Hospitals And Schools As Hubs For Building Healthy Communities
Hospitals and Schools as Hubs forBuilding Healthy CommunitiesStuart ButlerCarmen Diaznovember2016Economic Studies at BROOKINGS01
Stuart Butler is a Senior Fellow in the EconomicStudies Department at the Brookings Institution.Carmen Diaz co-authored this report while aResearch Assistant at the Brookings Institution.She is currently the Innovation Project Managerat Sibley Memorial Hospital in Washington, DC.This report does not represent the views of SibleyMemorial Hospital or the Johns Hopkins MedicalCenter.The Brookings Institution is a nonprofit organization devoted to independent research and policy solutions. Its mission is to conduct high-quality, independent research and, based on that research, toprovide innovative, practical recommendations for policymakers and the public. The conclusions andrecommendations of any Brookings publication are solely those of its authors, and do not reflect theviews of the Institution, its management, or its other scholars.Support for this publication was generously provided by the Robert Wood Johnson Foundation.Brookings recognizes that the value it provides is in its absolute commitment to quality, independence,and impact. Activities supported by its donors reflect this commitment.
ContentsIntroduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Challenges for Hospitals and Schools as Hubs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Data Collection and Value Measurement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Budget and Payment Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Inflexible Business Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Improve Data Collection and Sharing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Rethink Business Models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Increase Budget Flexibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Appendix: Advisory Group Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
IntroductionPractitioners and policymakers have becomeincreasingly aware in recent years thatachieving good health and economic vitality inneighborhoods requires the close collaborationof a variety of sectors. The growing focus on social determinants of health, for instance, stemsfrom the understanding that there are many“upstream” factors that influence health, fromhousing conditions to poverty and education,and that community development in lower-income communities can help improve residents’health.1 On the other side of the same coin, weknow that a person’s health condition can be animportant factor in their success at school and inthe workplace, influencing their ability to moveup the economic ladder. An analysis of spendingpatterns across countries shows that the UnitedStates is an outlier in spending on medical carecompared with social services, yet with little or noadvantage seen in health outcomes.2 This suggests that improvements in general health maybe achieved more effectively by spending outsidethe medical sector. Research on the balance ofhealth and social spending at the state level suggests the same conclusion.3Thus it is important to find ways for different sectors—such as housing, education, and health—tocollaborate more effectively, to be more flexiblein the sharing of resources, and to achieve thebroad goals of each sector. Collaboration doesnot occur in a vacuum; it is much more of an organic process. In communities and particularly inlower-income communities, institutions often provide a crucial focus for collaboration and are active agents in the process. We can describe thisfunction as carrying out the role of a “hub.”A hub in this sense means an organization or institution that is a focal point in a community andhelps blend together a range of stakeholders andservices that improve the health and economicmobility of residents. It does not necessarily leadactivities or function as the sole focal point—oftenit is a partner with other institutions. But throughpartnerships and its own services it enables organizations and people with particular skills, assets,and connections to work more effectively together to improve the neighborhood. A hub might be aschool. It could be a hospital, church, or housingproject. It could be a community-based organiza- ealth Affairs, “Culture of Health.” Center on Social Disparities in Health et al., “Making the Case for Linking CommunityHDevelopment and Health.”2Squires and Anderson, “U.S. Health Care from a Global Perspective.”3Bradley et al., “Variation in Health Outcomes.”1Economic Studies at BROOKINGS1
