Local Health Department/Hospital Partnerships

State: CA Type: Model Practice Year: 2013

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The San Francisco Department of Public Health (SFDPH) submits for consideration its partnership with nonprofit hospitals to assess the health of San Francisco and improve community health. In formal partnership since April 1996 and formed in response to California Senate Bill (SB) 697, SFDPH and nonprofit hospitals strive to improve the health of San Francisco City and County’s 805,235 residents with a focus on identifying and addressing population health disparities and inequities.

 

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San Francisco Department of Public Health
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Local Health Department/Hospital Partnerships
The San Francisco Department of Public Health (SFDPH) submits for consideration its partnership with nonprofit hospitals to assess the health of San Francisco and improve community health. In formal partnership since April 1996 and formed in response to California Senate Bill (SB) 697, SFDPH and nonprofit hospitals strive to improve the health of San Francisco City and County’s 805,235 residents with a focus on identifying and addressing population health disparities and inequities. POPULATION AGE GENDER According to the 2010 Decennial Census, 51 percent of San Francisco’s residents are male and 49 percent are female. San Francisco’s population is older than that of California overall. Seventy-seven (77) percent of San Franciscans are age 25 or over, compared to 64 percent statewide. Seven percent of residents are over age 75, compared to five percent statewide. The largest proportion of the population is between the ages of 25 and 44. Specifically:- 4.4 percent (35,203) of residents are children age 0-5; - 6.8 percent (54,761) of residents are between 6 and 14; - 11.8 percent (95,224) of residents are between 15 and 24; - 63.4 percent (510,205) of residents are adults between 25 and 64; and - 13.6 percent (109,842) of residents are seniors age 65 . POPULATION BY RACE/ETHNICITY Between 2000 and 2010, San Francisco experienced increases in the proportion of residents who are Asian, Latino, some other race, two or more races, and American Indian/Alaska Native. The proportion of the population that is White, Black/African American, and Pacific Islander decreased. The following list breaks down San Francisco’s population by race and ethnicity. Please note that since individuals may identify as more than one race or ethnicity, the totals do not add to 100 percent.- 48.5 percent (390,387) of residents are White; - 33.3 percent (267,915) of residents are Asian; - 15.1 percent (121,774) of residents are Hispanic or Latino (any race); - 6.1 percent (48,870) of residents are Black/African American; - 6.6 percent (53,021) of residents are “some other race”; - 4.7 percent (37,659) of residents are “two or more races”; and - 0.5 percent (4,024) of residents are American Indian or Alaska Native. The following reflects San Francisco’s population by Hispanic or Latino versus non-Hispanic or Latino categories. - 41.9 percent (337,451) of residents are White, non-Hispanic; - 15.1 percent (121,774) of residents are Hispanic or Latino of any race; and - 43.0 percent (346,010) of residents are “Other (non-Hispanic).” SOCIOECONOMIC STATUS Although the median household income in San Francisco is $70,040, San Francisco has the largest income inequality of the nine Bay Area counties. Income disparities also exist among San Francisco neighborhoods. Within San Francisco, people of color, on average, have lower household incomes compared to White/Caucasian residents. In addition, poverty rates exceed the city/county average for the following groups of people: females, people age 65 and older, Blacks/African Americans, people of “other” race, people of two or more races, Latinos, and female heads of households. Please note that increasing housing prices and lack of affordable housing contribute to San Francisco’s widening income and poverty disparities in San Francisco. MODEL PRACTICE SFDPH and nonprofit hospitals formed their official partnership in April 1996 under the name Building a Healthier San Francisco (BHSF). In Spring 2008, this partnership expanded into a second, complementary body called the Community Benefits Partnership (CBP). The SFDPH/hospital partnership formed to improve the health of San Francisco while responding to State nonprofit hospital requirements. In addition, the partnership strives to: - Assess the health of San Francisco. - Identify data-based health priorities for community action with a focus on health equity. - Monitor progress along identified priorities and indicators. The partnership has been successful in meeting its objectives as evidenced in Community Vital Signs (www.healthmattersinsf.org). BHSF/CBP have an annual budget of $114,600 – assessed in the form of annual hospital fees – plus in-kind contributions of staff time. Other jurisdictions could adopt this practice given the nonprofit hospital IRS health assessment requirements part of Health Reform. Major start-up activities include: - Convening potential partners to assess the need for – and benefits of – forming a partnership. - Developing a formal agreement that outlines each entity’s roles and responsibilities. - Determining the partnership’s funding structure. - Hiring a consultant for support activities. - Formalizing the leadership structure. - Developing a regular meeting schedule. - Developing a network of community stakeholders to inform and support the activities of the partnership. - If desired, creating an online portal for sharing and monitoring the progress of health improvement efforts.
