the hospital’s geographic location, which might have included multiple LHDs. There are a total of 167 hospitals in Missouri, of which 105 are nonprofit. After accounting for hospital duplication and exclusion criteria, our final study sample of hospitals to determine levels of joint action was 34, or 32% of all nonprofit hospitals in Missouri. We then used the remaining 71 nonprofit hospitals for the comparison study sample. Of these 71 comparison nonprofit hospitals, 50 (70%) had CHNAs that were publically available. Therefore, our final study
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sample included 34 study sample hospitals and 50 comparison hospitals.
Data Sources Community Health Needs Assessments document review. In 2014, we initially reviewed all publically available hospital documents to determine the best sources for identifying levels of joint action from the hospitals’ perspectives. Our review included a document search for partnerships or collaboration with the LHDs. The documents reviewed included (1) the CHNA, (2) the hospital community benefit implementation plan, (3) the Internal Revenue Service Form 990 Schedule H, (4) the hospital annual report, and (5) the Web site of each hospital. In reviewing these documents, we determined that the only consistent source of information for determining levels of joint actions with the LHDs was the CHNAs. Thus, we chose the CHNAs as the source for content analysis. We selected search terms to identify the varying levels of joint action between the hospital and LHDs. We identified the following search terms: “health dep,” “health agency,” “public health,” “health center,” “collab,” “coop,” and “partner.” We used abbreviated versions of the search terms to capture all forms of the word or phrase. CHNAs were reviewed for any mention of these search terms. Once the search term was identified in the CHNAs, we captured the surrounding text, including the search term, in a database. On the first review of the captured content, we needed further definition of terms to include more specific exclusion criteria of search terms. Our additional exclusion criteria included template language included in the CHNAs by the hospitals that repeated the regulation language from the Internal Revenue Service. In many cases, hospitals defined their community in a way that might have included more than 1 county jurisdiction, whereas the LHDs in Missouri were generally defined by county jurisdiction. Therefore, we included all mentions of health department(s) for each hospital. We reviewed the CHNAs of the comparison hospitals for mention of public health and health departments using the following search terms: “health dep,” “health agency,” “public health,” and “health center.” We had no
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expectations of joint action with the LHDs not previously named; therefore, we did not use the terms “collab,” “coop,” and “partner” used to extract levels of joint action. We used the same methods of language extraction for the study hospitals for the comparison hospitals. Hospital characteristics. The demographic and descriptive characteristics of hospitals included in the analysis of the study and comparison hospitals were (1) member of a health system or an independent hospital as self-reported via the hospital Web site, (2) county-level urban, suburban, and rural classification,24 (3) faith-based designation, and (4) staff- or consultant-led CHNA. Each CHNA indicated whether the assessment was conducted by an internal team or an outside consultant. We based the determination of faith- or not faith-based systems on a review of the hospital mission statement from the hospital Web site. We based the determination of the hospital’s classification on the 2013 National Center for Health Statistics UrbanRural Classification Scheme for Counties using the county in which the hospital resided. 24
Content Analysis We coded each block of captured text based on the levels of joint action defined by National Association of County and City Officials (NACCHO). These levels of joint action included networking, coordination, cooperation, and collaboration. We used the following definitions to identify each level: networking was considered “exchange of information,” coordination was “exchange of information and linking existing activities for mutual benefit,” cooperation was “sharing resources for mutual benefit and to create something new,” and collaboration was considered “working jointly to accomplish shared vision and mission using joint resources.”25 We coded each study hospital based on the blocks of text captured from the CHNA. If blocks of text within a hospital’s CHNA differed based on the level of joint action, we chose the highest level of joint action to define the hospital’s overall level of joint action with LHDs. Hospitals that had no blocks of text that met the criteria for levels of joint action were coded as “none.”
