Describing the Continuum of Collaboration Among Local Health Departments With Hospitals Around the Community Health Assessments Kristin D. Wilson, PhD, MHA; Lisa Buettner Mohr, PhD, MPH, CHES; Kate E. Beatty, PhD, MPH; Amanda Ciecior, BS rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Background: Hospitals and local health departments (LHDs) are under policy requirements from the Affordable Care Act and accreditation standards through the Public Health Accreditation Board. Tax exempt hospitals must perform a community health needs assessment (CHNA), similar to the community health assessment (CHA) required for LHDs. These efforts have led to a renewed interest in hospitals and LHDs working together to achieve common goals. Purpose: The purpose of this study is to gain a better understanding of levels of joint action leading toward collaboration between LHDs and hospitals and describe collaboration around CHAs. Methods: Local health departments were selected on the basis of reporting collaboration (n = 26) or unsure about collaboration (n = 29) with local hospitals. Local health departments were surveyed regarding their relationship with local hospitals. For LHDs currently collaborating with a hospital, a collaboration continuum scale was calculated. Appropriate nonparametric tests, chi-squares, and Spearman’s rank correlations were conducted to determine differences between groups. Results: A total of 44 LHDs responded to the survey (80.0%). Currently collaborating LHDs were more likely to be interested in accreditation and to refer to their CHA 5 or more times a year compared to the unsure LHDs. In the analysis, a collaboration continuum was created and is positively correlated with aspects of the CHA and CHA process. Conclusions: This study is the first attempt to quantify the level of collaboration between LHDs and hospitals around CHAs. Better understanding of the levels of joint action required may assist LHDs in making informed decisions regarding deployment of resources on the path to accreditation. J Public Health Management Practice, 2014, 20(6), 617–625 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
KEY WORDS: ACA, accreditation, collaboration, community
health assessment, health policy, local health departments, tax-exempt hospitals
The policy environment to improve population-level health is affecting various sectors of health care, both independently, and in conjunction with partners. Specifically, hospitals and local health departments (LHDs) are each under policy requirements from national legislation through the Patient Protection and Affordable Care Act (ACA),1 varying state-level policies, and policy influences such as the new national LHD accreditation standards through the Public Health Accreditation Board (PHAB).2 While there is much contained within these policy requirements that apply specifically to hospitals and LHDs independent of one another, there are also opportunities created within these policies that encourage various levels of joint action between hospitals and LHDs.3 In light of these policies, the literature and practice standards reflect the renewed importance for hospitals and LHDs to work together to achieve common population-level health improvement. In the state of Missouri, a natural experiment exists to explore joint actions between LHDs and local hospitals. Since 2003, the Missouri Institute for Community Health (MICH) has administered the only voluntary state-based accreditation program, the Missouri Voluntary Accreditation Author Affiliations: Health Management and Policy MPH Program (Dr Wilson) and Department of Health Management and Policy (Drs Wilson, Mohr, and Beatty and Ms Ciecior), Saint Louis University College for Public Health and Social Justice, Saint Louis, Missouri. The authors declare no conflicts of interest. Correspondence: Kristin D. Wilson, PhD, MHA, Health Management and Policy, Saint Louis University College for Public Health and Social Justice, 3545 Lafayette Ave, St Louis, MO 63114 ([email protected]). DOI: 10.1097/PHH.0000000000000030
617 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
618 ❘ Journal of Public Health Management and Practice Program (MOVAP) for LHDs in the nation, serving as one of the 5 legacy states for the Multi-State Learning Collaborative.4 In the past 8 years, 24 LHDs, or 21% of Missouri’s LHDs, have begun or successfully completed accreditation activities.5 At the national level, PHAB was established in 2006 by the American Public Health Association, Association of State and Territorial Health Officials, National Association of City and County Health Officials (NACCHO), and National Association of Local Boards of Health. This national voluntary accreditation program was launched in 2011. Similar to MOVAP, PHAB standards were based on findings from the Multi-State Learning Collaborative.4 Before LHDs can begin the process of accreditation through PHAB or MICH, they must meet 3 prerequisites included in the past 5 years: (1) a completed community health assessment (CHA), (2) community health improvement plan (CHIP), and (3) an agency-wide strategic plan. Contained within these prerequisites is the expectation that to achieve these prerequisites for accreditation, LHDs will collaborate with the community, which includes local hospitals.2 While we may be able to describe the types of activities conducted to complete a CHA and CHIP with community partners, what is not as well-known is how to quantify “collaboration” so that the impact of varying levels of joint action can be assessed more thoroughly during the process of accreditation. Most work done thus far around collaboration has been descriptive. By attempting to quantify what collaboration looks like, there is potential to translate it into necessary resources and a reasonable operating