Responsiveness The public health issue that this practice addressesThe SFDPH/nonprofit hospital partnership strives to assess and improve population health with a focus on health equity. This practice addresses several of the 10 essential public health services developed by the Core Public Health Functions Steering Committee in 1994. Among them: - Monitor health status to identify and solve community health problems. - Inform, educate, and empower people about health issues. - Mobilize community partnerships and action to identify and solve health problems. The specific public health issues (e.g., healthy eating and active living) addressed by the practice’s community health assessment and improvement efforts are data-based and community-informed, meaning that those targeted issues may change over time. This data- and community-informed practice allows the partnership to respond to San Francisco’s health needs as they evolve. The process used to determine the relevancy of the public health issue to the communityImproving health is a fundamental goal of SFDPH and its hospital partners. However, state and local policies served as the catalyst for the formal partnership forged between SFDPH and San Francisco’s nonprofit hospitals. California SB 697, established in 1994, triggered the formation of BHSF by requiring nonprofit hospitals “to complete, either alone, or in conjunction with other health providers…a community needs assessment evaluating the health needs of the community serviced by the hospital, that includes, but is not limited to, a process for consulting with community groups and local government officials in the identification and prioritization of community needs that the hospital can address, in collaboration with others, or through other organizational arrangement.” A complement to SFDPH’s mission of promoting and protecting the health of all San Franciscans, SFDPH and hospital partners responded to state law by creating BHSF, a citywide collaborative of non-profit hospitals, SFDPH, McKesson Foundation, San Francisco Foundation, United Way of the Bay Area, Metta Fund, Blue Cross of California-State Sponsored Business, and a variety of health organizations and philanthropic foundations. Since 1996 and in accordance with SB 697, BHSF has conducted a health needs assessment for San Francisco every three years. In Spring 2008, SFDPH and its hospital partners complemented the work of BHSF – and responded to the Charity Care Project established by San Francisco Ordinance No. 163-01 – with the creation of CBP. CBP seeks to harness the collective energy and resources of San Francisco’s nonprofit hospitals, City/County departments (SFDPH and Human Services), community clinics, health plans, and nonprofit providers and advocacy groups to improve the health status of San Francisco residents to address the health priorities established by BHSF. SFDPH and San Francisco’s nonprofit hospitals co-chair CBP. SFDPH and nonprofit hospitals vetted and received support for their collaboration from the San Francisco Health Commission, the Hospital Council of Northern California, local service providers, and community residents. How the practice addresses the issueThe SFDPH/nonprofit hospital partnership addresses the need for ongoing community health improvement by: - Conducting a comprehensive and community-driven community health assessment process every three years. - Identifying data-based health priorities for action with an emphasis on health equity, in accordance with SB 697. - Formulating measurable objectives tailored to each health priority to assess improvement within each priority area. - Harnessing collective impact to address each health priority and related objective. CBP, for example, has established “Champions” for each priority area objective to sustain both community and partner engagement on the issue and to ensure progress along each priority. Champions are often community leaders and experts in the objective issue area; they are not necessarily SFDPH or hospital staff. CBP has also developed “Affinity Groups” – community stakeholder groups interested and invested in identified health priority areas – to help implement strategies aimed at meeting priority objectives (short-term goal) and improving community health and wellbeing (long-term goal). - Evaluating progress made within each priority area as gauged by performance along specified objectives and indicators and disseminating evaluation findings. CBP shares its findings via its online platform, Community Vital Signs. As overarching principles, BHSF and CBP emphasize transparency as well as community engagement throughout the health assessment and improvement processes to ensure that residents are both involved and invested in bettering population health in San Francisco.   