To assess intercoder reliability on text extraction, 2 researchers (A. C. and L. S.) responsible for data collection selected a random set of 5 study hospitals and 6 comparison hospitals to code a second time, for a total of 22 CHNAs. Percent agreement was calculated at 82% for study hospitals and 83% for comparison hospitals. Areas of disagreement included the following: (1) collaboration: 1 coder included any citation of the word, and 1 coder only included it when it was in relation to another entity (external); (2) “partner”: as a title of an organization (Partnership Council): 1 coder included it in the search and the other coder did not; and (3) “partner” with the consulting group hired to do the CHNA: 1 coder included it in the search and the other coder did not. We further refined any areas of disagreement on coding of levels of joint action, and all CHNAs were recoded. Intercoder reliability on the highest captured level of joint action was performed on study sample CHNAs with 90% agreement. From the 34 CHNAs of the study hospitals, we captured 315 blocks of coded text.
Statistical Analysis We calculated the descriptive statistics for the study and comparison hospitals, and we performed 2 analyses: (1) a test for differences between study and comparison hospitals, and (2) a test for differences in hospital characteristics based on the level of joint action for study hospitals. We used the Pearson v2 analysis to test for differences between study and comparison hospitals, and we used the Fisher exact test to test for differences in hospital characteristics. Because of the small sample sizes for “cooperation” and “collaboration” levels of joint action, we combined these 2 levels for the Fisher exact test analyses. All statistical analyses were performed using SPSS (version 22; IBM, Armonk, NY).26
RESULTS We included 84 (80%) of the 105 Missouri nonprofit hospitals in the analysis of this study. Almost two thirds (65.5%) of all the hospitals reviewed were part of a larger health care system. Study and comparison hospitals differed significantly on membership to
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a health care system, with 74% of comparison hospitals compared with 52.9% of study hospitals belonging to a health system (v2 [1] = 3.97; P < .05). Of all the hospitals reviewed, approximately 58.3% were in urban counties, 17.9% were in suburban counties, and 23.8% were in rural counties. More than three quarter of hospitals (78.6%) completed the CHNA with internal staff, and 21.4% used an outside consultant. In addition, we identified 39.3% as faith-based hospitals. Study and comparison hospitals did not differ based on county-level urban, suburban, and rural classifications; hospital’s faith-based identification; or staff versus consultant-led CHNA (Table 1).
Levels of Joint Action in Study Sample Hospitals The content analysis of the study hospital CHNAs provided insight into how the hospitals documented their relationship with LHDs. Table 2 describes the highest level of joint action between the study hospitals and the LHDs. No significant differences in hospital characteristics were found based on level of joint action using the Fisher exact test. Table 3 provides examples of the CHNA content at each of the levels of joint action. More than one third (38.2%) of CHNAs were coded with “cooperation” as the highest level of joint action. An example of cooperation was working together to identify health professionals in the community to create advisory councils or work groups around a specific health issue. The next most common levels of joint action were networking and coordination, with both at 20.6%. Networking examples included providing completed CHNAs to the LHDs for distribution and the hospital’s use of information provided by the LHD to assist in completing the CHNA. Coordination examples included working together on the CHNA and conducting community focus groups to identify high priority community needs. Only 1 CHNA described a collaboration (2.9%) in which they worked with 2 LHDs to perform a community-wide needs assessment; from those identified needs, they jointly established a federally qualified health center. Approximately 18% of CHNAs in the study sample did not indicate any levels of joint
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Comparison Sample Community Health Needs Assessments Review
TABLE 1—Nonprofit Hospital Characteristics (n = 84): Missouri, 2014 Study (n = 34), No. (%) or %
Comparison (n = 50), No. (%) or %
Total (n = 84), No. (%) or %
Yesa
18 (52.9)
37 (74.0)
55 (65.5)
Noa
16 (47.1)
13 (26.0)
29 (34.5)
Characteristics Member of larger health care system
Faith-based designation Yes No
12 (35.3)
21 (42.0)
33 (39.3)
22 (64.7)
29 (58.0)
51 (60.7)
25 (73.5)
41 (82.0)
66 (78.6)
9 (26.5)
9 (18.0)
18 (21.4)
19 (55.9)
30 (60.0)
49 (58.3)
7 (20.6) 8 (23.5)
8 (16.0) 12 (24.0)
15 (17.9) 20 (23.8)
40.0
60.0
100.0
Completion of CHNA By hospital By consultant Hospital location Urban Suburban Rural Coverage of total population Note. CHNA = community health needs assessment. a 2 v (1) = 3.97; P < .05.
action in relation to LHDs. Examples in the CHNA included collaboration with local school districts or working on “public health”
issues like seat belt initiatives, but none of the 18% indicated working with a LHD on these issues.