tion. In a particular neighborhood, there are likely to be multiple hubs with different characteristics that partner with each other, such as a cliniclinked with a school.In this report we feature two such institutions thatpotentially can play a major role in helping to enhance health and long-term economic mobility ina community: hospitals and schools. We makesix broad recommendations involving a numberof steps. These are addressed to federal, stateand local governments, as well as hubs and theirpartners. The focus of the report is not on the primary mission of each institution—treating illnessand educating children—but rather how they canplay a collaborative role as a hub for a range ofservices. The purpose of the report is to suggestways to create the best policy environment forthese hubs to fulfill their enormous potential.Why did we pick these two particular institutions?It is not that others are unimportant, but that webelieve that with an improved policy environmenthospitals and schools could play a much largerrole in improving the health and economic mobility of many communities.Hospitals. We focus on hospitals, together withschools, because—with appropriate public policychanges and other steps—many hospitals havethe potential to become backbone hub organizations in their communities. There are manyreasons to look at hospitals in this way. For onething, the scale of operations and economic impact of a typical hospital make it a prominent anchor institution, with the capacity to improve localconditions beyond health. Hospitals are largeemployers and purchasers, for instance, so inpartnership with other institutions they can help452strengthen core health and social services.4 Manyengage in economic development and health improvement projects in their communities, oftenwith other important hubs such as communitydevelopment corporations and community-basedorganizations. A hospital, for example, might provide mental health services and cooperate with ahousing authority to reduce emergency room visits; it might partner with schools to help addressasthma and improve school attendance. Hospitals also have sophisticated data systems thatmight be used as a “data warehouse” for storingand processing nonhealth data for partners in acommunity. Thus, hospitals potentially have theresources to make a significant difference, notjust directly by providing health services, but also,as many now do, through a variety of nonmedicalventures that can improve health through suchactivities as housing development and improvement.5Hospitals are, of course, only one part of thehealth system servicing a community. Moreover, other parts of the health system tend to beclosely connected with the chronically ill and withothers in the community, such as school nurses,local clinics, and accountable care organizations(ACOs). It’s also true that, in general, hospitalshave not developed the infrastructure and external networks that would constitute a hub function.But there are many exceptions. Some hospitalsystems, such as Montefiore in New York Cityand several Catholic systems including TrinityHealth, and Dignity Health, have developed elaborate programs to work closely with communityorganizations, housing, and social services.Hospitals today also have incentives that encourage them to look outside their walls and pay great-See Norris and Howard, “Can Hospitals Heal America’s Communities?”See Trust for America’s Health and Robert Wood Johnson Foundation, “National Forum on Hospitals.”Hospitals and Schools as Hubs for Building Healthy Communities
Schools. In contrast to hospitals, schools havetraditionally been a central institution in mostneighborhoods, linking children and their parentstogether and playing a key social role. In principlethey are well placed to help address a range ofneeds. For instance, teachers and school nurseswill likely see the effects of problems related tochallenges at home; families generally trust theseprofessionals, and they may be the first responders available to tackle them—if they have the appropriate time and resources.address a variety of local needs. These includehealth care: most schools can provide somehealth services directly, such as through schoolnurses or school-based health centers (SBHCs).Community schools7 and some other schools already organize teams to function as case managers for a range of factors that might be called “social determinants of education.” Such teams workwith families and other organizations to addressa range of issues, including housing and familyproblems as well as encounters with the criminaljustice system. Meanwhile, organizations suchas the Health Schools Campaign8 provide training and support to parents who develop schoolwellness teams focusing on school policy andpractice to promote healthy eating and physicalactivity. Indeed, schools are increasingly seen ascritical institutions for improving children’s health.9Some schools, such as Briya Public CharterSchool in Washington, DC, pursue a two-generation approach, focusing on the needs of parentsas well as children, by providing in-house socialand educational services during the school day,such as parenting classes and literacy programs,and sometimes partnering with clinics for healthservices.10As existing, trusted, and familiar institutions incommunities, schools can be an ideal locationfor organizing and assembling partnerships toLike hospitals, however, schools face a numberof limitations and challenges in fulfilling their fullpotential as community hubs.er attention to community health services and thesocial factors that affect health.6 Most are subjectto Medicare readmission penalties, for example,and nonprofit hospitals are now required to catalog local health conditions and develop plans ofaction to address them.Thus, hospitals in the future could play a muchgreater role in improving health and economicconditions in communities. This report examinesboth the potential and the challenges for realizingthis greater role in the future and the actions thatcould enhance the activities of hospitals as partners and hubs.For example, see Butler, “Hospitals as Hubs to Create Healthy Communities.”Jacobson, “Community Schools.”8Health Schools Campaign, website.9Robert Wood Johnson Foundation, “Achieving Healthy Schools for All Kids in America.”10Butler et al., “Using Schools and Clinics as Hubs to Create Healthy Communities.”67Economic Studies at BROOKINGS3
