5
Case Example of Investment by a Health Care Organization
Leaders from University Hospitals (UH) in Cleveland, Ohio, were invited to share their example of investment by a health care–sector organization. Patricia DePompei of UH Rainbow Babies & Children’s Hospital and UH MacDonald Women’s Hospital shared her perspective from the clinical side. Heidi Gartland, also of UH, provided a community engagement perspective on how UH became an anchor institution in the community. The panel was moderated by Gary Gunderson of Wake Forest Baptist Health and Stakeholder Health. Gunderson emphasized that this discussion is about “real neighborhoods,” and about a health care leader sustaining their commitment to the real communities where their patients and employees live. (Highlights of this session are presented in Box 5-1.)
UH: STRIVING TOWARD A CULTURE OF POPULATION HEALTH
UH was founded in the Greater University Circle area of Cleveland in 1866. The UH system currently includes 18 hospitals and 40 health centers, and serves 1 million unique patients annually. The Greater University Circle area has experienced disinvestment over the years, Gartland said, and residents have experienced structural racism such as redlining (discriminatory lending practices based on the race and/or ethnicity of a neighborhood). The median household income in the Greater University Circle is $18,500, and one in two children live in poverty. Infant mortality is high (18.6 per 1,000 births) and disproportionately affects African American infants. The number of children under age 6 years with lead poisoning
is four times the national average. The unemployment rate is 24 percent, and many of those who need work have barriers to employment.
About 10 years ago, Gartland said, UH undertook an initiative to reinvest in the UH organization. As part of the planning process, it was decided that UH would not simply invest in its own infrastructure, but would also invest in its community to build health and wealth.
The Anchor Mission: Hire Local, Buy Local, Live Local
Initial thoughts, Gartland said, were that this initiative would be a one-time investment to build up the community, and then UH would step back. Instead, she continued, UH has established itself as an anchor institution, and investing in and interacting with the Greater University Circle area has “become a way of life.” For details, Gartland referred participants to the report The Anchor Mission: Leveraging the Power of Anchor Institutions to Build Community Wealth, which analyzes the UH initiative as
a case example of community investment.1 Briefly, UH planned to invest $750 million in the local economy through a strategy of “hire local, buy local, live local.”
Hire Local
The first element of this anchor strategy was to put an emphasis on hiring people from the local neighborhoods, especially those who were under- and unemployed. In partnership with community organizations, UH identified local residents who were interested in working in entry-level jobs at UH. Interested residents were provided with skills training, resume building, and interview training. Gartland said more than 1,000 people from the local community have been hired over the past 5 years for entry-level jobs. To make more entry-level jobs available, existing employees were also given opportunities to advance. In addition, several staffing programs were launched, including Step Up to UH, designed to develop a pipeline of incoming staff from the local community, and New Bridge, which trains people for jobs as phlebotomists, pharmacy technicians, nurses’ aides, and other in-demand roles.
Buy Local
UH planned to put money into the local economy through engagement with local businesses, especially women-owned and minority-owned businesses. One example described by Gartland was a $1 million investment in the development of the Green City Growers neighborhood cooperative, from which UH could then purchase fresh produce. She noted that thus far, UH has purchased $300,000 worth of lettuce. A similar venture is a laundry cooperative, which now handles a portion of UH’s massive laundry service needs. Gartland pointed out that many of the employees of these cooperatives are re-entry workers, local residents who have been incarcerated and have difficulty getting hired for good-paying jobs.
Live Local
UH encourages its employees to live locally by providing employees with financial and other assistance to help them purchase property, upgrade their existing homes, or rent in the surrounding communities. Gartland said several hundred employees have taken advantage of this program.
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1 Available at https://democracycollaborative.org/content/anchor-mission-leveraging-power-anchor-institutions-build-community-wealth (accessed June 23, 2021).
Health Local
UH has also embraced place-based community health and wellness as part of its anchor mission. Gartland noted the importance of the support of the UH leadership, including the Board and chief executive officer, which allowed them to take a different approach to investing than UH had done in the past. Together with the local county Board of Health, UH has been investing in equity and health in the local community.