Review of comparison hospital CHNAs for key terms showed little mention of specific activities or collaborative efforts with LHDs. Most often, comparison hospital CHNAs referenced health departments in regard to existing personnel working at the health department or community health initiatives which they were leading, with little description of what this meant for the 2 entities on a collaborative level. Another common acknowledgment of LHDs was with regard to the services that were provided by 1 or several of health departments in the area. Content related to the terms public health and health center was general in nature and included public health professionals or public health as an organization or professional title, such as Public Health Department or Master of Public Health and federally qualified health centers. These findings illustrated the differences in describing collaborative action between the comparison group and the study population.
Comparison of Reported Levels of Joint Action TABLE 2—Study Sample Nonprofit Hospital Characteristics by Level of Joint Action (n = 34): Missouri, 2014 None No. (%) or %
Networking No. (%) or %
Coordination, No. (%) or %
Cooperation or Collaboration, No. (%) or %
Yes
5 (27.8)
3 (16.7)
4 (22.2)
6 (33.3)
No
1 (6.3)
4 (25.0)
3 (18.8)
8 (50.0)
3 (25.0)
2 (16.7)
3 (25.0)
4 (33.3)
3 (13.6)
5 (22.7)
4 (18.2)
10 (45.5)
By hospital
5 (20.0)
3 (12.0)
5 (20.0)
12 (48.0)
By consultant
1 (11.1)
4 (44.4)
2 (22.2)
2 (22.2)
Characteristics Member of larger health care system
Faith-based designation Yes No Completion of CHNA
Hospital location Urban
3 (15.8)
5 (26.3)
5 (26.3)
6 (31.6)
Suburban Rural
2 (28.6) 1 (12.5)
1 (14.3) 1 (12.5)
1 (14.3) 1 (12.5)
3 (42.9) 5 (62.5)
17.6
20.6
20.6
41.2
Coverage of total population
Note. CHNA = community health needs assessment. Levels of joint action as defined by the National Association of County and City Officials. These levels included networking, coordination, cooperation, and collaboration. We used the following definitions to identify each level: networking was considered “exchange of information”; coordination was “exchange of information and linking existing activities for mutual benefit”; cooperation was “sharing resources for mutual benefit and to create something new”; and collaboration was considered “working jointly to accomplish shared vision and mission using joint resources.”25
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Table 4 provides information regarding the hospital and LHD perspectives on the levels of joint action. The hospital perspective was from the content analysis of our study, whereas the LHD perspective came from the LHD collaborative survey. Networking and coordination were fairly congruent between the LHD and hospital perspectives. Notably, there was incongruence between the hospital and LHD perspectives with respect to cooperation and collaboration. This incongruence might be the result of an overestimate of the levels of joint action by the LHDs or an underestimation of the levels of joint action by the hospitals. These results indicated a need for further investigation to more accurately measure both perspectives, because this might prove to be a crucial area of measurement and understanding of the assumptions around collaboration among hospitals and LHDs.
DISCUSSION As mentioned earlier, the LHD collaboration survey identified 32% of the nonprofit hospitals
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TABLE 3—Levels of Joint Action and Examples From Nonprofit Hospital Community Health Needs Assessment Content Analysis (n = 34): Missouri, 2014 Level of Joint Action Networking: exchange information.
Hospital, No. (%) 7 (20.6)
Content Example The local health center offers a number of online resources. Examples of the services available at the health center include immunizations, mental health counseling, women’s health services, and smoking cessation “Quit Kits.”
Coordination: exchange information
7 (20.6)
and link existing activities for mutual benefit.
