Mastering Community Outreach-The HSB Blog 10/19/22
Our Take:
As providers look for ways to more actively connect with the communities they serve, particularly those in underserved communities, they need to move away from passive, reactive approaches like surveys to more active, participatory methods that broaden their involvement in the communities themselves. Through outreach to community groups, religious organizations, social and commercial groups, providers need to form broad cross-sector partnerships to begin to develop an understanding of the needs, workings and resources available within their populations. By working with multiple stakeholders in the community and finding atypical ways to assess the resources and services needs of their catchment areas and engaging in effective community outreach, providers can build trust and create productive relationships for both the community and their providers. This benefit can take the forms of better, more appropriate culturally competent care and a more sustainable financial position.
Key Takeaways:
“You must have diverse teams to do SDOH”, underserved communities “don’t want to be saved and not by some 22-year-old white girl”
Each additional standard deviation improvement score that hospitals received in cultural competency, translated into an increase of 0.9% in nurse communication and 1.3% in staff responsiveness on patient satisfaction surveys.
Providers need to note factors such as their organizations own preconceptions and attitudes within the organization and a community’s history of being ignored and sense of powerlessness when trying to engage with local leaders.
Development of social capital in low-income communities should be prioritized to build partnerships between hospitals and populations.
The Problem:
Addressing the improvement of health outcomes requires approaching the issue both by targeting current and historic problems within that community which contributes to poor health for its residents, and cataloging available resources to determine resource gaps within the community. In addition, while providers in low-income communities often lack appropriate healthcare resources, such as available clinicians and facilities to treat the community, they also often lack access to the elements of the social determinants of health such as affordable housing, an ample supply of healthcare with enough hospitals and clinics to meet that need, and supermarkets offering nutritious, quality food. For example, according to the Association of American Medical Colleges and the USDA, 54 million people are food insecure and 23.5 million live in food deserts, meaning that 1 in 6 Americans struggles to eat daily. In addition to connecting people directly to resources, there is also an economic benefit. As noted in a 2011 study, “research on community engagement initiatives suggests that these partnerships generate benefits at both the individual and community levels”. For providers themselves these efforts can connect them directly to additional reimbursement streams since culturally competent care has been shown to help them with quality and engagement measures with patients. For example, a study in the Journal of Med Care found that each additional standard deviation improvement in the score that hospitals received in cultural competency, translated into an increase of 0.9% in nurse communication and 1.3% in staff responsiveness on patient satisfaction surveys.
Hospitals should commit to reinvestment into their communities, with dedicated teams charged with going into the community helping to inventory resources, talk with businesses and community leaders, and holding town halls within the communities. In addition, senior leaders of the organizations need to be brought into the process, not just for the cameras, but for meaningful, ongoing dialogue with members of the community for what will be a long and detailed planning process. In doing so, providers should resist the urge to solve the problem and actively listen to the community so they can take their feedback into account.
The Backdrop:
The presence or lack of key resources is one of the first things a hospital should assess when attempting to determine the needs of their community by cataloging the extent of any issues. Affordable housing is one of the most important factors for improving health outcomes as stable housing has been shown to be a key to improving pediatric health outcomes. As noted in a March 2019 article in the AMA Journal of Ethics, this is for 3 reasons: “1) housing plays a documented role in the health of children, 2) outreach efforts [often make] clear that housing [is] a neighborhood priority, 3) because of instability in housing, children were moving too frequently to make school-based or neighborhood-based programs effective’”
In addition, care utilization at local primary care providers and clinics should be assessed using annual community health assessments to determine the status of individuals’ needs and make recommendations for future interventions. Communities also need access to healthy and nutritious foods to improve their overall health. Not surprisingly, as noted in a study published in Health Affairs, among SNAP recipients, the opening of new federally funded supermarkets in poor neighborhoods found improved food security and dietary quality for these recipients. Additionally, of note in the study, participants in those neighborhoods “also experienced relative declines in the percentage of daily calories from solid fats, alcoholic beverages, and added sugars” all of which contribute to better health outcomes like reduced incidence of obesity and diabetes.
