Lessons and tips from the peer group call on November 3, 2016, with communities/public health departments on how to work effectively with hospitals to address social determinants of health in their communities.

1. Why do Hospitals/Health Systems Want to Partner with
Communities?
We want to create a health system that improves population health. Represented by the triple aim diagram below.
While the healthcare system plays a small role in improving population health
outcomes, it’s really the social, physical, economical, and cultural environment
in a community that has the greatest impact. As hospitals and health systems
are being held more accountable for population health improvement, this has
encouraged many to want to partner with communities. They recognize that
their expertise is the delivery of clinical care, and they need to partner with
communities to address the community determinants of health.
Source: IHI Triple Aim image courtesy of Northern New England Accountable
Care Collaborative: http://nneacc.com/
Healthcare as an Anchor Institution
This document from the Democracy Collaborative, “Can Hospitals Health America’s Communities?” discusses the
multiple roles health systems can play in promoting community health.
Human Resources/Pipeline— how does the hospital function as an employer?
 Hiring from the local community
 Providing a living wage
 Benefits allow for health access and also promote wellness
 Promoting a healthy environment for workers (bike parking, walking paths,
healthy food options)
 Increase the employment pipeline by supporting local schools and training
programs
Procurement and Supply— what does the hospital purchase?
 Make purchases from locally owned businesses
 Make purchases from women and minority-owned businesses
 Set environmental standards for purchased products
Government Relations/Policy Advocacy— how the hospital can influence local policy?
 Use institutional leadership position as a voice for local policy and practices that promote community health
 Develop and use infrastructure for tracking relevant social policy so the hospital can weigh in when
appropriate
Portfolio/Investor— how does the hospital invest?
 Most health systems have some treasury they need to invest somewhere
 Prioritize socially responsible investing, by the hospital and through stocks or retirement programs offered to
employees
Community Benefits— how can the hospital engage the community and support local prevention efforts?
 Use community benefit dollars to invest in community prevention
 Base supported efforts on CHNA findings
 Engage the local community throughout the process

2. Tips for building relationships with hospital partners
1. Make sure the hospital partner knows the goals of the project up front
Take time to orient them to their role in the project, the community served,
and to the underlying causes of health inequity that you’re trying to
address.
2. Match the goals of the project with the hospital priorities.
Look at your hospital’s last Community Health Needs Assessment (CHNA)
(these should be publically available and found online with a quick google
search). Try to align the priorities identified in that assessment with your
project goals. That will help garner support from the hospital since they will
be able to see how the work can benefit them as well.
More importantly, get engaged in the CHNA process the next time around! Try to get at the table for those
conversations to begin building those relationships and influence the health equity discussion.
EXAMPLE: One BUILD site’s partners were able to participate in the focus groups for the hospital’s CHNA process
this year. Another BUILD site was part of their hospital’s first CHNA process a few years ago and has found that
helpful to the current BUILD partnership in that it initiated some of that relationship building.
EXAMPLE: In one BUILD city, community organizations and the health department were routinely approached by
each of the hospitals in the area with the same series of questions and requests for population level data.
Eventually, the health department convened all the hospitals who agreed to work on a joint CHNA with a core set
of metrics that would serve the requirements. The hospitals decided to contract with the health department to
produce the joint CHNA. They had great success in this process and are now entering the next phase to update it.
Challenges to Collaborating on CHNAs/CHAs: Typically, health departments have to do a community health
assessment (CHA) every five years, while hospitals complete their CHNA every three years. Thus it’s often difficult
to sync the two calendars. The goal would be to have a joint assessment for the county that could be co-led by
local health departments and health systems.
3. Identify the right person in the hospital system early on.
EXAMPLE: One BUILD project began with a strong, accountable hospital partner, who had a thorough
understanding of the project, understood the hospital’s role, and understood the social determinants of health in
the project’s neighborhood. The hospital partner was planning to retire in the middle of the project, and in
preparation for his departure, he appointed a colleague to step in early and ease the transition. They spent a lot of
effort orienting this new person to the project to make sure she had the information needed to continue to support
the hospital’s investment in the project. After 8 months of working with the new hospital partner, they learned
there was actually a different person that oversees the hospitals community benefit funds, which were the source
of the hospital’s investment in the project. They reinitiated efforts to update this other person on their efforts, but
were pressed for time given the project deadlines. Ultimately, if they’d known to connect with the community
benefits person from the beginning they could have saved a lot of time and effort.
4. Plan ahead, have a specific ask, and have exact numbers when possible
If you know the exact amount of money (cash) needed from the hospital partner early on, that gives the hospital
more time to plan and figure out how to allot the funds.
It’s important that
hospitals understand the
direct link to health
outcomes and their
bottom line, and see
how the work aligns
with their mission.