Hospital system–wide sponsored community roundtable events in both 2010 and 2011. These initial assessments were followed up by meetings with community partners, such as the schools, health department, and regional planning efforts with the partnership council. Continuation of the community roundtable process across the hospital system began in 2013.
Cooperation: share resources for mutual benefit
13 (38.2)
and to create something new.
The hospital clinic provides primary care and is supported by the county 1 and county 2 health department, county regional medical center, and several volunteer health care professionals.
Collaboration: work jointly to accomplish shared vision
1 (2.9)
and mission using joint resources.
On July 1, 2008, the hospital and the county health department began providing a free clinic 1 night per week for the residents of the county who had no insurance, Medicare or Medicaid coverage. Modeled after this clinic, the hospital partnered with the local health departments to open a free clinic in county 1 in 2009 and in county 2 in 2010. The hospital also works with federal, state, and local organizations to improve access to care and the health of the community. Locally, the hospital works with county health departments as they evaluate health needs and work to help meet those needs. The Hospital worked with the county 1 and county 2 health departments to help establish a federally qualified health center in the town.
None
7 (17.7)
Creating healthy communities requires a high level of mutual understanding and collaboration with individuals and organizations in the community.
in Missouri as collaborating with the LHDs on the CHAs. With respect to the hospital characteristics, study and comparison hospitals differed on 1 characteristic—a lower percentage of study sample hospitals were part of a health system than that of the comparison sample. It was possible that without health system resources or support, those hospitals in the sample study were more motivated to seek out the assistance of the LHDs to complete the CHNA. More research is needed to better understand the relationship of a hospital as a member of a system and the impact on likelihood of collaboration with LHDs. For all other characteristics, hospitals in the study sample did not differ from comparison hospitals. Although additional research is needed to examine potential differences, it appeared that, at least through this study, hospitals conducting their CHNA at the local level without health system support were more likely to engage local resources to complete the CHNA. Within the study sample, we found no differences among the hospital characteristics based on the levels of joint
action identified through the CHNA content analysis. Our content analysis of the CHNAs provided important baseline information that described collaboration between hospitals and LHDs from the hospitals’ perspective. Earlier research that described collaboration with hospitals from the LHD perspective provided initial insight and a means to begin quantifying collaboration based on the levels of joint action as described by NACCHO.23 With these 2 studies that examined both LHD and hospital perspectives, initial insight into potential disconnect regarding collaboration was possible. Further research into the differing perspectives and realities of collaboration between hospitals and LHDs might provide a basis for improved or more appropriate collaboration to fulfill policy requirements and goals for improved population-level health. The LHD and hospital perspectives had different leverage points that encouraged collaboration with each other. The goal of public health accreditation is to improve performance and quality of health departments.
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By meeting the accreditation standards, which include the 10 essential services, health departments might be able to improve population health, provide efficiency (cost
TABLE 4—Comparison of Reported Levels of Joint Action Between Study Nonprofit Hospitals and the Local Health Department Collaborative Survey: Missouri, 2014 Reported Level of Joint Action
Hospital, No. (%)
Local Health Department, No. (%)
Networking
7 (20.6)
6 (27.2)
Coordination Cooperation
7 (20.6) 13 (38.2)
6 (27.2) 0 (0.0)
Collaboration
1 (2.9)
10 (45.5)
None
7 (17.7)
0 (0.0)
Total
34
22
Note. Numbers may not total 100 because of rounding. Source. Wilson et al.23 for local health department information.