Innovation This practice is new to the field of public health Process used to determine that the practice is new to the field of public healthIn 1996 when SFDPH and San Francisco’s nonprofit hospitals partnered formally to create BHSF, no other such partnerships were known to exist. (Please note, however, that similar partnerships may have been forged around that time in California in response to SB 697 and elsewhere in response to local factors and forces.) CBP, an outgrowth of BHSF formed in response to San Francisco’s Charity Care Ordinance (Ordinance No. 163-01), is also unique. San Francisco’s Charity Care Ordinance was the first of its kind in the nation and has supported a spirit of public disclosure locally that has been replicated in other municipalities and by the federal government as part of Health Reform. SFDPH is unaware of existing literature or data sources that catalogue local health department/hospital partnerships and, as such, assumes that its partnerships are of longer standing than most if not all such partnerships that exist today. In addition, an Internet search of “hospital health department partnerships” (and similar phrase combinations) does not yield information on any other formal local health department/hospital collaborations established before 1996. How the practice differs from other approaches used to address the public health issueThe SFDPH/nonprofit hospital partner is unique in its efforts to address community health improvement efforts because: - The partnership fosters greater alignment of the broader local public health system, while leveraging the strengths and resources of all collaborators. - The partnership has created an extensive network of community stakeholders – including San Francisco residents – which harnesses the collective impact of all parties to assess and improve community health in San Francisco. - The partnership represents a symbiotic relationship, helping nonprofit hospitals meet state and local – and, soon, federal – requirements, while supporting SFDPH in its charge to improve population health. Soon, this partnership will also be beneficial to SFDPH as it applies for public health department accreditation.
Primary stakeholdersSFDPH and San Francisco’s nonprofit hospitals are the primary stakeholders in the BHSF and CBP collaborations. A complete list of BHSF Collaboration partners include: - Anthem Blue Cross - California Pacific Medical Center - Chinese Hospital - Hospital Council of Northern and Central California - Kaiser Permanente Hospital - McKesson Foundation - Mount Zion Health Fund - NICOS Chinese Health Coalition - Saint Francis Memorial Hospital - San Francisco Community Clinic Consortium - San Francisco Human Services Agency - San Francisco Department of Public Health - San Francisco Foundation - San Francisco Medical Society - San Francisco Unified School District - St. Mary's Medical Center - UCSF Medical Center- United Way of the Bay Area CBP membership includes all entities listed above as well as stakeholders/content experts in all health priority indicator areas. SFDPH and a nonprofit hospital representative co-chair CBP. LHD's role SFDPH is a member of BHSF and a member and co-chair of CBP. In addition, designated SFDPH staff members: - Participate in all BHSF and CBP monthly meetings. - Lend in-kind staff support to all BHSF and CBP activities, as needed. - Assist with data collection and evaluation as part of community health assessment activities that take place every three years. - Help identify data-based health priorities and evidence-based strategies for action in conjunction hospital partners and community stakeholders. - Serve as health priority indicator “Champions” (as needed and appropriate) and members of CBP Affinity Groups. - Partner with nonprofit hospitals to engage community members and stakeholders in health assessment and improvement activities. - Represent BHSF and CBP before the San Francisco Health Commission, Mayor’s Office, and other elected bodies to communicate all partnership happenings and successes. Role of stakeholders/partners Like SFDPH, all nonprofit hospitals are members of BHSF and CBP. Two hospital representatives co-chair BHSF, and one hospital representative co-chairs CBP alongside SFDPH. In addition, San Francisco’s nonprofit hospitals: - Participate in all BHSF and CBP monthly meetings. - Pay annual fees to cover the licensing and maintenance of the Health Matters in San Francisco Website (www.healthmattersinsf.org), the online portal for tracking publicly the progress made along selected health priorities and indicators; hospital fees also fund a consultant retained to support BHSF and CBP activities and pay for additional partnership activities as needed. - Help identify data-based health priorities for action in conjunction with SFDPH and community stakeholders. - Lend in-kind staff support to all BHSF and CBP activities, as needed. - Assist with data collection and evaluation as part of community health assessment activities that take place every three years. - Serve as health priority indicator “Champions” (as needed and appropriate) and members of CBP Affinity Groups. - Partner with SFDPH to engage community members and stakeholders in health assessment and improvement activities. SFDPH and its hospital partners engage community stakeholders in many ways. For example: - Stakeholders are members of both BHSF and