TOOLBOX

Individual health is influenced on a daily basis by numerous factors that are outside the scope of clinical interventions. This is emphasized in the World Health Organization’s definition of health – “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. Lack of access to affordable and safe housing, public transportation, places to be physically active, healthy food, and jobs can all compromise a person’s well-being.

Health care is a continuum and relationships between hospitals, providers, community organizations, and patients facilitate the patient’s understanding of the community’s role, the health care system’s role and the individual’s role in maintaining health. Beyond clinical care, there are a number of federally and state funded agencies, local public health departments, community non-profits, civic organizations, and local government that collectively address the determinants of health, which include the social and economic environment, the physical environment, and a person’s individual characteristics and behaviors.

As hospitals increase their focus on improving population health in response to meeting the Centers for Medicare and Medicaid Services adoption of the Triple Aim, collaboration with local community services organizations is essential. These relationships provide an entryway for hospitals to provide patients with referrals to information, services, and educational opportunities to address a patient’s non-medical needs that may impact their overall wellness.

In many local communities, local services organizations have already established interagency collaborations to share information and network about services. Health care systems should consider joining such collaborative groups. In general, the local United Way agency serves as a facilitator of these types of interagency groups or can assist hospitals to join these entities. In Texas, Community Resource Coordinating Groups (CRCG) are a mechanism for state and local agencies and organizations to conduct shared client management. Although focused on jointly managing the needs of shared clients, the groups often include a networking and information session as part of their regular meetings which may be of benefit to hospitals.

Community health assessments provide hospital boards and administrators with an overview of a community’s health status, needs, resources, and priorities. The findings from these assessments not only help inform the strategic and operational planning of local hospitals, but also that of the entire local health care delivery system including public health departments, clinics, pharmacies, home health, and social services organizations that address social determinants of health, such as availability of safe housing, transportation, etc.

The following are key principles of community health assessment:

All phases of community health improvement: assessment, planning, investment, implementation, and evaluation. These are joint processes shared and owned by a multi-sector community collaboration that includes but is not limited to health care, social services, education, local government, civic organizations, and community advocates.

The process engages a broad cross-section of the community that ensures proactive, and diverse participation to improve results.

The community, as defined by the stakeholders, must be a significant enough area, (e.g. region, county, zip codes in largely populated areas), to allow for population-wide interventions and results that can be measured and evaluated. Additional focus should be given to address disparities among subpopulations, (e.g. uninsured or minority).

All phases of the process should be conducted with maximum transparency to encourage community engagement and provide a mechanism for public accountability.

Health improvement strategies will include the implementation of evidence-based interventions and the development of innovative practices that will be rigorously evaluated.

Evaluation of interventions will provide the data to design and implement a continuous improvement process.

The assessment will produce high quality data that will be available to a wide variety of public and private sources.

Although these types of assessments have been conducted by health care systems for years, the 2010 Patient Protection and Affordable Care act requires all non-profit hospitals to conduct a community health needs assessments every three years and implement strategies to address local health issues identified. The assessment process generally includes collecting information from a broad representation of the community members via discussion groups and/or surveys. Community feedback gathered through this process is analyzed and contextualized with existing data such as community demographics, chronic disease rates and prevalence, and mortality rates.

One of the most commonly mentioned barriers to access to care in rural communities is the lack of transportation, particularly for low-income and elderly residents. Transportation options such as public transit, ridesharing services (e.g. Uber, Lyft), or taxis are limited, if available at all, in rural areas. If services are available, affordability and reliability are issues for those who depend on transportation assistance. Alternatively, residents will inappropriately utilize emergency transportation as a means to accessing care which drives up the cost of care for all.

Residents who do not have reliable transportation options are more likely to delay going to a doctor, picking up medications, or attending follow-up treatment such as physical therapy. Missed appointments and the inability to secure prescriptions result in individuals who struggle to manage chronic disease which, in turn, leads to poorer health status.