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effectiveness) in programs and activities, and do so with equity to all people.27,28 By requiring completion of both the CHA and CHIP before applying for accreditation, LHDs are better situated to provide services and meet the needs of their community. These processes necessitate collaboration with community stakeholders, including hospitals. From the hospital perspective, ACA legislation and regulations require hospitals to “include individuals with expertise in public health.”1 Although the source of expertise is not required to be the LHD, the more accessible public health expertise for many hospitals is likely to be the LHD. Because of the proximity of hospitals and LHDs to one another, continuing to promote these areas of mutual requirements through further integration of services and collaboration might be a promising approach to leverage scarce resources and to improve population health.5,29 The benefits of collaboration as an efficient approach to forming goals and achieving positive population health outcomes compared with individuals or organizations working alone are well documented.15,16,30,31 For example, a recent study of Texas nonprofit hospitals found that the quality of the CHNAs improved significantly when hospitals partnered with LHDs.32 The ability to test the assumption of collaboration within the framework of the theory of change is only possible if the assumptions of collaboration (e.g., through levels of joint action) can be measured.33 The results of both our analysis and previous studies indicated that measuring NACCHO’s levels of joint action might be an approach to better understanding and identifying appropriate levels of collaboration, leading to better use of resources and population-level health changes. The content analysis of the CHNAs we reviewed for this study revealed additional observations. Within the comparison group, key words that represented some type of collaboration reflected relationships outside of the LHD. Many of the comparison hospitals mentioned community partners, but the lack of detail provided in the CHNAs did not allow for any identification of levels of joint action. The CHNAs from the study sample more often had action plans for partnerships in their CHNA.
Our study provided early clues on the identification and use of (or lack thereof) a common language around collaboration. In developing a more widely understood language of collaboration, including measurement, more appropriate levels of action desired or required for a specific set of outcomes might be possible. Working toward a shared language, vision, and common measurement of collaboration for hospitals and LHDs might be important for reducing barriers to collaboration and for appropriate deployment of resources as both work toward improved population-level health. NACCHO’s framing of the levels of joint action provides a starting point for a common language and measurement around collaboration. Once levels of joint action are able to be measured, optimal levels can be determined with a calculated return on investment.
Limitations There were limitations to our study. Content analysis was conducted only using the CHNAs that were publicly available through hospitals Web sites, which represented 80% (n = 84) of nonprofit hospitals in Missouri. In determining our study sample, only 34 Missouri nonprofit hospitals were identified by the LHDs, representing 32% of all nonprofit hospitals in Missouri. In addition, methodological challenges existed because of differing geographical boundaries for LHDs and hospitals. A nationally representative sample is needed to generalize the results There was also an underlying assumption that the CHNA captured the full relationship between the LHDS and the hospitals. It was possible that collaborative efforts between hospitals and LHDs occurred, but were not captured in the CHNAs. Although the CHNA might not have completely captured the collaborative efforts, it provided a baseline for exploration. A longitudinal review of future CHNAs would allow for a review of CHNA changes made over time. Although differences in characteristics between study and comparison hospitals were reported, more information is needed to confirm differences, draw any conclusions related to these differences, or to understand potential implications related to those differences. A more in-depth survey of hospitals, coupled with content analysis, might provide
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a more robust identification of the collaborative relationships. Although a rigorous process for interpreting the content was applied, further analysis that includes direct questions to study sample hospitals is needed to fully develop a collaboration continuum and to begin to test the collaboration assumptions. Finally, our content analysis did not allow for the measurement of the frequency of levels of joint action, but only allowed measurement of the presence or absence of levels of joint action as reported through the CHNAs of the hospitals.
Implications As available resources for both hospitals and LHDs become more scarce, and various health sectors are encouraged to collaborate as a way to break down a “silo” approach to improving population-level health, alignment of various incentives, including policy incentives, becomes important.4 To break down barriers of collaboration and work toward common goals, it is important for these various sectors, including hospitals and LHDs, to identify and measure a common language of collaboration. Where common goals and requirements exist, it may be a more efficient and effective use of resources to determine the most appropriate levels of joint action to achieve goals. Hospitals and LHDs working together on the identification of health needs, determining priorities within their communities, and developing and implementing plans to address the identified priorities are specific approaches that begin to break down the silo approach. To foster a collaborative pathway and to fulfill policy requirements, both sectors should have a congruent perspective on how and why collaboration is of value to both sectors. Although the existing level of collaboration between hospitals and LHDs is varied, LHDs have an important and unique role in facilitating levels of joint action related to health assessments and planning. Assessment is 1 of the core functions of public health.34 Accreditation efforts, including the requirement of CHAs and CHIPs, provide LHDs with the incentive to actively engage hospitals and other stakeholders during the process. In addition, LHDs can actively position themselves as the public health experts in the
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community and engage hospitals as they complete their own CHNAs and implementation plans. LHDs in the past have often waited for the hospital to contact them to collaborate instead of pursuing the collaboration. 2 4 Collaboration requires time and financial resources. Depending on the level of joint action required, the intensity of time and financial resources can vary. Resources are scarce within LHDs and hospitals to carry out the policy requirements around the CHAs and CHNAs. Quantifying the specific levels of action necessary may lead to better understanding as to the most appropriate level of action given the desired outcome. Resources may then be more specifically planned and targeted without incurring possible diminishing returns on investment of time and resources for unnecessary levels of joint action.
