The Workshop

As part of its effort to collect and analyze information on current and planned performance monitoring activities, the committee held a workshop on May 24–25, 1995. The workshop gave the committee the opportunity to meet with researchers studying performance monitoring and with representatives of public and private organizations conducting or developing performance monitoring activities. The committee was also able to hear about experiences with community health reporting. The workshop included a series of presentations that, in combination, constituted a case study of the experience in Washington State and Seattle–King County. This report summarizes the workshop presentations and discussion. It does not present any formal recommendations or conclusions from the committee.

CONNECTING WITH THE COMMUNITY

Improving the health of communities requires looking beyond the contributions of medical care and providers of personal health care services. Similarly, measures of community health must be based on a broader population than those who have received medical care or who are members of a particular health plan. The first two workshop presentations gave the committee an opportunity to learn about two projects based on building links between the medical and the community perspectives.

Assessing a Community's Health1

Washington Heights/Inwood is a neighborhood of about 200,000 residents, predominantly lower-income and Latino, in the northern part of Manhattan in New York City. It also is the home of the widely known Columbia Presbyterian Medical Center, a major referral center with many patients from outside its immediate neighborhood. A 1994 report, Washington Heights/Inwood: The Health of a Community (Garfield and Abramson, 1994), is the product of an effort by the Health of the Public Program at Columbia University to use data gathering for an assessment of the community's health as a way to build better ties between the academic health center and the community. The project sought to highlight community assets that could promote good health as well as identify problem areas.

The report presents a broad range of information about the community. Health-related data include health status measures such as death rates by age and cause of death, AIDS incidence, and immunization rates. Among the health

1  

This section is based on a presentation by Richard Garfield.



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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary The Workshop As part of its effort to collect and analyze information on current and planned performance monitoring activities, the committee held a workshop on May 24–25, 1995. The workshop gave the committee the opportunity to meet with researchers studying performance monitoring and with representatives of public and private organizations conducting or developing performance monitoring activities. The committee was also able to hear about experiences with community health reporting. The workshop included a series of presentations that, in combination, constituted a case study of the experience in Washington State and Seattle–King County. This report summarizes the workshop presentations and discussion. It does not present any formal recommendations or conclusions from the committee. CONNECTING WITH THE COMMUNITY Improving the health of communities requires looking beyond the contributions of medical care and providers of personal health care services. Similarly, measures of community health must be based on a broader population than those who have received medical care or who are members of a particular health plan. The first two workshop presentations gave the committee an opportunity to learn about two projects based on building links between the medical and the community perspectives. Assessing a Community's Health1 Washington Heights/Inwood is a neighborhood of about 200,000 residents, predominantly lower-income and Latino, in the northern part of Manhattan in New York City. It also is the home of the widely known Columbia Presbyterian Medical Center, a major referral center with many patients from outside its immediate neighborhood. A 1994 report, Washington Heights/Inwood: The Health of a Community (Garfield and Abramson, 1994), is the product of an effort by the Health of the Public Program at Columbia University to use data gathering for an assessment of the community's health as a way to build better ties between the academic health center and the community. The project sought to highlight community assets that could promote good health as well as identify problem areas. The report presents a broad range of information about the community. Health-related data include health status measures such as death rates by age and cause of death, AIDS incidence, and immunization rates. Among the health 1   This section is based on a presentation by Richard Garfield.

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary services measures are ambulatory care visits, emergency department use, inpatient insurance status, and numbers of physicians by specialty. Also presented are data on characteristics of the population and the community that can influence health. Among these are ethnic distribution, immigration status, household composition, per capita income, adult educational attainment, primary school reading and math scores, and crime rates. For many measures, the report shows that Washington Heights/Inwood has relatively good health status. This population-based perspective is a valuable counter to the impressions that many medical center clinicians had developed from caring for those residents who are sick. The relatively positive findings also raised questions about why risk factors usually associated with poor health outcomes had a less adverse effect in this neighborhood. Possible explanations include greater household stability than might be expected among a predominantly immigrant population and the availability of informal employment to offset some of the “official” unemployment. The neighborhood is not without health problems, however. Of particular concern are violence, AIDS, and teen pregnancy. The report has been a way to bring information about the community 's health to many interested groups that did not have such information and has been helpful in dispelling myths about the community. The report's neighborhood focus, which differs from the city health department 's program-based organization, has encouraged greater contact among the program managers in that health district. Columbia Presbyterian Medical Center has found the report valuable for orientation programs for students, interns, and residents. Clinicians have also been able to use specific pieces of information in preparing grant proposals. It seems too soon to tell whether the report has stimulated greater interest in population-based research. A variety of groups in the community have been able to use the report and also have contributed additional insight into some health and health care issues. Schools, for example, have been able to reveal that many adolescents miss classes because they must take relatives to the doctor. This suggests that access to care may be affected by factors such as transportation or language barriers. Many other absences are pregnancy-related. Churches are seeing the impact of some of the circumstances documented in the report such as lack of insurance. To assist their members, churches have taken on an important community role in facilitating access to health services. Discussion at the workshop of some of the differences between immigrant communities in California and New York highlighted the importance of understanding local conditions. In contrast to patterns seen in California, the Washington Heights/Inwood population were less likely to return to their country of origin for care when they were ill, were less likely to seek care from traditional healers, and were less likely to be deterred from seeking mainstream care by concerns about documentation of their immigration status.