Community outreach and connecting with communities is arguably the most important step as it involves direct action with the patients that hospitals intend to treat, and has the potential for the greatest influence. Hospitals must realize that their goals to improve health outcomes may not always be in line with the desires of the community, like advocating for the closing of liquor stores. Doing so in the short term would cost the community jobs and deprive some people other non-health-related benefits. This plays into addressing disparities between communities such as the much higher density of vice stores (fast food restaurants, liquor stores, smoke shops, etc.) prevalent in low-income communities in New York and in other major cities across the country according to an article published in the Journal of Applied Geography.
There also needs to be a push to include community members in the strategic planning process, particularly leaders such as pastors, business owners, local government representatives and more. Such individuals often have the best understanding of the problems their communities face and may have valuable insight. However, properly identifying these people is a potential hurdle for many hospitals so hospitals may instead blindly send out large quantities of Press Ganey and HCAHPS surveys hoping people will answer them. One of the best ways to identify people that might have important feedback to share would be to walk around the neighborhood, talk to people, and ask questions. In addition, it is important to recognize potential obstacles to community participation in the process. As highlighted in the Community Tool Box from the Center for Community Health and Development at the University of Kansas, it is important to take note of factors such as: 1) preconceptions and attitudes within your organization; 2) inadequate community communication about opportunities people to get involved in, in the community; 3) a history of being ignored and sense of powerlessness; 4) a lack of resources for community members to get involved such as time off work, lack of child care, lack of transportation, etc.
Evidence-based decision making should also be employed in the surveying process to identify people who might have valuable feedback. Questions need to be informed and descriptive, asking about demographic information, feedback on available or previous healthcare services delivered to the patient, opinions on community deficits and needs, and much more. Often, it is necessary to make efforts to consult with neighborhood locals who are familiar with the community and its biggest players, which literally may require the difficult work of walking the neighborhoods and knocking on doors. However, these efforts will reap rewards as community members see the genuine concern and commitment of organization leaders. Alternatively, if leaders and administrators don’t take the time to go into their communities and meet the people who live and work there daily then they may never truly understand what it means to be part of the community.
Cultural competence is important here as well, as it makes employees more culturally aware and familiar with people from different backgrounds, it prepares employees to face situations they may not have had to deal with in their personal lives, and it also increases health outcomes when the patient can connect with their doctor, and they feel confident to discuss their health status. Diversity among the community workers and hospital staff is important here as well. As a community activist once so forthrightly put it to us, “[underserved populations] don’t want to be saved and not by some 22-year-old white girl, you must have diverse teams to do SDOH”. This applies to when patients from the community are taken in for treatment as well, as they want to deal with someone who looks like them and can speak their language. Additionally, a multilingual staff can help create and translate resources in a multitude of languages and communicate ideas to a wide variety of cultures with ease. Offering training sessions on cultural competency to hospital staff should be a bare minimum for modern organizations adapting to changing workforce standards, and can pay off immensely with the potential for increased patient satisfaction, health outcomes, communication skills, and more. For as noted in a 2017 Harvard Medical School Blog article “we know that our own subconscious prejudices, also called implicit bias, can affect the way we treat patients”.
Implications:
Creating connections between hospitals and communities will not occur quickly or easily and will require significant facetime and financial investment on stakeholders’ behalf to build. A study published in the Journal of Social Science & Medicine - Population Health found that neighborhoods with higher social capital are more likely to see partnerships between hospitals and other agencies jointly running population health outreach programs. Collaborative efforts with communities may be made easier through the opportunities presented by high social capital and the networking that can occur, getting people in touch with each other. By investing into their neighborhoods and taking the time to form the right connections, stakeholders can form cross-sector partnerships that are critical for improving overall health outcomes of populations. Moreover, by doing a deeper dive than just surveys you can get to a more robust and sustainable solution. As pointed out by the Community Tool Box at the University of Kansas involving people affected by the problem, and helping solve the problem empowers your organization to 1) have a better understanding of the causes of the problem and the barriers to managing or preventing the problem, and 2) it empowers the people experiencing the problem to tackle the problems they confront. As highlighted by a recent article in HealthLeaders, SDOH initiatives like community health workers can have an ROI but it will take time and “health systems must set clear priorities and know their role”.
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