Hospitals interested in providing more than clinical services see the value of connecting with United Ways to go “upstream.” United Ways can assist their hospital partners with addressing the social determinants of health—housing, employment, income and education—in a comprehensive way. The work of the Community Health Initiative at the Cincinnati Children’s Hospital Medical Center and their relationship with United Way of Greater Cincinnati is just one example.
Hospitals and Community Organizing: Q&A with Robert Kahn Robert Kahn, Cincinnati Children's Hospital Medical Center (photo courtesy of the hospital)
The Community Health Initiative (CHI), a program of the Cincinnati Children’s Hospital Medical Center in Ohio, includes work with nontraditional community partners to support community organizing and address critical children’s health issues in the community. For example, using geocoding technology to identify areas of greatest need—“hotspots”—by mapping clusters of readmitted asthma patients to substandard housing units owned by the same landlord. CHI partnered with the Legal Aid Society of Greater Cincinnati, which helped tenants form an association and compel the property owner to make repairs. CHI also makes referrals to Legal Aid for patients who need help with Medicaid benefits or require other legal assistance. CHI has developed specific health metrics with which it evaluates the effectiveness of its programs and shares these data with local community organizations and CHI’s community partners.
The CHI work was featured in a new community benefit issue brief from The Hilltop Institute at UMBC, “Community Building and the Root Causes of Poor Health.”
NewPublicHealth recently spoke with Robert Kahn, MD, MPH, who is the Director of Research in the Division of General and Community Pediatrics at Cincinnati Children’s Hospital.
NewPublicHealth: What are the goals of the Community Health Initiative?
Robert Kahn: The Cincinnati Children's Hospital board established in its strategic plan for 2015 four goals that relate to the health of all 190,000 children in our county. The goals relate to: infant mortality, unintentional injuries, asthma, and obesity rates as they relate to hospital readmissions. Our plan is to build a strategy and an infrastructure to cover the ground between a more traditional clinical approach and a truly public and social wellbeing approach to these conditions.
NPH: Why are partners so critical?
Robert Kahn: The hospital realized it can't possibly do this on its own. We need community collaborators to work with. The strategy we've taken is to think about how quality improvement approaches that we've used internally, say, to reduce central line infections, could be applied in a more public health kind of a way. So, how can we pick a small geographic area, think about rates of asthma or unintentional injury in that geographic area, begin to identify partners who would like to work on it with us, develop a shared understanding of the need and the drivers of the problem, and then begin to try to move at least the intermediate measures and eventually the final outcome measures.
NPH: Using unintentional injury as an example, how did the collaborations happen?
Robert Kahn: The hospital’s head of trauma surgery is leading our unintentional injury initiative. He used hospital discharge data to find the rates of unintentional injury between ages 1 and 4 in over 90 neighborhoods. Using one neighborhood, Norwood, as an example, he sat down with the mayor, the head of the fire department, EMS, and the public health department to begin thinking collectively about what we could do. They tried a few strategies that didn't work to get into homes to install safety equipment, and now they’ve shifted to community-wide safety days to attract parent attention and interest.
They’ve had two safety days in which they’ve gotten tremendous numbers of volunteers and they've actually installed safety equipment in about 20 percent of all the homes in that community with children under age 5, with equipment such as smoke alarms and safety gates. But the hospital soon realized that we can't be in the business of doing this in every community ourselves. Now we’re looking at how we can develop a cadre of community leaders so that it can eventually be scalable to other neighborhoods. And we are able to share with communities the rates of unintentional injuries in children in their community, because we take care of 90 percent of the emergency room visits and hospitalizations for kids in the county. So, essentially we are a population-based provider and can almost take on a more public health frame because we have all that discharge data.
NPH: How do you crystalize the hospital’s role in community organizing?
Robert Kahn: I see our role as bringing the health data and our strength in methodology to the community, and in some sense helping be a catalyst or an instigator for creating change on the ground. For the actual organizing, I would much rather find an existing child health consortium on the ground. A community has to own this in the long run for it to be sustainable.
NPH: Who are the partners that are so critical to get perspective beyond health care?
Robert Kahn: I think the goal, from my standpoint, is to get upstream of the health problems and actually think about the social determinants of health and help address issues like housing, employment, income and education. As we think about that, we've tried to consciously identify who are the very high leverage organizations that can help county-wide, as well as local organizations that can do more of the grassroots work. We're really trying to develop collaboration, for example, with the United Way of Greater Cincinnati. They have bold education and income goals and increasingly are developing bold health goals. So, how can we partner with an organization like United Way that distributes funding to agencies in the community, and use that as a high leverage point for action. Similarly, the Cincinnati public schools play a pivotal role in the lives of tens of thousands of children. How can we work at the highest levels with them as well to develop an agenda around good nutrition and physical activity?
NPH: Tell us about the asthma hot spotting project.
Robert Kahn: With the hospital discharge data for asthma, we can look at uncontrolled asthma practically in real-time, and then geocode those events to neighborhoods. We have maps now of the counties where we know where the asthma hotspots are, for example. We can give feedback on a monthly basis to see if things are changing. That drives a sense of urgency for us and also hopefully for the community partners to create change as quickly as possible, or to create improvements as quickly as possible.
NPH: And what is an example of an innovative partnership the hospital engaged in to tackle issues that span beyond clinical care?
Robert Kahn: An absolutely amazing collaboration is one between physicians taking care of low income kids and lawyers committed to low income families through the Legal Aid Society of Greater Cincinnati. We've built a partnership in which there's a legal advocate in our clinic five days a week. We now send over 700 referrals a year to the legal aid advocate. In that clinic, we have 15,000 children and over 35,000 visits a year and physicians ask about housing conditions, but this partnership with legal aid has uncovered really important patterns. Three separate physicians referred a family to legal aid where the family reported that the landlord told them, in the heat of summer, that they'd be evicted if they put in a portable air conditioner into the unit.
Legal aid asked the simple question that a physician never would have asked—who's your landlord? They discovered there was a single developer who owned 19 buildings in Cincinnati who had gone into foreclosure, and all 19 buildings, with over 600 units, were falling into disrepair. They went in and formed tenant associations, worked with Fannie Mae and the property management company for the buildings to institute systemic repairs in about eleven of the buildings including new roofs, cooling and heating. By physicians working hand in glove with a great organization like legal aid, whose mission is stabilizing housing, stabilizing income, we together achieved sort the broader aim of addressing social determinants.
>>Read a brand new study published in Pediatrics describing the outcomes of this medical-legal partnership.
NPH: Have you seen any progress so far, on any of these issues?
Robert Kahn: That's always the hard question. We think we're beginning to see a signal, especially with the injury work in Norwood. It's very early and we still have a lot of mistakes to make and learn from. For asthma, there's a team that's been working on the issue for a while, and we see a reduction in readmissions among children on Medicaid. And they've done that by trying to move more of the care out into the communities, such as a home health program where they're working on self-management of asthma in the home, as well as home delivery of asthma medication to improve adherence.
One of the huge wins for me was when I saw some of the hospitals' approach to goal setting and data-informed approaches appearing in grants that community organizations are submitting, independent of us. They’ve now put in a couple of grants to support their own neighborhood work where they’ve asked to borrow our key driver diagram or asked us to suggest quality improvement approaches. They’re finding value in what we’ve offered to put into proposals of their own, which creates a more sustainable model for change.