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary Although the response to the report has been largely positive, there have been a few less favorable reactions. The Medical Center, for example, felt that the report did not adequately reflect its contribution to the community's health status. There was also some concern that documenting the relatively good outcomes might make it more difficult to obtain grant support for further improvements. The report's comparisons between Washington Heights/Inwood and Harlem, which generally showed less favorable conditions in Harlem, were unpopular with the Harlem community. The authors of the report had not anticipated that reaction, expecting instead that the comparisons could be a helpful guide to problem areas in Harlem. The process of assembling Washington Heights/Inwood: The Health of a Community included discussions with a variety of groups to identify issues of interest and potential sources of data that could address those issues. Useful data are available from many sources, but in some cases data thought to be available could not be located or were not population-based and therefore not suitable for the report. Surveys to collect data on topics of particular interest may be appropriate in some cases but are generally too expensive for routine use in regularly published reports of performance indicators. Workshop participants suggested that a future report ought to include more information on other determinants of health such as genetic factors, individual behavior, and the social and physical environment. The report also might provide more information on the health services and other resources in the community that might be expected to have a role in community health issues. Comments at the workshop emphasized the need to consult with the likely audience for such reports and to produce data and reports that are understandable to a broad audience. Involving the community and responding to its concerns may increase the community's interest in and acceptance of the findings, particularly negative ones. The presentation emphasized the importance of being as clear as possible about the nature of the data presented, the limits of its accuracy, and why it is being presented. For example, comparisons over time or with other communities or perhaps with state or national data should have a specific purpose, which is explained to the reader. Workshop participants commented that the graphics used to display the data and the photographs used throughout Washington Heights/Inwood: The Health of a Community seemed particularly effective in making the report accessible to a mixed professional and lay audience. The important and difficult question of how to sustain publication of reports such as this was raised. No simple answers were available. In Washington Heights/Inwood, an effort is underway to identify possible sources of support, particularly among those who have found the report useful, but no long-term resources are currently available. In Canada, a program in Hamilton-Wentworth, Ontario, to monitor and report on community health (see Reynolds and Chambers, 1992) has benefited from a 10-year grant but is now facing the

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary need to find other sources of support. Some provincial funds have been promised for broader regional reporting. Additional support will be needed to continue the current district-level activity. Adapting Health Plan Performance Indicators for the Community2 In connection with the California Wellness Foundation's Health Improvement Initiative, the Center for the Advancement of Health in Washington, D.C., has considered how performance indicators developed for health plans might become a tool for accountability to the stakeholders in the communities served by health plans (see Sofaer, 1995). These stakeholders include consumers, employers, and public agencies, including regulators. Such indicators can also assist consumers and purchasers of health services in making informed choices among health plans and the services they provide. In addition, performance indicators can play a role in promoting changes in the health care system. Using the Center's expanded view of health, this project looked beyond a medical model for performance indicators. The framework used emphasizes psychosocial and behavioral aspects of the delivery of health services and bringing a public health perspective to the assessment of the services needed to protect and improve health. The project identified several functions of performance indicators. Such indicators reflect criteria for evaluation and certain values regarding health and health services. They also make explicit the expectations for some aspects of health care delivery. Performance indicators provide information to support decisionmaking regarding health services and can contribute to efforts in quality assessment and improvement for health care providers and communities. Health plans can be expected to use performance indicators as marketing tools. In addition, indicators have the potential to guide the development of information systems. Currently, however, the limitations on what can be measured with available information systems are guiding the selection of indicators. With these varied functions for performance indicators, further consideration focused on their normative, technical, strategic, and operational aspects. The normative element reflects the value judgments made in selecting the areas of performance (i.e., health outcomes) for which health plans or other organizations or individuals will be held accountable. Within a community it may be necessary to reconcile conflicting values for performance. For example, gun-related violence may be acknowledged as a health problem in many communities, but gun control may not be an acceptable preventive action in some of those communities. It is also necessary to establish whose performance 2   This section is based on a presentation by Shoshanna Sofaer.

