Category Archives: Hospitals
A Hospital Helps Revitalize the Community Outside Its Walls: Q&A with George Kleb and Christine Madigan
Over the last few months, NewPublicHealth has reported on initiatives of the participating members of Stakeholder Health, formerly known as the Health Systems Learning Group. Stakeholder Health is a learning collaborative made up of more than 40 organizations, including 36 non-profit health systems that share innovative practices aimed at improving health and economic viability of communities.
>>Read more on the Stakeholder Health effort to leverage health care systems to improve community health.
One Stakeholder Health member is the Bon Secours Baltimore Health System in Maryland, whose Community Works initiative helps improve the lives of the people in one of the poorest neighborhoods in the city. Bon Secours Baltimore is part of a national health system founded by the Sisters of the Order of Bon Secours.
Bon Secours engaged the community before embarking on projects and have created programs aimed at improving the community’s health through services that include the hospital, community clinics and visiting nurse programs, as well as housing, GED and financial literacy programs and revitalization programs.
The ambitious housing program will ultimately provide more than 1,000 units of affordable housing in the streets just around the hospital.
Bon Secours’ partner in its housing program is Enterprise Community Partners Inc., which builds affordable housing throughout the United States. NewPublicHealth recently visited the Bon Secours housing and services sites in Baltimore and spoke with George Kleb, executive director Bon Secours Health System, and Christine Madigan, senior vice president of development at Enterprise Homes.
NewPublicHealth: When did the housing program begin?
George Kleb: Bon Secours here in Baltimore has been developing and operating housing since 1988. We started by developing a couple of senior buildings through a U.S. Department of Housing and Urban Development (HUD) program. Both buildings had been schools that were part of the surplus capacity in Baltimore. The HUD program serves people who are elderly, disabled, or very low income. There was a clear need and so we pursued that, and that was the start of our reach into housing. Then in the ‘90s we began work on housing really in line with a neighborhood revitalization strategy attached to our presence in the neighborhood of Southwest Baltimore. There was an area of West Baltimore Street, which is the street the hospital is on, that had become largely vacant. Two-thirds of the units in the three blocks leading up to the hospital were empty and we acquired 31 of those buildings and started a project we now call Bon Secours Apartments. We renovated three-story Victorian row homes into affordable apartments, and that’s when we started working with Enterprise. That’s a relationship that goes back to the mid-1990s.
What’s that cute blue thing shining its lights in the patient rooms and hallways of the National Institutes of Health’s (NIH) clinical center in Bethesda, Md.? A literal life saver.
Tru-D, a new robot now gainfully employed at the NIH, shoots beams of ultraviolet (UV) light. The rays kill a range of pathogens, including many of the bacterial strains—such as MRSA and C.diff—that have been linked to 90,000 health system deaths each year, according to the U.S. Centers for Disease Control and Prevention (CDC).
Manual disinfecting rids surfaces of about half of the bacteria in an area. Limitations of human cleaning squads include the probability they can miss a few—or many—spots and that disinfectants must remain wet on a surface for a full ten minutes to fully do their job and then be rinsed away. That time commitment is often very costly for hospitals that typically need to turn over patient rooms quickly. But incomplete disinfection can leave a lot of disease. MRSA, for example, can remain on surfaces for as long as nine months.
The UV light units work by disrupting the DNA structure of pathogens, which destroys some and makes others harmless.
Tru-D is just one of several UV light units on the market. It has been getting some attention recently both because of the NIH purchase and because it has some especially interesting features, including a cloud-computing system that lets it link up to health system records and automatically chart which rooms have been disinfected.
UV light doesn’t come cheap. Units, which come in different sizes that determine how wide a space they can disinfect simultaneously, can range from about $60,000 to $120,000. But hospitals also consider what they’re saving by making the purchase—such as new fines under the Affordable Care Act for some hospital readmissions before thirty days after a discharge. And some of those readmissions are for infections acquired during a hospital stay.
