Health Systems Learning Group: NewPublicHealth Q&A with Gary Gunderson
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.
NPH: What is the big picture on the role of hospitals and how that role may be changing when it comes to improving community health?
Gary Gunderson: Well, the most fundamental thing going on is that the line is blurring between community-health strategies and hospital strategies, and primary-care and social-service strategies. Rather than a medical model that assumes someone comes for treatment, whether it’s billable or not, we’re looking at a new model that looks at hospitals as just one stage on a cycle of care. And to say cycle of care is different from saying a continuum of care because it assumes that the relationship doesn’t end. When our patients are not in one of our medical environments, they’re in a life that has many other factors going on that determine the effectiveness of the part that we contribute to that life—the treatment.
So what’s really happening is hospitals are more and more aware that the quality, effectiveness, value, efficiency and cost of what hospitals provide during that cycle of care is heavily determined most concretely by where the patient was 100 days before they became our patient. And where is that patient 100 days after they leave us? For the most part, their care is being managed by somebody other than us and in many cases it’s not being managed by any medical professional. They are really in the care of their family or their social network and in some cases our social services network.
So the notion that hospitals really are a part of a much more complex web of services demands that hospitals understand their community as not just being part of our system of care, but a part of a community system of care. That’s very decentering for a hospital because we’re by far the most expensive part of the process and so we think we ought to be in charge of it, but that’s actually not true. Hospitals do not—should not—be placed in charge of organizing community. No one wants to live in a hospital. But they can play a role.
NPH: Why are health systems such a critical partner in public health and community health efforts?
Gary Gunderson: Hospitals are critical if for no other reason than the fact that we absorb such a huge portion of the national budget for wellbeing. Hospitals absorb a huge fraction of that funding—and not just in terms of the treatment dollars, but also in terms of research dollars.
Very practically, we’re also at a place where the hospital sits at a critical learning moment for the entire system. So things that happen in the hospital frequently can be, if handled well, a profound time of life change and life evaluation ranging from spirituality to health behaviors. So hospitals are a learning landmark in that cycle of care that can be a tremendous opportunity, and for the most part it’s a wasted opportunity right now.
And, if you look at hospitals from a community systems perspective they are usually one of the largest employers in the city. They have a huge political and moral weight in the community they’re in and have the capacity to use that full institutional weight to do something more than protect them. They can lend that way to really advancing the consciousness, as well as the efficiency of the services of the whole community.
Let me use our hospital as an example. I’m at Wake Forest Baptist Medical Center and we have 13,000 employees—more employees than any other business in the city of Winston-Salem. Our employees aren’t just employees during the eight hours they’re in our buildings—they go back onto those streets and they very frequently are citizens with a presence and a role in every conceivable neighborhood organization, every congregation, every not-for-profit. If you really mapped the full social influence of our employees, as well as our formal corporate decision making, it’s an enormous asset for the health of the whole community. Right now, for the most part, hospitals describe our impact in terms of the services we sell or give away, and I think hospitals need to be accountable for their full social footprint in the community. We actually are doing a lot more than we get credit for and the effectiveness of the full social footprint could be much greater.
NPH: What are the recommendations of the HSLG so far?
Gary Gunderson: The heart of the recommendations lies in three critical components of what we’re calling an ensemble of practices.
First, address the social complexity of our most challenging patients by engaging at the neighborhood level. So, it’s a move from patient-focused to place-focused.
The second part of the ensemble is to do this in the context of large-scale, meaningful, sustained partnerships in the community. There are many partners who know these neighborhoods far better than the hospital does. Hospitals are always on everybody’s list of who to ask for money, but frequently the nature of that relationship is not transparent in terms of what we know about communities, what we know about people. We’re talking about going to a deeper level of partnership. These partnerships need to be built not at the symbolic or political level, but at the level of working together to change systems at the community scale.
And the third component is to spend our money proactively. For every single hospital involved in the Health Systems Learning Group, the largest single number in our operating budgets is charity care. And in every single case, that number is not really a budget—it’s a projection of what we will spend on charity care. I think quite simply what we’re recommending is for hospitals to develop the financial discipline to enable them to spend some portion of those funds proactively instead of reactively. In the case of Wake Forest, we project that we’ll spend about $65 million in charity care—entirely unreimbursed care—this year. But what if we looked at the neighborhoods where that care is concentrated and spent say 5 percent of that amount by going out and helping to create a healthier community? Could we actually control the cost of that care by being proactive and our answer is yes, because for the most part, the most expensive possible care is the reactive kind of care that we provide at the emergency room. So if we could be proactive probably we could find ourselves spending less, but even more importantly we’ll be fulfilling our mission.
The fundamental insight of the Health Systems Learning Group is that the money we need to do community engagement is the money we are already spending—but we’re spending it ineffectively and reactively on charity care instead of on prevention and public health.
NPH: Do your strategies benefit from the community benefit requirements of the Affordable Care Act?
Gary Gunderson: We didn’t invite any hospital into the Learning Group that was actually worried about whether or not they were going to fulfill community benefit rules. Those rules are quite minimal. But our mission asks us to do more than community benefit. It actually suggests something more like community transformation and that requires a different standard. Community benefit legislation doesn’t really require us to lay down a strategy to actually improve the health of the community. It really just requires us to try and show that we assessed the needs of the community and that our strategy shows some semblance of seriousness about a good faith effort to make it better. But effectively, if you do those two things you’re not going to lose your tax status.
Well, that’s just not enough. We turn around and hold the management of this very strong, very smart organization to a much higher standard, with a real transformational goal in mind.
NPH: Can you give us some examples of innovation happening in this area?
Gary Gunderson: The Wake Forest Baptist Medical Center is directly employing the learning that’s come out of the Health Systems Learning Group. For instance, the Faith Health Division (which works on community partnerships and addressing socially complex determinants of health in the community) is actually relocating into new shared office space with our care transitions department (which works on the transitions from hospital to community and preventing readmissions). We’re locating these two teams together precisely so that we can integrate clinical and community strategies for engaging the high-utilizing patients in their community. That’s very directly informed by the Learning Group.
NPH: What do you anticipate your community will be doing with proactive spending for targeted community work?
Gary Gunderson: We’re taking community mapping from the zip code level and bringing it down to the census track level where we can understand community needs at a more granular level. We have said to our board that over the next three years we expect to see gross charity care at census track levels decline because of our proactive engagement, because of our community partnerships including with United Way, as well as with congregations.
We have excellent data. We can tell you exactly census track by census track how much charity care has been received by people who live in those areas. We’re actually overlaying 20 different kinds of data from not just our own charity care, but also public health data and other kinds of data such as graduation rates and food deserts and all sorts of stuff to bring in to very sharp clarity the current status of wellbeing. Using that, we aim to then figure out how to actually combine our body of work and take action. But we anticipate being held accountable not just patient by patient, but also focusing on the most concentrated opportunities to advance health in the worst census tracks. But that turns on the imagination. Hospitals don’t think about populations as being people who live in a particular place, they think of populations as being a groups of people organized by what kind of disease they have in common—the congestive heart failure population, for instance. So this census track focus has helped our board and our senior management and our clergy partners to see the community with new eyes, as a set of issues you can actually do something proactively about. So it’s actually pretty revolutionary by hospital standards. It’s a change in how we might be accountable not just to other people’s demands on us, but to the mission that’s actually deep in the heart of the organization.