Public Health and Health Care Working Together: Paul Kuehnert Q&A
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.
NPH: The new requirements around hospital community benefit are often discussed as being among the greatest opportunities for working together across public health and health care. From both a public health and health care perspective, what do you see as the promise of this area?
>>What's new with community benefit? Read up in a new brief.
Paul Kuehnert: There’s tremendous promise in hospital community benefit, particularly around three areas. One is more effective and more efficient use of local community resources. Another is that this area of collaboration between hospitals and public health can lead to a better understanding of community health problems. And lastly, both public health and health care institutions can have more of an impact on ‘moving the ball down the field’ on health if we work together and coordinate our work.
The new community benefit requirement for hospitals to do community assessments coincides with health department accreditation requirements to also do these assessments. Accreditation is about the health department setting up systems both within its agency and with partners in the community, including hospitals, to really get a handle on critical health problems coming up in the community. It is also about making sure there are systems and methods for collecting the right information or data, understanding that data, communicating to the community about it, and then really taking community-wide actions to address those problems systematically.
>>Read up on a series of conversations about transforming public health.
NPH: What’s an example of how public health and health care can work together?
Paul Kuehnert: In Kane County, Illinois, where I worked before the Foundation, we formed a collaborative to do a Community Health Assessment that would meet the requirements of the health department for accreditation, and would also meet the hospital’s IRS requirements for community benefit. As I talked to hospital executives about this when we were exploring the opportunity, I found out that the last time hospitals did a needs assessment they had each spent about $60,000. I also talked to our two largest United Ways, they had spent similar amounts. So when we looked at a potential partnership of five hospitals, two United Ways and our community mental health board, we were able to combine resources and spend only about $20,000 a piece for what turned out to be a much more comprehensive assessment. That in turn gave us data to better understand the community health needs.
In our case we chose to conduct a survey and instead of the usual community survey that has about 300 respondents, we were able to contract to get about 2,000 respondents because we had the resources and we wanted to be able to understand what was happening at a neighborhood level. One example of what that helped us understand was that even though our adult smoking rate in Kane County had fallen down to 12 percent, which is outstanding, the data showed that low-income Latino men were smoking at rates of about 30 percent. So, we were able to expend our resources more efficiently and still find out more about a very significant health problem. That in turn allowed us to really target our efforts. The health department conducted a really targeted media campaign, and the hospitals and health centers were prepared to conduct smoking cessation classes and counseling and provide the medical support for this population. That example really shows how we can get better impact by working together. Collaboration between health and health care has great potential in making that happen.
NPH: What do you think are some other key areas of opportunity for public health and health care to work together?
Paul Kuehnert: Health information technology and health information exchanges are another key area for more collaboration between health and health care. There are also opportunities around better systems coordination in prevention efforts. We know that we need community-based prevention and policy changes to address barriers to good health. But that doesn’t work by itself, if there’s not a clinical component. You can have a policy to ban smoking, but if you don’t have a way for smokers to get the help they need to quit, it’s not as effective. And likewise, having doctors and nurse practitioners advising and giving someone tools to quit smoking doesn’t work as well if there aren’t community changes in place like smoke-free indoor spaces that make it easier for them to quit. There’s an opportunity for collaboration at the very local level—doctors and nurses working together with public health so that both are aware of the community resources, and have the data to be able to focus on what the community really needs.
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Public health nursing is another good example of a role that can bridge a clinical focus with a community focus. For example, public health nurses may be working with high-risk infants or young pregnant moms. The nurse can be very effective in delivering individualized prevention messages to that mom—helping her understand the development of her child, anticipating things that would support the healthy growth of the baby, and educating on critical areas like lead paint poisoning prevention. As a public health nurse, she’s also in a very unique position to step back from that one family and look at her caseload and notice that she has a number of families in older homes in great disrepair, allowing her to identify a risk for lead poisoning in that community as a whole. That nurse can be a connecting point between the individual-oriented care and education, and working within the city or county government to advocate for lead poisoning prevention by improving a neighborhood’s housing. So that role can span both worlds.
>>Health Leads: Read about a program that uses health care settings to connect patients with the resources they need to be healthy.
There’s also a very powerful role that clinicians, doctors and nurses can play in public policy. In Kane County, we were working on banning smoking in bars and restaurants to protect people from secondhand smoke. Probably the most effective person who spoke at a local hearing was an oncologist from the community hospital in town. He told a very compelling story about one of his patients he was treating for cancer, and had traced it back to the fact that this individual was exposed to secondhand smoke for a very long time. That story had more impact on that city council than anybody else who talked that night. When they went into deliberations, that’s the story they kept coming back to. That’s another area for very effective collaboration between health and health care. Public health has the data to reveal the problems in a community, but the clinicians have those one on one connections and the stories that can bring the issue to life.
NPH: What do you feel are some of the key challenges to collaboration between public health and health care, and what is needed to overcome those challenges?
Paul Kuehnert: I think there are a number of challenges. First of all there are differences in the health care and public health agencies in terms of language and culture. Each field approaches problems from a different point of view. For example, the word “prevention” may mean one thing to the public health community—preventing disease for a whole group of people—while on the clinical side, people are thinking of preventing disease for an individual person, one clinical intervention at a time.
Another issue is that everyone has a shortage of time. That can be a real barrier. Because if we’re going to address these cultural differences between the fields, the solution is spending time together to build those relationships from the ground up. I think the way they can be addressed is at the local level by providing ways and means for people to make connections. Just as an example, people from the public health department can have discussions and meetings on a regular basis with providers in the medical community, and spend time building those bridges as professionals. Eventually, the shared understanding and the connections should overcome the barriers.
NPH: What more work is needed to make progress in this area?
Paul Kuehnert: The Foundation is interested in finding out more about these kinds of collaborations because fundamentally we care about improving health and health care for everyone. At this point, we’re really interested in understanding what is going on in communities across America, how bridges between public health and health care are being built, and the research behind what works. I think we’re at a place right now where we really need to know more about these kinds of efforts underway in many communities across the country. We need to understand the specifics, to hear the stories, and then pull this together as evidence of what works and share the best practices with all of our communities across the country.