The units won’t displace the human cleaning staff, says Steve Streed, system director of Epidemiology/Infection Control at the Lee Memorial Health System in Fort Myers, Fla. and a member of the Association for Professionals in Infection Control and Epidemiology For example, the robots can’t rid spaces of blood and other substances humans leave behind.
UV units can disinfect a space in ten or twenty minutes. One limitation on their power and cleaning time is the wattage in hospitals. Units can be made more powerful but would blow out a hospital’s circuits. Streed says one company is working on a hybrid unit that would use both electricity and battery to amp up the wattage—and likely reduce the time needed—to disinfect hospital spaces.
Streed says recent studies have found that human disinfecting still leaves 50 percent of residual bacteria and UV light gets rid of 99 percent of what remains. Another disinfecting system, fogging rooms with hydrogen peroxide, gets rid of 99.9 percent, but takes more time since air ducts have to be closed before it use and then reopened afterwards. Either option gets rid of sufficient bacteria, says Streed. What remains is generally not in high enough levels to infect a patient.
>>Bonus Link: Read a CDC Vital Signs Report on Hospital Acquired Infections.
On a busy night at the Stamford (CT) Hospital ER on the snowy East Coast this past holiday weekend, wait times for emergencies were just minutes thanks to a system that has a technician take vital signs within moments of patients walking through the entrance. Those metrics are passed to the medical staff to review in a room just a couple of steps from the reception area which, through a back door, opens onto several emergency suites where treatment can begin almost instantaneously. Contrast that with recent reports of hours-long waits, reduced staff and insufficient equipment at many rural hospitals, which often face budget, staff and equipment constraints.
One solution may be sharing those resources, according to a new study in Health Affairs by researchers at the University of Iowa College of Public Health. The researchers evaluated a tele-emergency service in the upper Midwest that provides 24/7 connection between an urban “hub” emergency department and 71 remote hospitals. At any time, clinical staff at the remote hospitals can press a button for an immediate audio/video connection to the tele-emergency hub Emergency Department.
A survey of the staff members at the rural hospitals found that 95 percent of those responding found that that the relationship significantly improve care for their patients in several ways:
- Improved quality of care
- Provided clinical second opinions for the rural medical staff
- Increased the use of evidence based treatment
“Tele-emergency improves patient care through integrated services that deliver the right care at the right time and the right place,” says Keith Mueller, PHD, head of the Department of Health Management and Policy and lead author of the report. “Our country’s health care system is in a massive state of change, and it’s through services such as this that we’ll be able to address patient need and assist in the financial concerns of smaller medical care units.”
Read the Health Affairs abstract.
The Health Systems Learning Group (HSLG) is made up of 43 organizations, including 36 non-profit health systems that have met for the last eighteen months to share innovative practices aimed at improving health and economic viability of communities.
The idea for the learning collaborative came from a series of meetings at the White House Office and U.S. Department of Health & Human Services Center for Faith-Based & Neighborhood Partnerships. The HSLG’s administrative team is based at Methodist Le Bonheur Healthcare Center for Excellence in Faith and Health in Memphis, Tenn., and at Wake Forest Baptist Health System in Winston-Salem, N.C. The Robert Wood Johnson Foundation provided a grant to share the group’s findings and lessons learned.
In addition to its other work, earlier this year the HSLG released a monograph that aims to help identify and activate proven community health practices and partnerships. Once identified, they can be combined with other evidence-based initiatives to reveal new pathways to transform unmanaged charity care into strategic, sustainable community health improvement.
Recently, NewPublicHealth spoke with the Reverend Doctor Gary Gunderson, vice president of the Division of Faith and Health Ministries at Wake Forest Baptist Health and co-principal investigator of the Health Systems Learning Group, about their vision for the future of healthy communities and the role that hospitals and health systems will play.
NewPublicHealth: What are the goals of the Health Systems Learning Group?
Gary Gunderson: The essence of the task was to help each other learn how we can fulfill our most basic mission. All of the Health Systems Learning Group members are not-profit. The vast majority are faith-based, and so in every case our essential mission boils down to improving the health of the community that created us.