Solving transportation issues in rural communities may require implementing a combination of smaller scale services that can be coordinated and sustained locally. Funding and maintaining a public bus system in a rural area, for example, is not a realistic option because the cost of the operations could not be recovered through an affordable bus fare. However, there are rural communities who have successfully implemented and continue to operate locally-based transportation options. These vary from volunteer drivers who use personal vehicles or church vans to transport people to health-related destinations to partnerships between hospitals and social services agencies that leverage their resources to extend and manage transportation options to their patients and clients.

The hospital’s public relations officer has many opportunities to set the stage and to establish transparency between facility and community. How and in what venue a message is delivered is just as important as the message itself. While the traditional communication methods of television, radio, and print may be familiar, remember to include social media to reach all community members. When a hospital is facing challenges and threats, it is vital that the message NOT lead with a negative. Too often, a story that leads with a negative leaves a negative residue unable to be overcome by a more positive message buried under the lead. Teachers and supervisors employ the “sandwich” method – lead with a positive, give a criticism or bad news, end with a positive. The message is still delivered but it is easier to find the silver lining.

Former president, Ronald Reagan was a master at knowing his audience and while his platform or message was ultimately the same regardless of which region of the country he spoke, he custom fit his introduction and summary for each audience…he made it personal and memorable. Those who carry the burden and opportunity of being the communicator should study ways of message delivery that gives all the necessary information and leaves the audience with hope, enthusiasm, and eagerness for the next steps. In “Speaking My Mind,” a collection of Reagan’s speeches, the president said that his ability to give a good speech was based on two things: “to be honest” in what you are saying, and “to be in touch with [your] audience.” In his early career as a radio broadcaster in Iowa, he discovered a basic rule that he followed all his life: “Talk to your audience, not over their heads or through them. Don’t try to talk in a special language of broadcasting or even of politics, just use normal everyday words.”

It is of upmost importance that the message, given to the community, be agreed upon by leadership (the board, the CEO, the medical staff), put into language that the community can understand, and insist that part of the message includes expectations, next steps, or “now what”. Put into somewhat different words: Plan the message – what information do you plan to convey. Be brief in delivering the message– don’t ramble and start rationalizing. Justifying the bad news will make the situation worse. Finally, deliver a message that has clarity. Remember to have empathy and be human. Take some time to listen and respond after your message is delivered. While it may not change the course of your message, listening can go a long way towards showing you care about the community.

Evaluating and processing patient feedback is important for understanding and solving quality of care issues in hospitals. It is critical for rural communities to understand their demographics in order to target specific care options. By involving patients in the process of identifying community needs and weak areas of service within the hospital, administrators can expect to see specialized patient care oriented feedback. Quickly, the process of patient feedback and changes made by administration becomes a positive feedback loop of quality care improvement.

Hospitals should consider patient feedback as a toolkit for improving the quality of care in their hospital. Multiple approaches should be implemented so that information from the widest range of patients possible is received. The process of implementation as described by Planetree is to begin analyzing survey information, implement Patient Advisory Committees (PAC) with agendas based on survey data, and finally identify patients from the committee that can serve as patient leaders in the hospital. Maintaining diversity while recognizing the demographics of your community is essential for this process. A misrepresentation of the community within the PACs can provide information without value to the majority of the population.

In small communities, hospitals need to use their distinct populations to their advantage. Increasing quality of care for patients as well as the increase in community support is too valuable to pass up. With information gained from surveys, PACs, and patient leaders, administrators can make positive & sustainable change.

How do you know what is going on in your community and conversely, how does your community know what is changing at the hospital? The days where an open meeting and a synopsis in the local newspaper reached the vast majority of the population is over. Social media is emerging as a new, and free, medium for dialogue that can cut across social divides. It can be used to engage your community as well as to increase awareness of what the hospital has to offer. It can also increase awareness of what the community prioritizes in terms of health care.