3. EXAMPLE One BUILD site, due to staff transitions, didn’t know the exact cost of the project at the beginning of the
planning period, and was only able to secure an in-kind match from the hospital, where cash would have been
more beneficial to the project. If they had communicated the request earlier in the process, they might have
secured more cash dollars in the match.
5. Keep the hospital engaged and informed on project deliverables and timelines throughout the project
It’s important to keep the hospital partner engaged throughout the process, so they feel invested and you don’t
just include them when it’s time to ask for funding support. Invite them to key meetings, and to be a part of the
planning committees.
6. Find the best lane (fit) for the hospital system in the partnership
It’s helpful to utilize the hospitals’ expertise and find the best fit for their skills in the structure of the partnership.
They need to feel like they have the win from that relationship as much as the community does for having them at
the table.
EXAMPLE: The primary healthcare partner in one BUILD project is not a non-profit hospital, so they do not have the
community benefit requirement. Therefore, their contribution to the work has been to provide evaluation support
entirely in-kind, and significantly so, possibly even more than the 1:1 match requirement. The hospital has served
as the lead evaluators for the project, including designing the shared measurement system, collecting data in the
pre-test phase, and partnering with the local school of public health to analyze and publish the results. This has
truly been a win-win for both the hospital and the community and a strength of the partnership, because they were
able to identify that “best fit”.
How Can Hospitals Support Communities?
By providing funding support…
Hospitals can use community benefit dollars to invest in community prevention. Many non-profit hospitals are this
year in the process of completing their second CHNA as required by the IRS.
SAMPLE BREAKDOWN OF HOSPITAL MATCH DOLLARS
 Funding salaries of two Community Health Workers
 $25,000 + in scholarships to high school students who will pursue careers in the healthcare industry
 $25,000 towards monitoring and evaluation – In-kind technical assistance
 $22,000 to train healthcare providers in target neighborhood
BANDWIDTH – how much staff time does it take to drive the hospital/community partnership
component forward? (e.g. effort and time commitment)
 ONE BUILD SITE FUNDS A 50% FTE PROJECT/NETWORK “WEAVER”. THEY ALSO HAVE AN IN-KIND PROJECT
WEAVER FROM THE CITY, AND FROM THE HOSPITAL. THEY HAVE FOUND IT IMPORTANT TO HAVE A
DEDICATED STAFF PERSON FROM EACH SYSTEM.
 GRADUATE FELLOWS FOCUSING ON POLICY WERE ALSO PLACED IN EACH OFFICE TO INCREASE STAFF
CAPACITY.
IF YOU DON’T HAVE THE RESOURCES, IT’S NOT A LOST CAUSE! WHAT YOU CAN’T DO IN VOLUME YOU CAN
OFTEN DO OVER TIME.