Community Health Needs Assessment
DePompei elaborated on the UH investment in place-based community health and wellness—specifically, their efforts to address the health care needs of infants, children, and women in the communities that are direct neighbors of UH.
In 2015, UH updated its approach to its community health needs assessment, evolving from a primarily quantitative assessment to a more qualitative assessment that engaged the community. The response from the community was “loud and clear,” DePompei said. The assessment found there was a lack of trust between the community and UH. There were aspects of health care that the community believed were not being sufficiently addressed, especially access to behavioral and mental health services and access to dental care. The assessment also revealed the need for UH to better engage the entire family, especially men, and pay more attention to multigenerational care.
In response to the findings of the community health needs assessment, in March 2016, UH convened a Community Advisory Board. Invitations were sent to patients and stakeholders from the community across a broad range of sectors. DePompei noted that there was 100 percent attendance by the invitees to the initial Community Advisory Board meeting, which she added was during an ice storm in sub-zero temperatures. This Community Advisory Board continues to have a very high level of participation and engagement, she continued.
Advice from the Community Advisory Board was to redesign the delivery of primary care for the women and children in the neighborhoods surrounding UH. DePompei said clinic services were housed on the first floor of Rainbow Babies & Children’s Hospital, and these clinics were the main training sites for pediatric and obstetric/gynecologic residents. To understand the needs of patients and their families who are served by the Rainbow ambulatory pediatric practice and the MacDonald Women’s and Children’s obstetrics/gynecology service, a longitudinal patient/caregiver survey was conducted.
The survey response rate was high (80 percent). Patients and families reported significant health-related needs, and stress resulting from unmet
needs. Social factors reported included housing instability, financial concerns and inability to pay bills, food insecurity, and transportation issues. DePompei noted that, even though about 85 percent of the families surveyed are employed, they often have low-paying jobs. Food insecurity was compounded by the lack of a local supermarket in the neighborhoods bordering UH. Lack of a direct bus line was a barrier to patient access to health care at the clinic.
Providers were also surveyed for input on what would be an ideal model of primary care delivery. Responding providers understood the need to address the social determinants of health, DePompei said, and they were interested in guidance on how to accomplish this while keeping up with busy clinic schedules.
A New Medical Home in the Community
In partnership with patients and families and the Community Advisory Board, UH set out to build a medical practice that would meet both health care and community-based needs. In July 2018, the Rainbow Center for Women & Children opened. DePompei noted that construction of the new center was fully funded through New Markets Tax Credits and philanthropy. The center, which she described as welcoming and vibrant, features artwork by local artists. Services include primary care pediatrics, obstetrics/gynecology, maternal–fetal medicine and imaging, dental, optometry, pharmacy, mental health and addiction services, a women/infants/children office, onsite legal aid, and social needs navigation. DePompei said that the center is so busy that additional bus stops and parking are being added.
Securing Funding and Internal Stakeholder Buy-In
Gunderson asked DePompei to elaborate on funding creative initiatives to meet community needs. The first point, she said, is that initiatives need to be part of the overall mission of the organization to garner support from leadership. For UH, the construction of the new center was clearly within its mission. One then needs a clear business case for the initiative, and this was more challenging, she said. Financially, 91 percent of the pediatric patients served by the clinic and 90 percent of the women are covered by Medicaid, which she said has generally poor reimbursement for primary care services. For that reason, it was important to rally support from community members by making them aware of the unacceptable community health statistics, such as the racial and geographic disparities in infant life expectancy in the surrounding neighborhoods versus nearby suburbs. Next, it was necessary to secure the funding
for the capital project. DePompei said UH was encouraged by the Robert Wood Johnson Foundation to pursue New Markets Tax Credits. As noted earlier, the center was fully funded through New Markets Tax Credits and philanthropy. She added that the Ohio Department of Medicaid has funded many of the programs. As an example, she mentioned Centering Pregnancy, a group model of care delivery with proven results (e.g., reduced rates of preterm delivery). DePompei said they continue to look for ways to increase efficiency and drive more volume at the center to ensure sustainability.