A best practice to utilize social media platforms is to start with the mission and vision of the health care facility. Strategically think about how to build ethics and privacy into your feeds. A health care facility can easily spark conversations on health related topics and yet you want to protect participants from full disclosure of personal information that, once made public on the internet, can never fully be redacted. Honesty and transparency are critical in social media exchanges as the public places a high value on authenticity. Along the lines of authenticity, make sure your employees are engaged in your social media efforts. If your employees do not follow your feeds, then that also sends a message to the community.

Next, decide on which venue(s) you want your health care facility to be active. Each major site has a different capacity and may attract a different audience. It is essential to match your message to what is appropriate for the venue; however, the etiquette and norms for the major sites are easy to learn. Be committed to keeping your message fresh. It is better to maintain a dialogue on one platform than to be an unattended presence on multiple venues. Also, regularly monitor your feed. This will allow you to address complaints and problems quickly. Additionally, this shows your commitment to customer service. Remember that a happy patient will tell their family about the wonderful care they received at your hospital; an unhappy patient will post negative reviews to hundreds of people. Social media platforms enable you to respond directly and quickly to these people. Utilize the data available with social media platforms to track your engagement and outreach. The data can give you an idea of how any particular issue is perceived by your community and enable you to join the conversation in a meaningful manner.

Engaging one’s community may be challenging but rural hospitals exist much closer to the members of the entire community than do their urban counterparts. Additionally, rural hospitals often represent a large slice of the economic well-being of the community. Thus, finding ways to engage the community in tracking the health of the local delivery system and in helping to move the community’s health forward is challenging, necessary, and important.

The access to health care problems of rural areas are best understood by those who live there. Thus, the most likely solutions are those that are proposed by or at least supported by those who live in rural areas. Community engagement is the process through which hospitals work collaboratively with individuals and local stakeholders to identify needs and then create and implement meaningful strategies to meet those needs. As the United States healthcare system transitions to paying for value, community engagement will only increase in importance. A healthier population will almost by definition spend less on health care, a community that invests in keeping its population healthy becomes an ideal partner for health care delivery systems that want to care for a healthier population.

Whether engaging to improve the health of the hospital or the health of the population, it appears that having the community engaged will improve the likelihood of successful development and preservation of access to healthcare for all of the community.

In the evolving healthcare industry, availability of care, quality of service, and patient satisfaction are important considerations when looking to improve volume in your hospital. Understanding the healthcare needs of a community is the first step to solidifying a hospital as the “go to” source for medical care in an area. Maintaining the quality of care is also imperative, especially for services that have been identified to be critical in an area. Patient wait times, call success rate, and the communication between healthcare provider and patient cannot be overlooked when attempting to increase volume. Using patient satisfaction metrics, a hospital can understand from a patient prospective how to improve performance.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey, is a standardized data collection method for hospitals to collect and report patient satisfaction data. This data is then analyzed by CMS and reported publicly on a quarterly basis. While reporting on the satisfaction of your patients publically could be viewed as a poor decision for struggling hospitals, it is clear that transparency is important to patients. Hospital administrators that are willing to recognize and address concerns publically, especially in smaller communities, can help community leaders understand and lobby for beneficial legislation, help rally local support for new service lines, and even address personnel issues. With an understanding of the issues facing their community healthcare services and a clear plan for improvement, citizens are more likely to support locally provided services and less likely to have a negative reaction to tax increases.

Accepting the patient as a consumer is essential for understanding the importance of patient satisfaction and understanding how to improve it. Using satisfaction metrics like the HCAHPS survey and other data collection methods to improve patient satisfaction; hospitals can reduce costs and increase community support.

Rural residents’ ability to access health care and social services is often limited due to a variety of factors such as the absence of locally available care, lack of public transportation, distance to care, and poor promotion of existing services in the community. In 2002, a regional health partnership in Texas, comprised of health care providers, social services organizations, and rural community stakeholders, organized to address these rural “access-to-care” issues. Through a process of assessment, planning, and commitment of local resources, the concept of community health resource centers – “one-stop shops” for health and human services – emerged.