CBP. - Stakeholders, including residents, have informed San Francisco’s health assessment and improvement efforts by collaborating to create health values and elements of a health vision for San Francisco. - Stakeholders, including residents, infuse the health assessment process with community voice through qualitative data collected via focus groups, public comment at community meetings, and other events. - Stakeholders participate in the prioritization of data-based health issues for action every three years as part of San Francisco’s community health improvement process and as captured in Community Vital Signs. - Stakeholders help identify goals, indicators, and action strategies for each data-driven health priority. - Stakeholders often serve as “Champions” of priority indicators, ensuring accountability for priority-focused action and increasing the likelihood of “moving the needle” along those indicators and the broader health priority to which they pertain. - Stakeholders serve on “Affinity Groups,” parties interested in learning about and fostering action along priority health issues and indicators. These relationships add validity to San Francisco’s community health assessment and improvement activities by: - Assuring that these processes reflect community values and needs; - Engaging stakeholders and creating opportunities for them to take action along identified health priorities in ways best suited to San Francisco’s diverse population; - Embodying the reality that improving population health is a community act – one encompassing the broader local public health system – and not solely the purview of SFDPH and nonprofit hospitals; and - Ensuring transparency and accountability at all stages of community health assessment and improvement. Lessons LearnedLessons learned include: - Community stakeholders want to be involved in health assessment and improvement activities. As such, collaboration leadership engages stakeholders regularly (via monthly BHSF and CBP meetings as well as special events related to community health assessment and improvement). - View community stakeholders as equal partners with expertise and energy to contribute to the health improvement process. For this reason, BHSF and CBP leverage community stakeholders as priority indicator Champions and Affinity Group members. - Recognize community stakeholders for their contributions. To this end, BHSF and CBP host an annual community recognition event to honor the continued contributions made by community members. In terms of challenges, BHSF and CBP are constantly seeking meaningful ways to engage community stakeholders to sustain their collective momentum for improving population health in San Francisco. This means remaining in regular contact to keep community stakeholders informed of developments as they occur. This also means convening regular meetings of substance, and cancelling meetings when they do not seem a productive use of stakeholder time. Tasks taken that achieve each goal and objective OBJECTIVE 1 - Convening potential partners to assess the need for and benefits of forming a partnership (2-hour session). - Developing a formal agreement to partner that outlines roles and responsibilities (developed over 3-4 week time frame). - Designating work groups to complete components of the first health assessment. (Workgroup designation initially took place at an in-person meeting and evolved over time.) - Agreeing on funding structure. (Hospitals pay a specified yearly amount based on their size.) - Formalizing the leadership structure and designating co-chairs for BHSF and CBP. - Developing a regular meeting schedule for BHSF and CBP. (Each body meets monthly for two hours.) Please note that many of these steps took place over time in the context of regular BHSF and CBP meetings. OBJECTIVE 2 - Engaging community residents in developing a community health vision and values. (Completed in one full-day session and via a series of community focus groups. Planning for these events took place over 3-4 weeks.) - Conducting focus groups. (Each focus groups lasted approximately two hours and were conducted over a span of three months. Prep for each focus group took 3-4 weeks.) - Convening public meetings. (SFDPH recently conducted 10 public meetings that occurred monthly. Meetings lasted 2.5 hours each. Each meeting took about three weeks to plan.) - Hosting regular BHSF meetings. (Meetings occur monthly and last two hours.) OBJECTIVE 3 - Identifying data-based health priorities. (San Francisco most recently completed this process in a half-day session that took approximately six weeks to plan.) - Developing priority goals, objectives, measures, and strategies. (San Francisco is undergoing this process currently and anticipates completing these tasks over a series of targeted community sessions spanning approximately 12 hours total.) - Identifying Champions for each indicator. (The Champion assignment process can take several weeks.) - Forming Affinity Groups. (Ongoing.) - Hosting regular CBP meetings. (Meetings of occur monthly and last two hours.) - Creating an online portal for