budget. Also, once collaboration is quantified, we can begin to correlate it with outputs and quality of collaboration in addition to identifying variables that most correlate with collaboration to aid in future improvements. With the passage of the ACA, tax-exempt hospitals must also perform a community health needs assessment (CHNA) every 3 years. This CHNA is very similar to the CHA required for the LHDs. The CHNA is intended to be a collaborative effort between the hospital and relevant community agencies, including LHDs.6 In addition, hospitals are required to collaborate and include in the process public health expertise when completing both the CHNA and Community Benefit Plan.1 This requirement contained within the ACA creates the main incentive for hospitals to engage with their LHD on CHNAs. This increased pressure on both LHDs and taxexempt hospitals to better identify the needs of their community makes joint action between the 2 organizations a rational choice, as identified in the 2012 Institute of Medicine report, “Primary Care and Public Health: Exploring Integration to Improve Population Health.”3 In the most recent (2012) Missouri De-
partment of Health and Senior Services’ Infrastructure and Needs Survey (MO DHSS Infrastructure Survey), LHDs are asked if they are collaborating with their local hospitals on the CHA.7 Within this survey, “collaboration” is not defined. The results of this survey indicate that many LHDs in Missouri have chosen not to “collaborate,” or are unsure as to whether or not they will “collaborate” in the future. Because MO DHSS uses the term “collaboration” broadly, the levels of joint action are not clear. In addition, being unsure about collaboration is not clearly defined, which through our study we sought further clarify. NACCHO defines collaboration as “ . . . working jointly to accomplish shared vision and mission using joint resources.”7 It further describes levels of joint action to include networking, coordination, cooperation, and collaboration. By evaluating the current levels of joint action between LHDs and nonprofit hospitals in the state, there is an opportunity to identify areas of improvement and make future partnerships more efficient and effective in achieving mutual goals and objectives for improved population level health while continuing to fulfill various policy requirements.7 Current infrastructure and long-standing practices within LHDs and hospitals may create barriers between LHDs and local hospitals in fostering joint action.3,8 The LHDs have reported barriers to joint action, and these barriers may provide challenges in achieving the intent of the policies designed to foster collaboration for improved population-level health.9 To reduce these barriers, a better description and understanding of the current levels of joint action around CHAs is necessary. The purpose of this study was to gain better understanding of levels of joint action leading to collaboration, and describe, qualitatively and quantitatively, the collaboration between hospitals and LHDs from the LHD perspective. Specifically, we (1) examined the differences between LHDs that were currently collaborating with their local hospitals on the CHA and those who were unsure about collaborating, (2) described the collaboration among those LHDs currently collaborating, and (3) among those unsure about collaborating.
● Methods Participant selection In 2012, the MO DHSS Infrastructure Survey was administered to all LHDs (n = 115) in the state of Missouri. Local health departments were asked if they collaborated with local hospitals on a CHA. Our study chose to examine more closely those LHDs that reported being in collaboration (n = 26) or unsure about collaboration (n = 29) with local hospitals. In our study, those LHDs
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Continuum of Collaboration Among LHDs
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that reported a future desire to collaborate as indicated on the Infrastructure Survey, no desire to collaborate, or do not have a hospital in their jurisdiction were excluded as this study looks at only those who are collaborating or have a greater likelihood of collaborating.
selves with peer agencies. In addition, it reflects capacity of the administration, facility, workforce, services and programs offered, and information related to their governing bodies.11 Data from these 2 surveys were matched by LHD and merged with the data collected from the collaboration survey.
Key informant surveys
Analysis
The Saint Louis University institutional review board deemed this study exempt from oversight, as it did not qualify as human subjects’ research. Surveys were sent to LHD administrators in the form of a Qualtrics survey attached to a short e-mail and statement about the research being conducted. Time to fill out the online survey was estimated at less than 10 minutes and all questions were regarding the organization itself with no personal identifying factors included. Nearly all administrators who responded are full-time employees at their LHD, with the majority being older than 40 years. More than 90% of the administrators were Caucasian, and 95% held a bachelor’s degree or higher. Two distinct e-mails were sent to those LHDs that were either currently collaborating (n = 26) or unsure about collaboration (n = 29). Those who did not fill out the survey within 1 week’s time received the same email a second time. Administrators who still did not fill out the survey received a phone call after another week of no response. During the phone call, key informants were introduced to this project and given the option of taking the survey online by resending the Web link a third time or completing the survey over the phone. This was the last attempt at contact with the key informants.