To incentivize providers to offer services in rural communities, the partnership developed a community health resource center (HRC) model in which communities would donate local facility space and administrative support to health care providers and social services organizations. The types of facilities range from free-standing community buildings to space allocations inside hospitals. Overhead costs – e.g. rent, utilities, internet – are covered by a combination of funding and in-kind donations from community stakeholders such as county and/or city government, hospital districts, health care systems, and school districts.

Services available through each HRC vary based on facility size, community needs, local financial and in-kind support, and provider availability. Common resource center services include information and referral, case management, free transportation to health-related destinations located in the regional hub, and telehealth access to remote services such as mental health counseling. Other services offered through HRCs include evidence-based health education programs, support groups for patients and caregivers, free legal aid, counseling for at-risk youth, audiology, and substance abuse prevention screenings.

Small and rural hospitals are challenged to offer the services that will keep patients in their facility, are appropriate for the physician and provider staff they can maintain, and which will be profitable with their patient mix. Constant evaluation of the service lines should be part of management’s role – removing services that are not profitable or cannot be provided with high quality, and adding services that will slow or stop outmigration, as well as enhancing services that are profitable and popular. According to Mark Loos, system vice president for clinical services at Palmetto Health, “Service lines (should be) designed not only for improved clinical care and outcomes, but also with an eye to the manner in which the organization can attract (patients) into the system”.

Existing service lines should be evaluated for performance. Are quality benchmarks being met? Is the average length of stay meeting state or national standards? Are there process changes that can make each service line shine so that it serves to attract patients and reduce outmigration?

Changes in the healthcare delivery system offer some relatively new possibilities for the rural hospital to consider. The new focus on the continuum of care includes the initial admission, how services are provided within that admission to create the most efficient process for a quick, yet appropriate discharge, a discharge to the appropriate post-acute setting, follow-ups, and ultimately return of the patient to continuity care. Few, if any, small hospitals will do a joint replacement program. However, seeking to use local facilities to enhance a tertiary facility’s program can be a win for both. Surgical outcomes are improved when patients’ chronic diseases are well managed, and they engage in preoperative exercise and toning. Re-engaging the patient post-discharge to resume chronic care management and oversee rehabilitation can get the patient back to their support community while enhancing the full recovery from a major intervention. “Selling” this sort of partnership to a tertiary center could increase their surgical program and increase the small hospital’s traffic as well.

Hospitals are increasingly asked to create formal population health management programs in order to gather health data analytics on local patients as a way to address potential health problems before they become costly, chronic issues. Controlling costs of healthcare and starting to bend the cost curve downward, will require looking at things from the perspective of population health management. If hospitals can analyze data and cost figures associated with chronic diseases — such as diabetes, cardiovascular disease, asthma, hypertension and others — they can reach out to their communities to start chronic care programs to mitigate costly, long-term health problems. Management of the population that costs most per capita per year will make a community hospital attractive to new organizations like accountable care organizations.

Surveys of community desires, evaluation of outmigration data, and consideration of tools like ECHO or telemedicine should be considered when evaluating service lines.

Rural hospitals around the country are looking for alternatives when it comes to specialized care options. Telemedicine can provide hospitals with providers they might not have locally. Hospitals using telemedicine, can fill provider gaps to better serve their communities, and reduce the amount of travel the community is doing for healthcare. One barrier to these services in rural areas is the lack of connectivity. However, a dedicated connection is only required for eEmergency services. With a recommended internet speed of 10mb/s, hospitals should be able to host this service even with satellite internet connection.