sharing and monitoring the progress of health improvement efforts. (The Website went live after approximately six months of planning and development. Site maintenance is ongoing.)Outline of some basic steps taken in implementing Basic steps taken to form a successful SFDPH/hospital partnership include: - Convening potential partners to assess the need and desire for – as well as benefits of – forming a partnership. - Developing a formal agreement to work together that outlines each entity’s roles and responsibilities. - In its original iteration, designating work groups to complete various components of San Francisco’s first health assessment. - Determining the funding structure of the partnership. (Hospitals support BHSF/CBP financially by paying a specified yearly amount based on their size.) - Formalizing the leadership structure, designating co-chairs for both BHSF and CBP. - Hiring a consultant to provide logistic/communication support to the partnership. - Developing a regular meeting schedule for both BHSF and CBP. - Developing a network of community stakeholders to inform and support the activities of the partnership. - Creating an online portal for sharing and monitoring the progress of health improvement efforts. Lessons learned Lessons learned include: - Partnerships take time to establish. SFDPH’s collaboration with San Francisco’s nonprofit hospitals has evolved over time as evidence in the creation of CBP, which built on BHSF’s earlier success. SFDPH anticipates that this partnership will continue to become more refined as hospital requirements change under Health Reform and as SFDPH pursues public health department accreditation. - Partners need to find a common language as a starting point to successful collaboration. For example, nonprofit hospitals talk about “Community Health Needs Assessments” while SFDPH talks about “Community Health Assessment (CHA)” and “Community Health Profiles.” - Partnerships are most successful when they leverage each entity’s existing resources. Through continued effort, SFDPH and nonprofit hospitals have been able to pool resources (e.g., staff time, expertise, consultants, Website for content dissemination) and reduce duplication of effort. - Partnerships allow for greater collective impact through the alignment of goals, objectives, and strategies; collaboration increases the likelihood of improving community health in San Francisco. Cost of implementationBHSF/CBP have a combined annual budget of $114,600, which comes from fees assessed of each nonprofit hospital based on its size. Of that: - $42,600 goes toward the licensing and maintenance of Health Matters in San Francisco (www.healthmattersinsf.org), the online portal for Community Vital Signs.- $72,000 ($6,000/month x 12months) supports a consultant than handles BHSF/CBP communications, meeting logistics, and help maintaining the Health Matters in San Francisco Website (www.healthmattersinsf.org). In terms of start-up, BHSF/CBP paid approximately $30,000 to the Healthy Communities Institute (http://www.healthycommunitiesinstitute.com/) for the creation and licensing of Health Matters in San Francisco, the online portal through which BHSF and CBP disseminate information and report on progress along health priority indicators (Community Vital Signs). SFDPH and hospital staff time is provided in-kind, varies, and is not tracked. As such, the value of staff time cannot be accurately quantified.
Objective 1:CREATE A LONG-TERM, SUSTAINABLE PARTNERSHIP BETWEEN SFDPH AND SAN FRANCISCO’S NONPROFIT HOSPITALS. Performance measures and data sources used to evaluate success along this objective include: - Community health assessment reports created from 1996 onward. (Source: Hard copy reports on file.) - Agendas for BHSF and CBP meetings held over time – reminder that CBP did not form until 2008. (Source: Health Matters in San Francisco Website as well as hard copy/electronic agendas housed elsewhere.) - Existence and maintenance of Health Matters in San Francisco Website (www.healthmattersinsf.org), which briefly describes BHSF’s and CBP’s histories, documents partnership activities, and disseminates information on health priorities and indicators. (Source: www.healthmattersinsf.org) The above measures and data sources indicate the SFDPH and its hospital partners have successfully realized the objective of forming a sustainable partnership. As evidenced by the creation of CBP, the SFDPH/hospital partnership has evolved over time in response to external factors (e.g., legislation) as well as partner feedback captured by collaboration leadership to strengthen San Francisco’s health assessment and improvement processes. Objective 2:ENGAGE THE BROADER COMMUNITY AND LOCAL PUBLIC HEALTH SYSTEM IN HEALTH ASSESSMENT ACTIVITIES. Sample performance measures and data sources used to evaluate success along this objective include: - Diversity of invitation lists to BHSF meetings as well as special health assessment events (Source: BHSF invite lists) - Sign-in sheets from BHSF meetings as well as those from special health assessment events. (Source: Meeting and event sign-in