4. SAMPLE BREAKDOWN OF HOSPITAL MATCH DOLLARS
 Funding cost for Community Health Workers to co-locate in health department office
 Share the rent for that office
In another BUILD site, the hospital exceeded the 1:1 match and also invested
 $39,000 in a clinical community health worker pilot
 $5,000 in training for that team
In addition to funding, hospitals can…
1. Heighten awareness and bring legitimacy to the work
Having a major institution like the hospital at the table, often allows communities to capture the attention of
mainstream audiences and key decision-makers.
EXAMPLE: One BUILD site leveraged the relationship between their city planning and city community services
departments, and the hospital. The city departments had great relationships with the hospital community
benefits partner and having the hospital partner at the table brought legitimacy to their request to the city for
support on their project.
2. Advocate in policy and systems change work
EXAMPLE: One BUILD community developed a comprehensive budget request for the city council (nearly $60
million for staffing, operations, and capital investments to address public safety issues). The hospital provided
support by adding their voice to the cause. The Hospital CEO wrote a letter to the city council supporting the
budget request emphasizing that they as a hospital were happy to support this cause, but that it is ultimately
the city government’s responsibility to address public safety in their neighborhoods. The CEO encouraged city
council to at least match the hospital’s contribution to the BUILD project. The city council was impressed that a
major institution (with an emphasis on healthcare) was stepping up to influence policy around public safety.
How do you engage hospitals in upstream interventions?
Many communities have found it challenging to translate their community action plans, which are centered on
upstream interventions and do not involve a lot of clinical interventions, to something the hospital can get involved in.
There is often a disconnect and finding the hospital’s significant role in implementing the community action plan can
prove challenging.
1. Frame issues (e.g. housing, public safety, access to green space) in ways that align to a direct delivery of some
kind of service.
It’s important to translate the budget for the hospital/health system in terms of delivery of services.
EXAMPLE: One BUILD site is creating a Housing and Healthcare partnership to facilitate sustainable relationships
between hospitals and affordable housing providers to bring resources and education directly to residents in
affordable housing buildings. The hospital feels comfortable providing those health education resources, so that
was one way to plug them into the intervention. The community organization learned to find those places where
hospitals feel comfortable providing services, but also recognize that they are not going to be the ones looking at
economic development. It’s important to speak a language that appeals to them and ultimately to the hospital
board that approves the funding.
2. Remember that Hospitals are Businesses
A hospital’s reputation in a community helps them achieve market share in a competitive market, e.g. people want
to go to their hospital because they believe that hospital is doing good in the community.

5. 3. Communities can help hospitals reduce their cost
Hospitals are legally required to serve uninsured patients – that is a cost for the hospital. We can make the case
that if community environments were better, that would reduce illness/injury rates and drive down costs for the
uninsured. Hospitals would be able to then devote resources away from unnecessary illness/injury, and towards
the more complex patients.
Addressing Power Dynamics
How do you work equitably with an organization that has much more
power and resources than you do?
We’re all trying to reduce disparities and improve health equity, but we first need to reduce inequity within our own
partnerships. By design, community-based organizations are usually small, grassroots organizations. Because of the
BUILD 1:1 dollar match requirement with hospitals, the burden falls on the community organization to appeal to these
major institutions (hospitals) who carry a lot of financial power, political power, and general size. So naturally that
leads to unequal power dynamics.
How can we start the processes in a way to facilitate more equitable partnerships?
1. Coach hospitals to approach meetings with collaborative members differently than they are used to:
Hospital partners need to come as listeners and learners. Hospitals are used to being in leadership roles, but need
to rethink roles for equitable partnerships.
- Speak last – if they speak first and take up all the oxygen in the room, the power dynamics are such that
community members often won’t speak up after that.
2. Lead with metrics/framework previously defined and validated
For initial planning meetings, lead with common metrics or goals (perhaps from Community Health Improvement
Plan- something the hospital has already been involved in) to start the conversation about resource
blending/braiding and strategy alignment. By doing so you can sometimes cut through the power dynamics. Data
is powerful and having a clear vision about how these systems can work together can help the community org
bring some power to the table.
3. Ask people to use reflective listening techniques
Before you talk, reframe what someone just told you. This technique helps people:
1) know you were listening to them
2) know that you heard them correctly
4. Negotiation skills in general are helpful to address power dynamics.
5. Good facilitation can help equalize the power dynamics in the room
For meetings, have a facilitator who is aware of some of these power dynamics. They can use facilitation
techniques to address those issues during the meeting.