All of the HSLG members are financially stable and we all provide a lot of charity care, but that does not add up to necessarily fulfilling our real aspirational mission and that’s what we came together: to see whether it’s possible to do that in the current environment. And our fundamental answer is that it is possible to do that, but we have to have some new competencies and expanded commitments in order to do it.
There is great promise in leveraging the strengths and resources of both the health care and public health systems to create healthier communities. Hospital community benefit is one critical area of opportunity for greater collaboration. Historically, nonprofit hospitals, as a condition of their tax-exempt status, have been required to enhance the health and welfare of their communities. Through the Affordable Care Act, nonprofit hospitals will have the opportunity to direct their community benefit efforts toward public health interventions and collaborate more effectively with local health departments.
Paul Kuehnert, MS, RN, senior program officer and director of the Public Health Team at the Robert Wood Johnson Foundation (RWJF), shared his insights on the opportunities and challenges that lie in integrating health and health care. Prior to joining the Foundation, he was county health officer and executive director for health for Kane County, Ill., where he led a partnership between the health department, hospitals and other partners to assess and address the community’s health needs. Paul is a Pediatric Nurse Practitioner and worked as a primary care provider in schools and other community settings in Missouri and Illinois.
NewPublicHealth: There has been lots of conversation across the public health field about the need for more strategic coordination or integration with health care. Why is there so much focus on this now?
Paul Kuehnert: There are a couple of reasons for that. One of the primary reasons is that we know that there are increasingly limited dollars for public health. We really have to be as efficient and effective as we can be in trying to improve health in our communities. There’s a common interest between public health and health care around controlling the overall cost of health care. At the same time, we’re not getting the kinds of health outcomes we need. There’s this dynamic of mutual interest in controlling cost and finding ways to improve health and get to the best health outcomes for the community.
Several sessions at this week’s American Public Health Association meeting in San Francisco urged nonprofit hospitals and public health departments seeking national accreditation to join forces on community assessment reports that both are required to file.
Assessments can reveal critical needs in a community, such as asthma trends that could point to poor housing conditions. In a growing number of cities, such reports are providing the evidence needed to marshal resources and action such as dispatching case workers to make home visits to help prevent and reduce asthma emergencies. Such expenditures can reduce the cost burden of paying for emergency care and prevent more health crises in the first place.
In San Francisco, the health department and the city’s non-profit hospitals have been collaborating on community benefit and needs assessments reports since 1994 and have achieved much more than “just a sheaf of papers that sits on a shelf,” says Jim Soos, Assistant Director of Policy & Planning at San Francisco Department of Public Health. The collaboration has resulted in a number of critical efforts to improve health here, including San Francisco’s Community Health Improvement Plan (CHIP), which will be launched by early in 2013.
>>EDITOR'S NOTE: On 9/13/2012 CeaseFire changed its name to Cure Violence.
Sheila Regan manages hospital partnerships for Cure Violence, formerly CeaseFire, an organization based in Chicago that has pioneered a public health approach to stopping shootings and killings. A grantee of the Robert Wood Johnson Foundation, Cure Violence has been successful at reducing violence in cities across America.
This week at APHA, Cure Violence shared how violence presents all the same characteristics of an infectious disease. Like tuberculosis or cholera, violence appears in clusters; it spreads and can be transmitted. By changing the frame on violence, Cure Violence is able to use proven public health strategies from other epidemics to stop shootings and killings. Hospital partnerships are a key part in stopping the spread and transmission of violence.
NewPublicHealth: Can you explain how Cure Violence’s hospital partnerships work?
Sheila Regan: We have a number of partnerships with level I trauma centers that are committed to the public health approach to violence prevention. We serve patients who are violently injured, typically shootings, stabbings or beatings and work to prevent further violence, retaliation or re-injury, which are seen as normal in our culture. There are the doctors, police, nurses, social workers, and everybody you’d expect to see in the hospital. What we’re trying to do is introduce a third party—our workers—who can impact behavior and mindset around violence at an opportune moment.
NPH: When someone has been injured, what is the goal of Cure Violence working with them in the hospital?