Because of the small sample size (n = 55), the data are not normally distributed and do not meet the underlying assumptions of parametric techniques. Because of this, Mann-Whitney U tests were used to determine differences between groups for continuous variables. Kruskal-Wallis tests were used for categorical variables with more than 2 categories, Fisher exact tests were used for dichotomous variables, and Spearman rank correlations were used to determine bivariate relationships between variables. An alpha level of .05 was chosen a priori. All statistical analysis was completed using SPSS version 20.12 Five of those LHDs who reported being unsure about collaboration on the MO DHSS Infrastructure Survey reported on our survey that they were now collaborating with 1 or more local hospitals on a CHA. All analyses were run with these 5 LHDs included in the unsure category and with them removed from the analysis. There was no statistical difference between their inclusion and exclusion, so for the purposes of this study, they were included in the unsure category, per the original study design. For those LHDs currently collaborating with 1 or more local hospitals, a collaboration continuum scale was calculated using information from the questions regarding levels of joint action7 with the local hospitals and frequency of contact with the hospital(s) regarding the CHA. Frequency of contact was scaled from a “1” for contact every 6 months to a “7” for intense contact 3 to 5 days a week. Levels in between the “1” and the “7” reflect varying degrees of frequency of contact. The level of joint action was scaled as a “1” for exchanging information, “2” for exchanging information and linking existing activities, “3” for sharing resources for mutual benefit and to create something new, and “4” for working jointly to accomplish a shared vision and mission using joint resources. These 2 scaled variables were then multiplied together to create a scale of collaboration, which was defined as level of joint action × frequency of contact. Possible values for the collaboration continuum range from “0” to “28.”
Secondary data sets used in analysis Data from the NACCHO 2010 National Profile of Local Health Departments Study (2010 Profile Study) and the MO DHSS Infrastructure Survey were included to create a data set of characteristics of Missouri LHDs. Of the 115 LHDs receiving the NACHHO survey, 97 responded (84.3%). The purpose of the 2010 Profile Study is to provide a closer look at the funding, staffing, governance, and activities of LHDs with an emphasis on understanding how these patterns vary across the country and by the size of the population served by the LHD.10 The MO DHSS Infrastructure Survey is an online survey of the 115 LHDs in Missouri. Data were collected in 2012 and includes questions related to accreditation through the MOVAP and CHA, all 115 LHDs responded to this survey. The MO DHSS Infrastructure Survey collects information about public health system capabilities, identifies variation among agencies, and provides agencies a means to compare them-
● Results Of the total 26 surveys sent out to LHDs that were identified from the MO DHSS Infrastructure Survey
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620 ❘ Journal of Public Health Management and Practice as currently collaborating with local hospital(s), 22 responded (response rate = 84.6%). Of the 29 surveys sent out to LHDs identified by the MO DHSS Infrastructure Survey as unsure about collaboration, 22 responded (response rate = 75.9%), for a total response sample size of 44 LHDs (overall response rate = 80.0%). Those LHDs currently collaborating with 1 or more local hospitals served a population with a smaller percentage of individuals older than 65 years (p = .03) and a higher median household income (p = .01) than those LHDs who reported being unsure about collaboration with local hospitals. Currently collaborating LHDs were also more likely to have higher total expenditures (p = .02), be interested in PHAB accreditation (p = .01), and have an administrator with a bachelor’s degree or higher (p = .01) when compared with the unsure LHDs. Unsure LHDs were more likely to report having no interest in accreditation (p = .04) and to have an administrator with an associate’s degree (p = .01). Currently collaborating LHDs were also more likely to refer to or use their community health assessment 5 or more times in a year compared with unsure LHDs (p = .01) (Table 1). Among those LHDs who were unsure about collaborating with local hospital(s) on a CHA, 22.7% stated they were unsure if the local hospital wanted to collaborate; 22.7% stated they had not been contacted by a local hospital; and 22.7% stated that they are now collaborating with a local hospital on a CHA. Almost half of the unsure LHDs reported working with 1 or more local hospitals on another initiative (45.5%). These initiatives included emergency preparedness, community-wide health initiative committees, community health assessments, rural health centers, and grant applications. Of those who were working with a local hospital, 