One roadblock for many hospitals when considering Telemedicine services is the reaction of their community. Will rural communities be overwhelmed with technology or not have a positive reaction to seeing a provider over the internet? An executive, from Avera eCare, states that hospital staff plays a key role in helping the community adapt to a new service. If the staff treats the telemedicine service as another tool to help the patient then generally the patients receive it well.

Telemedicine should be seen as an innovative way hospitals can provide services that are not available in their communities. Companies like Avera eCare are not a replacement for local providers, but rather a resource for those providers.

The Omnibus Reconciliation Act of 1980 (part A: section 904) provides the initial definition, standards and procedures of swing-bed programs. The goal of this program is to give rural and critical access hospitals the ability to provide extended post-op and post diagnostic care to patients without the need to transport them to another facility at an unreasonable distance. To furnish swing-beds, hospitals may use any acute care patient beds with the exception of beds located in their inpatient prospective payment system excluding rehabilitation or psychiatric unit, intensive care, or newborn unit. This flexibility allows minimal physical and procedural restructuring of the hospital when implementing the swing-bed program.

Swing-beds can provide a necessary service to rural communities in need at a relatively low cost to hospitals that currently provide inpatient care. Reducing travel times for aging residents, reducing the need for transfer, and increased flexibility of hospitals are extremely valuable products of the swing-bed system. However, hospitals considering implementing swing-beds should do a thorough analysis of the community’s needs, the hospital’s assets, and the amount of time and resources it would take to establish this program in their community. Swing-beds can have a significant positive impact, but the resources used to implement them might be better put towards other community needs. Certain communities might want to look into other ways to invest resources. These communities might already have competent, skilled nursing facilities in the area, a lack of ability to provide inpatient care, and a population that isn’t under significant stress due to overcrowded nursing facilities or facing extreme driving distances to urban centers.

There is a growing trend for rural hospitals to contract with management companies to oversee the day-to-day operations of the facility. Management companies can provide a level of expertise that is not otherwise available to the hospital locally. Unfortunately, the hospital is often left in a lurch if the management company closes and the contract contains no penalties for closing without notice.

Anecdotal reports show several common issues with contracts and one resounding piece of advice. The lesson learned is that while it may be financially difficult to a struggling hospital, it is essential to hire appropriate legal counsel to review contracts. Contracts need to contain protection for the hospital so there is adequate notice of the management company closing (90-180 days at least). Data and technology ownership must be discussed so that the facility can resume function as soon as possible after a management company leaves. There are examples of management companies leaving hardware with no operating software and electronic medical records (EMRs) that are not accessible by the staff and providers who stayed in town. Other management companies have left an operating EMR, but the cost of that contract was more than the struggling hospital could afford. Skilled legal review, in addition to connecting to a network of fellow rural hospitals to discuss common contract problems can help hospital board members navigate contracts in a more knowledgeable and strait forward manner.

While education is essential, board members should undergo an on-boarding or orientation process to ensure their success. This process should cover not only the board members responsibilities to the hospital, but also their responsibility to the community. Orientation should start with a written job description as well as the hospital’s mission, vision, and goals. These three components (mission, vision, and goals) drive strategic planning which is a Board responsibility.

New board members will also need an orientation to the health needs and concerns of their community which may best be achieved via a community needs-assessment. The history of the hospital within the community in terms of funding and politics should also be considered essential orientation material. On-boarding should be viewed as a process rather than a singular event; an effective orientation may take up to a year.

The healthcare sector underwent a major transformation with the Affordable Care Act and continues to evolve. As a result, hospital boards find themselves being held to a higher standard while working within newly defined strategic and financial parameters. It is essential that board membership be broad and strong to meet the challenges of rural hospitals today. Board members need to have a deep understanding of health insurance, risk management, quality of care, and finance, as well as expertise in information technology. Fortunately these skills can be learned. Equally important, the composition of the board must reflect the diversity of the community.