New Markets Tax Credits are intended to incentivize development in economically distressed areas, and Gartland said the Greater University Circle area is one of the most economically underresourced areas in Northeast Ohio. She acknowledged the leadership and support from the Board for allowing the necessary legal structures to be implemented to secure the New Markets Tax Credits. This was a calculated risk for UH, Gartland said, but she explained that DePompei has a history of being able to deliver on projects and promises and had the trust of the Board to lead this effort. Gartland also noted that the local community development financial institutions were eager to participate in the development of the center. DePompei agreed and emphasized the value of New Markets Tax Credits “as a catalyst for economic growth.” The intent is that the building of the anchor institution (in this case, the primary care center) will lead to other community growth, and she mentioned the opening of a grocery store and coffee shop in what had been a food desert.
Gunderson emphasized the point by Gartland about delivering on promises made to internal stakeholders and the community. He suggested that leaders who fulfill their promises create momentum and inspire others to partner in the initiatives. DePompei agreed and said that delivering on the promises made to patients and their families is the primary goal. As an executive, she must also ensure that regulatory requirements are met, and that profits and losses meet expectations.
Gartland called the process “a journey” that began with the UH Vision 2010 strategic plan that recognized the need to invest in the community. She mentioned that one of the earlier steps in the journey was a $12 million Center for Medicare & Medicaid Innovation (CMMI) Health Care Innovation Award in 2012. Part of the project included the building of a new office that was first slated for the suburbs, near where the providers lived, but was ultimately built in one of the Greater University Circle neighborhoods near UH, where the population to be served lived. Gartland noted the challenge of changing the mindset of the providers to begin to understand the importance of location. Later, having this office already in the Greater University Circle area helped with provider acceptance and support of locating the new center there as well.
Gunderson asked how young professionals entering the health care field are responding to these initiatives. An unexpected benefit of the new center, DePompei said, has been as a recruitment tool for top medical residents and other practitioners. Many up-and-coming residents, physicians, nurse practitioners, nurse midwives, and other practitioners understand the importance of addressing the social determinants and are excited by the work of the center.
DISCUSSION
Coordination Across Payers Serving a Population
Sanne Magnan asked the panelists to discuss the policy or system change they would most like to see made by their largest payer, Medicaid. Gartland said she would like to have much more coordination across contractual arrangements with managed care organizations. She noted the challenge of translating innovative total cost of care models across five separate contracts. Some payers are “more enlightened” with respect to population health, and others are less so, she said, which can be a barrier to implementing a model of care for an entire population. She suggested finding ways to incentivize payers to be more aligned with the care models that are reducing costs. Gartland also called for a share of the savings to be returned to the health system. DePompei concurred and said the state has supported the Centering Pregnancy Program because of the demonstrated cost savings from the reduction in neonatal intensive care unit admissions. There are many examples of how upstream interventions can reduce overall costs of care, but she added that the models must be sustainable. Magnan referred participants to a recent publication by Pham and Ginsburg on coordinating contracting in payment reform (Pham and Ginsburg, 2018).
Gauging Success
Alexander Rossides of Social Impact Exchange inquired about the size of the population being served by the center; whether the patient volume or revenue have increased sufficiently to confirm the economic argument for building the center; the population health outcomes and timeframes the center hopes to achieve; and the “gravitational pull” of the center in attracting other businesses to invest in the area.
Gartland said Cuyahoga County has a population of about 1 million, the city of Cleveland has a population of nearly 400,000, and the Greater University Circle area has just under 200,000. Demographically, she said, the East side is primarily African American and the West side is mostly white and Hispanic.
As an example of how UH has been a catalyst, she said that UH partnered with the county and city Boards of Health on developing a joint community health needs assessment in 2018, 2 years before a state requirement for joint needs assessments goes into effect in 2020. This has prompted other health systems to step up as well. She said that although health systems compete on patient care, there should not be competition on community health. From an economic perspective, Gartland said that UH has established itself as an anchor health care institution that continues to invest in the community, and other businesses are eager to be “anywhere UH is.”