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary is to be monitored. Workshop participants noted that views may well differ over the appropriate scope of accountability for individuals and organizations providing health-related services. The technical aspects of performance indicators include measurement issues such as the quality of the data being used and the validity and reliability of the indicators. It also is important for indicators to permit meaningful comparisons across entities. Another issue is selecting indicators that are effective proxies for a range of important characteristics of system performance. Strategic concerns relate to the purposes indicators are expected to serve. The appropriate number, focus, and mix of indicators (e.g., outcomes versus structure or process) require consideration as does setting targets for desired performance at levels that will lead to meaningful improvements. Among the operational issues are the feasibility of obtaining needed data at a reasonable cost and planning the ways in which the data will be used. Attention also needs to be given to packaging and disseminating data in ways appropriate for the intended audience. A review by the Center for the Advancement of Health and the Western Consortium for Public Health (1995) of many activities in the public and private sectors to develop and use performance indicators examined the extent to which the indicators addressed a range of consumer and community health concerns. Much of this work was found to focus on the performance of individual providers and the use of health services. With programs such as the Health Plan Employer Data and Information Set (HEDIS), which the National Committee for Quality Assurance (1993) now sponsors, attention is spreading beyond users of health services to entire enrolled populations in managed care plans. Expanding the scope of performance monitoring beyond enrollees to an entire community raises questions about the limits of health plans' responsibility and accountability for nonmembers and for aspects of health that are beyond the traditional realm of medical care. Currently, without a population-based “system” to promote the health of the public, being able to adopt a community perspective depends on the willing cooperation of the various organizations contributing to health and health care. Several kinds of “gaps” were noted among the indicators reviewed by the Center for the Advancement of Health and the Western Consortium for Public Health. Little attention is given to individuals' functional status or health-related quality of life. Behavioral and psychosocial aspects of illness and health care are generally not addressed well. Mental health and substance abuse services receive some attention, but the common practice of assigning those services to separate specialty provider groups works against identifying problems in the integration of psychosocial services with other aspects of care. Health promotion indicators are generally limited to clinical preventive services and do not capture broader community-oriented activities such as policies related to tobacco control. Indicators of health plan contributions to the

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Using Performance Monitoring to Improve Community Health: Exploring the Issues: Workshop Summary community, referred to as community benefit in qualifying for nonprofit tax status, are another commonly missing element. Workshop participants commented that indicators generally do not address age-related aspects of health for the young and the old. Also missed is the intergenerational impact of health problems (e.g., parents caring for children or adult children caring for aging parents). Environmental health determinants need attention as well. Also raised was the idea of performance indicators for employers, both for care provided at the worksite and for work-related health problems such as injuries or pollution. Such indicators would require careful definition of the population or community to which they apply. The discussion drew attention to the lack of data on the effectiveness of many health services and the problem that it can create for selecting performance indicators. Another challenge is determining appropriate indicators for multidimensional health issues. Where the determinants of health are not adequately understood, it may be necessary to turn to indicators for performance in areas such as service capacity or processes of care. Some users may find those indicators less satisfactory. For example, employers evaluating health plans may care more about enrollee quit rates for smoking than the availability of smoking cessation programs. Issues related to accountability generated much discussion. One concern is reaching agreement among stakeholders on where accountability for health outcomes can and should lie. In particular, the role that private sector health plans (and other medical care providers) should be expected to play in community-based health improvement efforts is a source of concern and debate. Health plans can, for example, make valuable contributions by responding to known concerns (e.g., smoking) and by identifying community-based problems (e.g., toxic exposures) through the need they create for health care services. Health plans could also benefit from community-based health assessments that generate information about factors affecting the health—and health care needs —of their members. The question of how to “operationalize” health plan accountability was raised. Currently, employers are a principal locus of oversight and influence. It is not clear whether the plan selections made by individual consumers are an adequate mechanism to enforce accountability. Regulatory requirements for health plan performance are possible but may not be the most acceptable approach. In response to a question, it was suggested that performance monitoring efforts have given little attention to understanding the readiness or capacity of health plans to make changes to respond to community health needs or to meet broader population-based expectations for accountability. The observation was made that while some plans are willing to accept limited responsibility for elements of community health many are not ready to do so. A more acceptable alternative to holding health plans accountable for