In 2017, the American Hospital Association (AHA) focused its trustee education efforts on the emerging challenges in healthcare as well as the good governance practices crucial to success and advancing health in every community in America. There are numerous resources on their website and AHA has created a Trustee track of programming at their three flagship meetings. The American College of Healthcare Executives (ACHE) is a professional society dedicated to advancing healthcare management excellence. Their website provides many resources regarding hospital board education. Additionally, ACHE offers live classes with a focus on hospital board skills and can customize a course and deliver it on site. The state of Texas has the benefit of TORCH (Texas Organization of Rural and Community Hospitals), an organization that provides leadership in addressing the special needs of rural hospitals. These needs include education and guidance for hospital boards.

Hospital boards are responsible for ensuring quality of patient care as well as the financial health of their hospital. Baseline education is recommended to help board members fulfill their responsibilities. Continuing education will help board members navigate the rapidly changing landscape of healthcare.

Rural hospitals, and their hospital boards, are facing unprecedented challenges in today’s changing healthcare landscape. Members of the board are accountable for the well-being and success of their hospital which directly links to the need for involvement in strategic planning. Board members need to work with management to create the long range vision that will ensure sustainability of their hospital. Essentially, a strategic plan details where we are now, where we are going, and how we will get there. Planning enables the hospital to avoid the “Cheshire cat” trap as written by Lewis Carroll in his book, Alice in Wonderland. “Would you tell me, please, which way I ought to go from here?” That depends a good deal on where you want to get to,” said the Cat. “I don’t much care where…” said Alice. “Then it doesn’t matter which way you go,” said the Cat.

Healthcare is changing rapidly. Board members need to stay current with these changes and suggest alterations to the strategic plan. Flexibility and adaptability within the mission, vision, and goals of a hospital will help steer an organization in the most advantageous direction. Connecting with an organization(s) created to provide guidance to rural hospitals is a recommended action step. Several member organizations, listed below, provide early warnings of healthcare change, gatherings of experts to discuss what the change means and how the change can be navigated successfully. In addition, there are many educational resources available to assist in decision making.

Managing to keep the doors open when a hospital is struggling is a juggling act between volume, collections, service mix, and community support. One aspect of the juggling act is maximizing third party contracts. While it may be a grim time with Medicare reimbursement reductions, the decision by Texas to not take the Medicaid expansion, and ever more competitive and complex third party contracting, there are some things that hospitals can do to maintain or enhance solvency.

Roughly 80 percent of uninsured patients who come into the ER are eligible for some type of publically funded program. Hospitals should make it a priority to help ER patients complete applications for publicly funded health coverage like Medicaid or identify other programmatic assistance including DARS, Texas Women’s Medicaid, CPRIT and others.

Maintaining a good relationship with payors and renegotiating contracts in a timely fashion is imperative. Approximately 35% of the bottom line comes from non- governmental, third party payors. Poor contracts or contentious relationships with carriers can be problematic. Hospitals must take the time to understand existing contracts, benchmark contracts against each other, conduct research to know what percentage of the insurer’s business comes from the hospital, routinely update stagnant and evergreen contracts, and look for carve-out opportunities. Hospitals must be prepared, when renegotiating contracts, to maintain a level of respectful dialogue in order to avoid fallouts which could impact reimbursement as well as public relations. Often times, people don’t consider that mutual respect must occur between the payor and institution. That relationship is earned over time in a manner that allows a facility to help collaborate, design, and develop the care delivery models and product designs that those payors will ultimately use.

There are specialized consultants who evaluate contracts, review billing/and collecting procedures, and otherwise help hospitals achieve maximum impact. However, many small rural facilities cannot afford a consultant; these facilities must develop their own internal expertise. This includes understanding their contracts to ensure all terms are met, identifying coding issues and leaks in the processes, i.e. the time it takes to get a bill out the door, what percentage of those are returned to be reworked due to inaccuracies or holes in the bill, etc. Many organizations that represent either hospitals or their providers have services that may be able to assist with negotiating competitive contracts within the state.