Future Research Using CHNAs coupled with CHAs and resulting plans provide new and potentially rich information as to the best collaborative approaches for improved population-level health. Quantifying collaboration through a more in-depth survey similar to our survey that was administered to LHDs would provide more detailed information from the hospital perspective.23 More appropriately categorizing levels of joint action through quantitative and qualitative measurement would also assist in the allocation of appropriate time and financial resources. Comparing the new iterations of the CHNAs with the baseline CHNAs for modification of language and collaborative activity with LHDs might prove useful to identify innovation within communities. Future research considerations should also include the impact of policies on the assumptions of collaboration with respect to desired outcomes, and the discovery and impact of the most appropriate levels of joint action coupled with the impact of strategies and intended population-level outcomes. j
About the Authors Kate E. Beatty is with the Department of Health Services Management & Policy, College of Public Health, East Tennessee State University, Johnson City. Kristin D. Wilson is with the Health Management and Policy Masters in Public Health Program, Department of Health Management and Policy, Saint Louis University College for Public Health
and Social Justice, St. Louis, MO. Amanda Ciecior is with the Department of Vermont Health Access, Vermont Agency of Human Services, Winooski. Lisa Stringer is with the Department of Health Management and Policy, Saint Louis University College for Public Health and Social Justice, St. Louis. Correspondence should be sent to Kate E. Beatty, Assistant Professor, Department of Health Services Management & Policy, College of Public Health, East Tennessee State University, Box 70264, Johnson City, TN 37614 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted November 23, 2014.
Contributors K. E. Beatty and K. D. Wilson originated and supervised the study, and contributed to the writing of the article. A. Ciecior and L. Stringer completed the content analysis and assisted in completing the article.
Acknowledgments We thank Lisa Buettner-Mohr for her work on the LHD collaboration survey study, and Olivia Peavler and Tyler Carpenter for reviewing later drafts of this article.
health needs assessments. 2012. Available at: http:// ascendient.com/2011/06/the-patient-protectionand-affordable-care-act-newly-required-communityhealth-needs-assessments-2. Accessed September 8, 2014. 10. Folkemer DC, Spicer LA, Mueller CH, et al. Hospital Community Benefits After the ACA: The Emerging Federal Framework. Baltimore, MD: Hilltop Institute; 2011. 11. Somerville MH, Nolin MA, Mueller CH, et al. Hospital Community Benefits After the ACA: Building on State Experience. 2011. Available at: http://www.hilltopinstitute.org/publications/ HospitalCommunityBenefitsAfterTheACAHCBPIssueBrief2-April2011.pdf. Accessed September 8, 2014. 12. Beitsch LM, Thielen L, Mays G, et al. The multistate learning collaborative, states as laboratories: informing the national public health accreditation dialogue. J Public Health Manag Pract. 2006;12(3):217---231.
Human Participant Protection
13. Bender K, Benjamin G, Carden J, et al. Final recommendations for a voluntary national accreditation program for state and local health departments: steering committee report. J Public Health Manag Pract. 2007;13(4):342---348.
This study did not require institutional review board approval, as our study was a review of publically available documents that did not meet the threshold of human participant research.
14. National Public Health Department. National Public Health Department Accreditation Readiness Checklists Version 1.0. Alexandria, VA: Public Health Accreditation Board; 2011.
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