DePompei said that basic short- and longer-term health care delivery metrics were established as part of the original CMMI award (e.g., reducing emergency pediatric psychiatry inpatient admissions by addressing behavioral and mental health in outpatient visits; reducing the rate of children needing dental surgery due to untreated dental caries by applying fluoride varnish to newly erupted molars; increasing immunization rates). Other metrics being tracked include the no-show rate for patients at the pediatric and women’s health clinics. She suggested that ease of access and respect for the patients have contributed to increased numbers of patients keeping appointments. From a growth perspective, the center was expected to have 45,000 patient visits annually, and a metric of 5 percent growth in patient volume was factored into the New Markets Tax Credit agreement. She expressed optimism and said that “the initial indicators are incredibly promising.”
Going to Scale
Marc Gourevitch observed that the UH board and leadership were mission driven in embracing the Greater University Circle anchor strategy. He asked how boards and chief executive officers of other organizations that are less mission driven might be convinced to embrace “doing well by doing good.” Gartland said the UH system has hospitals in other low-income, underserved neighborhoods and is working strategically to implement similar place-based approaches in areas of need. UH is also participating with other hospitals and organizations to spread the anchor mission more broadly, including The Root Cause Coalition and the Healthcare Anchor Network. She acknowledged that leadership support is essential.
Job Training
John Auerbach asked whether the anchor strategy included job creation or job training opportunities for the community. DePompei pointed
out that New Markets Tax Credits applicants must indicate the number of new jobs that will be created as part of the capital project. She reiterated that the hire-local aspect of the strategy was a core component of the UH commitment to the community, and it included hiring locally for both the construction of the center and the staffing of the completed center. The Step Up to UH Program was launched to help local residents gain entry-level jobs in health care and to access ongoing workforce training needed for career advancement. Gartland mentioned the Bridge to Your Future workforce development program in association with local community colleges that helps employees to develop the skills needed to pursue a certification or college degree. There are also job coaches who help employees navigate the life challenges that impact continued employment. This has reduced the turnover rate for new employees from the community from 80 percent to less than 20 percent, she said.
Equity as the Core of Advancing Population Health
Terry Allan, health commissioner for Cuyahoga County, where UH is based, said the mandate from the state of Ohio to begin conducting coordinated county-level health assessments across multiple systems presents opportunities as well as uncertainties and challenges. For example, he noted that a given health system can have a wide reach, beyond a specific county’s borders. He acknowledged the role of UH in working through the challenges as assessments are conducted to meet regulatory requirements and to advance population health in the communities. He noted that it was exciting to see the conversations happening across multiple health systems, and the new priorities being discussed. He also acknowledged the role of workshop participants in these conversations and their authority to make decisions based on the discussions. He specifically recognized Danielle Price of UH for her focus on ensuring that health equity is part of the conversation, reinforcing the need to deploy resources to address the “compounding disadvantages that a subset of the population deals with in underresourced communities.” As the hospitals in a county or a region work toward population health, equity should be the “guiding principle,” he said.
Competition and Collaboration
Milstein asked how the implementation of the anchor institution strategy has affected competition or collaboration among UH and the other systems in the area. Those institutions include Case Western Reserve University and the Cleveland Clinic in the Greater University Circle area, and MetroHealth to the west. Gartland said she is chair of The Center for
Health Affairs, the local hospital association for Northeast Ohio. It serves as the convener for the collective community health needs assessments and as a place to work collaboratively. She mentioned several community health initiatives that the health systems have worked on collectively, for example, First Year Cleveland, which is focused on reducing infant mortality, and the Northeast Ohio Hospital Opioid Consortium. She noted that federal antitrust regulations prohibit the health systems from discussing the core business aspects of their care delivery, but allow the systems to work together to address issues of public health. She suggested that the anchor mission of hire local, buy local, live local is not competitive. Similarly, although UH might have been first to step into the community health space, all of the health systems are now working collaboratively. The chief executive officers of the health systems meet regularly, which she said was important for being servant leaders to the community. DePompei added that the health systems joke about “stealing shamelessly from each other,” meaning that if one has shown success with a community health effort, such as the new UH center in the Greater University Circle area, the others should try to replicate it in their communities.