Several sessions at this year’s American Public Health Association meeting include brass-tacks guidelines for initiating and furthering partnerships between public health and hospitals to improve community health. In a session yesterday, Michael Bilton, who co-founded and leads the Association for Community Health Improvement of the American Hospital Association, spoke about the value of partnerships between public health and hospitals, since both have requirements to complete similar community needs assessments.
Health departments seeking public health accreditation must complete a community needs assessment, and non-profit hospitals must complete community benefits reports every three years under the Affordable Care Act.
Bilton pointed out that for many communities, the collaboration won’t be one that starts from scratch. San Francisco has had a community benefit requirement for non-profit hospitals since 1994, “which promoted a sense of collaboration in many communities,” Bilton told the audience at the APHA session.
Bilton says the collaboration also aligns with the National Prevention Strategy, released by the Surgeon General last year, which is promoting partnerships across federal agencies to improve community health.
>>Read an interview series on the National Prevention Strategy on NewPublicHealth.
Bilton says the Strategy specifically points to community needs assessments as a way to identify and begin working on many of the priorities in the Strategy. “And those priorities have already been identified by many hospitals,” says Bilton. The joined forces of hospitals and public health departments also help achieve the “triple aim” of additional goals stressed in the Affordable Care Act including improving improving care, improving health care quality and reducing costs. These collaborations underscore the notion that helping to manage population health is the role of hospitals as well, said Bilton.
Bilton advised public health officials anxious to collaborate with hospitals on community benefit requirements to do several things including:
- Become acquainted with hospital regulations
- Approach hospitals as early as possible in your process
- Find out who is leading the assessment
- Ask hospitals about their assessment process and goals
- Offer to help hospitals with with data, communications, facilitation or staff expertise, as appropriate
- Balance short term needs such as fulfilling IRS or accreditation requirements with longer term opportunities—sustained health improvement collaboration.
>>Bonus Link: Read a NewPublicHealth interview with Laurie Cammisa from Children's Hospital Boston on community benefit collaboration.
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?
Jose T. Montero, MD, director of the Division of Public Health Services at the New Hampshire Department of Health and Human Services, was elected president of the Association of State and Territorial Health Officials (ASTHO) during the association’s recent annual meeting in Austin, Texas.
Dr. Montero began his medical career in Putumayo, Colombia, where he served as a local, county and state health official. He then went to teach family and preventive medicine and later became Colombia’s public health director. Dr. Montero began his service in New Hampshire in 1999 as chief of the New Hampshire Communicable Disease Section in the Division of Public Health. Before becoming director of the New Hampshire Division of Public Health Services, Dr. Montero was the state epidemiologist. He is an adjunct professor of family medicine and a member of the preventive medicine residency advisory committee at Dartmouth Geisel School of Medicine.
NewPublicHealth spoke with Dr. Montero about the new ASTHO President's Challenge, which will focus this year on the integration of public health and health care.
NewPublicHealth: Why is so critical now to work toward the improved integration of public health and health care?
Dr. Montero: We keep talking about the health system but there is not much that is health-focused—it’s currently mostly about providing care after people becomes ill. From a public health perspective we’re trying to improve outcomes and quality, without spending the amount of money on health that we’re currently spending because we can’t sustain that. The system needs to continue changing and evolving, but we don’t yet know what exactly how it will look or how it should look. We need to create a new system. Based on the experiences of some states, such as Massachusetts and Oregon, we know gaining access to health insurance has expanded use, but we don’t know if they’ve achieved improved health outcomes yet. We’re working toward that. But we need to work on the right indicators that allow us to consistently measure total population health.
When you look across the country, you see that public health entities provide the continuum of care throughout the life cycle. We are already integrating health care and the public health system at several different places and levels, but it’s not consistent. To prepare ourselves for the future, we need to be able to look at public health and health delivery systems and integrate them philosophically. We need to capture examples, decode them, and see what works and what doesn’t and how to use which in different parts of the country. We have different cultures, different investment levels, and different expectations. We can’t just copy and paste.
NPH: What are the critical issues you’re looking at?