sheets.) - Photographs from health assessment depicting community involvement. (Source: Photographs) - History of tri-annual needs assessments since 1996. (Source: Hard copy and electronic files) The above measures and data sources indicate the SFDPH and its hospital partners have successfully engaged the community in San Francisco health assessment activities. BHSF leadership often discuss how best to keep community stakeholders engaged and modify the structure of their meetings and special events accordingly. Objective 3:ENGAGE THE BROADER COMMUNITY AND LOCAL PUBLIC HEALTH SYSTEM IN HEALTH IMPROVEMENT ACTIVITIES. Sample performance measures and data sources used to evaluate success along this objective include: - Diversity of invitation lists to CBP meetings as well as special health improvement events (e.g., health issue prioritization events). (Source: CBP invite lists) - Sign-in sheets from CBP meetings as well as those from special health as improvement events (e.g., health issue prioritization events). (Source: Meeting and event sign-in sheets.) - Breadth of Affinity Group membership lists. (Source: Affinity Group membership lists) - Photographs from health improvement events depicting community involvement. (Source: Photographs) The above measures and data sources indicate the SFDPH and its hospital partners have successfully engaged the community in San Francisco health improvement activities. Health improvement outcome measures also exist for this objective. Specifically, as part of its last health assessment and improvement effort in 2010, CBP identified the following 10 health priorities for action: - Increase Access to Quality Medical Care - Increase Physical Activity and Healthy Eating to Reduce Chronic Disease - Stop the Spread of Infectious Disease - Improve Behavioral Health - Prevent and Detect Cancer - Raise Healthy Kids - Have a Safe and Healthy Place to Live - Improve Health and Health Care Access for Persons with Disabilities - Promote Healthy Aging - Eliminate Health Disparities For each priority exists corresponding indicators and measures, which are evaluated on an ongoing basis to determine whether partners “move the needle” on community health over time. Progress has been noted along several measures since 2010 such as: - Reduction in the number of adults who smoke - Reduction in the rate of hospitalizations due to immunization-preventable pneumonia and influenza - Reduction in the rate of hospitalizations due to hip fracture for both men and women age 65 - Reduction in the gonorrhea incidence rate - Increase in the number of clinicians on the San Francisco Heap B Free Clinician’s Honor Roll - Reduction in the age-adjusted death rate due to suicide - Improvement in the ration of bike lanes and paths to miles of road - Increase in the number of SFDPH-subsidized supportive housing units For more specific information on the above, readers are invited to explore Community Vital Signs indicators online. Please note that San Francisco is completing a more current community health assessment and improvement process currently. As such, the 10 goals listed above will evolve to reflect current community-identified health priorities.  
Stakeholder CommitmentSFDPH anticipates that there is sufficient stakeholder commitment to sustain the SFDPH/hospital partnership. This commitment is ensured by: - A shared commitment to improve community health in San Francisco. - A shared need to maximize limited resources to reduce duplication of effort. By leveraging each partner’s resources (e.g., monetary, in-kind staff time, knowledge/expertise, etc.), SFDPH and its hospital partners are better able to identify and meet community health needs despite the current constrained fiscal climate. - Hospital requirements. San Francisco’s nonprofit hospitals are still accountable for meeting the requirements of California SB 697 as well as new, similar IRS requirements resulting from Health Reform. In addition, San Francisco’s nonprofit hospitals are still subject to the local Charity Care Ordinance (San Francisco Ordinance No. 163-01). - SFDPH requirements. In its pursuit of local public health department accreditation, SFDPH must demonstrate recent evidence of having completed a community health assessment and improvement process for the City and County of San Francisco. As hospitals face similar requirements, the current partnership allows all entities to meet individual requirements more efficiently and effectively. SustainabilityThe SFDPH/hospital partnership is self-sustaining as: - The partnership has a stable funding stream supported by hospital annual fees. - SFDPH and its hospital partners are committed to continuing to leverage in-kind staff time to support community health assessment and improvement efforts in San Francisco. Please note, however, that SFDPH and its hospital partners – as well as other community stakeholders – are meeting currently to discuss how their collaboration may need to evolve to be even more effective in addressing San Francisco’s prioritized health needs.
 
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