Challenges for Hospitals andSchools as HubsAs part of a Brookings Institution project supported by the Robert Wood Johnson Foundation, we interviewed a range of individuals engaged in efforts to improve collaboration acrosssectors, and we have studied several institutions.In a series of meetings, we also brought together experts and practitioners to explore the role ofhospitals and schools as hubs, the challengesthey face, and policy steps that could help improve their effectiveness.In the discussions of challenges, we found threebroad areas of concern for both hospitals andschools.Data Collection and ValueMeasurementCollecting good data and sharing it between organizations are crucial to effective collaboration forthree reasons. The first is epidemiology: data areneeded to define and understand a population’sneeds and risk factors. Second, data are neededto develop the evidence base to select appropriate interventions that are likely to succeed. Assembling good information on the health, housing, education, and other conditions of a personor household or group is essential for coordinat114ing assistance. Organizations need to share dataif they are to be effective in tackling the multipleneeds of a community. And third, it is essentialfor evaluation, which is necessary to ensure resources are used efficiently and to make possiblecontinuous improvement. To measure success, itis important to be able to identify the impact onother sectors of initiatives in any one sector, andso calculate a true return on investment (ROI).Regrettably, pervasive shortcomings and barriers can interrupt the collection and sharing ofimportant information. For instance, in the healthsector, social and other risk factors are often notincluded in personal health records, making comprehensive epidemiology difficult. The NationalAcademy of Medicine and other organizationsconcerned with social determinants of healthhave called for incorporating broader backgroundquestions in electronic health records.11Data are also often not collected by governmentagencies or private organizations in a standardized way that makes sharing easy, and agenciesand organizations are often reluctant to sharedata. With health and education data, this reluctance can be due in part to concerns about privacy requirements emanating from the Health Insurance Portability and Accountability Act (HIPAA) For instance, see Institute of Medicine of the National Academies, “Capturing Social & Behavioral Domains.”Hospitals and Schools as Hubs for Building Healthy Communities
and the Family Educational Rights and PrivacyAct (FERPA). Many experts argue that, especially with HIPAA, there are ways to share information that maintain appropriate privacy. But uncertainty about the law and regulations often inhibitssharing, especially by smaller organizations andinstitutions. In addition, despite data system improvements in the health system, data continueto be entered in different ways—sometimes electronically, sometimes on paper. Requirements fordata to be collected differ, and what one facilityor agency considers important data may not beimportant to another, often making it difficult toacquire data from different systems or to calculate the full ROI.Data collection itself can be problematic. Buildingand maintaining the capacity to collect data area normal part of a hospital’s activities and thoseof larger schools. But it can be a challenge forsmaller institutions; collecting and analyzing datacan be costly and require skills that are not readily available. This can make it difficult for a largerhub to have an effective partnership with a smallorganization in the community.When data are difficult to collect and share, itmakes it hard, for example, to coordinate supportfor a young student because accessible data normally do not make it easy to “follow the child,”such as when they change schools or have anencounter with a health care facility or the juvenile justice system.On the larger scale, there are considerable limitations in our ability to measure the true ROI of ahub or partnership because it is rare for adequateresearch to be conducted to show the broad impact—or “value-added”—of an initiative in onesector. In the health sector, there is a growing12body of research analyzing the impact on healthquality and costs of efforts to address health-related housing issues (for example, reducing fallsor eliminating mold),12 but that captures only partof the value of intersector activities and initiatives.For instance, if a hospital engages in an initiativeto reduce obesity among schoolchildren or mental illness among the homeless, the ripple effectcan be very wide, including higher graduationrates and better future earnings, reduced use ofsocial services, and better results from job training for the homeless.But these broad impacts are not usually fully calculated to assess the full ROI of the hospital initiative. Moreover, a hospital’s accounting systemdoes not capture the full value that the hospitalactivities generate in the community unless thereis a direct positive benefit to the hospital. Indeed,a hospital’s accounting system measures only thecost associated with activities that generate medical benefits. The same is true of schools. A schoolnurse or social worker may have a long-term positive impact on the family of a student, but that impact is typically not measured. There are many impacts that could be measured, such as reductionsin school absenteeism, greater family stability, andimproved economic mobility. But as we note in thisreport, there are troubling deficiencies in our abilityto measure the full ROI, ranging from inadequatedata to the costs faced by cutting-edge organizations in conducting such analysis.Budget and Payment ProblemsDeficiencies in measuring ROI exacerbate theunderlying “wrong pocket” problem commonlyassociated with intersector collaboration—the situation in which one institution or sector incurs the See, for example, Green & Health Homes Initiative, website; and National Center for Healthy Housing, “Research.”Economic Studies at BROOKINGS5
cost of an activity but a significant benefit accruesto another institution or sector. This problem isaccentuated by different agencies consideringtheir problems, costs, and measures of valueto be unique to their sector. Not adequately recognizing and measuring these broader benefitsmakes it difficult for a level of government to budget efficiently by investing adequately in one sector or institution to generate benefits elsewhere.With little ability to measure ROI for communityactivities, institutions have trouble establishingand justifying budgets for this work. The result isa suboptimal pattern of investment in hubs thatincur costs in organizing services or partnershipsthat benefit the broader community.Siloed program budgets and payment systemsadd to this problem. Public budgets are generally designed within agencies and committeesof jurisdiction that focus on specific policy areas.Thus, the rules governing payments and the useof money by recipients are normally focused onthat area. It is usually very difficult for a schoolor hospital functioning as a hub to obtain permission to use funds for services outside their coreactivities or to incur overhead costs associatedwith partnerships that benefit the broader community. Payment streams to hospitals do nottypically cover a hospital’s nonmedical activitiesor personnel costs that create value in the community by acting as a hub and improving socialdeterminants of community health—although thisis beginning to change with the advantage of value-based care and associated delivery models,such as ACOs. Such payment problems arise inexamples such as hospitals working with localhousing associations to stabilize homeless people with mental illness or employing social workers to help patients obtain social welfare benefitsthat might contribute to their long-term health.Similarly, in the case of schools, even thoughteachers, school nurses, and other school staff6may be well placed to work with local householdsto address social and health problems that
2 Hospitals and Schools as Hubs for Building Healthy Communities tion. In a particular neighborhood, there are like-ly to be multiple hubs with different characteris-tics that partner with each .
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orange; Poor hubs amber; and Illiquid hubs red. The colours used in Tables 1 to 6 are slightly different and will be explained with each Table. Map 1: European gas regions, markets and hubs in 2016 Key Element 1: Market participants The number of companies trading at a gas hub is an important indicator as to the development of that
TIPS ON FORD 4WD LOCKING HUBS The following information is from Ford service article 95-5-18 and covers the automatic locking hubs on 1983-90 Bronco II, 1983-95 Ford Ranger and 1991-94 Explorer. Ford says that the automatic locking hubs on these vehicles have an O-ring seal between the hublock and wheel hub to prevent contamination.
Introduction The Creative Hubs Report 2016 7 creative economy, which alerts us to the differences between creative hubs and hi-tech, maker, new media, etc. hubs. The first is that the creative hub is more than a building and more than a network. Success depends on collaboration and exchange between its members.
Building your dome should be great fun and the last thing we want is for people to hurt themselves. Here are a few things to watch out for:! The benefi ts that hubs bring to the build and adaptation of domes comes at the cost of ultimate strength. Domes built with hubs are still satisfyingly sturdy structures
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Aug 08, 2016 · more than 4,000 physicians and the addition of seven hospitals increases the number of hospitals in the Canopy Health provider network to 12 hospitals. The network also includes two John Muir hospitals in Concord and Walnut Creek and three UC San Francisco hospitals. “We have
This paper aims to extend this range and introduces a novel engineering application of Origami: Folded Textured Sheets. Existing applications of Origami in engineering can broadly be catego-rized into three areas. Firstly, many deployable structures take inspiration from, or are directly derived from, Origami folding. Examples are diverse and range from wrapping solar sails [Guest and .