80.0% indicated they were satisfied or very satisfied with the relationship (Table 2). Among those LHDs currently collaborating with local hospital(s) on a CHA, 27.2% reported they are exchanging information; 27.2% reported they are exchanging information and linking existing activities for mutual benefit; and 50.0% reported they are working jointly to accomplish a shared vision and mission using joint resources. Common reasons for working with local hospitals on the CHA include bringing more stakeholders to the table (59.1%), maximizing resources (54.4%), bringing more credibility in the community (50.0%), sharing the cost and resources (36.4%), and extending population reach (31.8%) (Table 3). Models, standards, and tools commonly used by currently collaborating LHDs in developing their CHA include the following: Missouri Information for Community Assessment (50.0%), Health People 2020 (36.4%), National Public Health Performance Standards Program (22.7%), and Mobilizing for Action through Plan-
ning and Partnership (18.2%). Seven LHDs (31.8%) reported either not using any model, standard, or tool or developing their own (Table 3). Only those currently collaborating were surveyed about the tools used to complete the CHA. Currently collaborating LHDs reported varying frequency of contact with the local hospital(s) regarding the CHA. Nine percent stated they contacted the hospital 1 to 2 days a week; 18.2% contacted the hospital a few times a month; 27.3% contacted the hospital once a month; 9.1% contacted the hospital less than once a month; 9.1% contacted the hospital quarterly; and 18.2% contacted the hospital every 6 months. The majority (63.6%) of currently collaborating LHDs were satisfied or very satisfied with their working relationship with the local hospital(s), and 27.3% were neutral about the relationship (Table 3). Almost all local hospital(s) working with the collaborating LHDs were tax-exempt hospitals (93.8%). Common challenges in the current relationship identified by the LHDs included a lack of health department staff and time (40.1%) and a lack of resources (31.8%). Almost half of the relationships with hospitals were first established more than 10 years ago (45.5%); 13.6% were established 6 to 10 years ago; 27.2% were established 1 to 5 years ago; and 4.5% were established less than 1 year ago. The results for the collaboration continuum scale ranged from “1” to “24” with a mean of 10.3 (SD = 7.5) (Table 3). Spearman rank order correlations found the collaboration continuum was positively correlated with (1) having a CHA (r = 0.46, p = .04), (2) how often the CHA is used during the year (r = 0.59, p = .006), and (3) satisfaction with the hospital relationship (r = 0.57, p = .009). How often the LHDs uses the CHA was positively correlated with having current MICH accreditation (r = 0.56, p = .007) and interest in PHAB accreditation (r = 0.52, p = .01). Frequency of LHD CHA use was negatively correlated with having no interest in accreditation (r = −0.54, p = .01) (Table 4).
● Discussion This cross-sectional study sought to provide a more qualitative and quantitative description of the actual practices of LHDs around levels of joint action leading toward collaboration with their respective hospitals in their geographical area. In doing so, LHDs may be able to make more informed decisions on resource allocation based on their goals. Quantifying the collaboration between LHDs and local hospital(s) provides a means to begin evaluating and making informed decisions about the extent of collaboration necessary for each LHD to achieve goals and objectives around such
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TABLE 1 ● Characteristics of MO LHDs Who Are Currently Collaborating and Unsure About Collaborating (N = 55)
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq Currently Collaborating (n = 26)
Unsure (n = 29)
Total population, mean (SD) 127 331 (250 170) 29 775 (25 258) Percentage minority population, mean (SD) 10.1 (6.3) 5.4 (2.9) Percentage female, mean (SD) 50.8 (1.3) 50.7 (1.1) 17.3 (4.0)a Percentage 65 y of age and older, mean (SD) 15.2 (3.3)a Percentage rural, mean (SD) 48.5 (26.4) 67.0 (23.7) 37 926 (7604)a Median household income, mean (SD) 42 500 (8300)a Percentage children eligible for free lunch, mean (SD) 35.9 (7.6) 38.2 (8.5) Total revenue, most recent year, mean (SD) 5 029 147 (11 825 769) 1 060 481 (1 069 908) 1 078 888 (1 124 353)a Total expenditures, most recent year, mean (SD) 6 539 957 (13 427 987)a Average per person revenue, mean (SD) 42.79 (24.47) 46.01 (42.97) Average per person expenditure, mean (SD) 42.62 (23.72) 45.91 (42.86) Has local Board of Health, n (%) 16 (72.7%) 15 (68.2%) Has completed CHA in the last 5 y, n (%) 20 (76.9%) 20 (70.0%) Has completed in the last 5 y or is currently working on Community Health 18 (81.8%) 14 (63.6%) Improvement Plan, n (%) Has a strategic plan, n (%) 13 (59.1%) 7 (31.8%) Currently MICH accredited, n (%) 5 (22.7%) 3 (13.6%) Seeking MICH accreditation in 1-2 y, n (%) 4 (18.4%) 3 (13.6%) Seeking MICH accreditation 5 y, n (%) 5 (22.7%) 4 (18.2%) 3 (13.6%)b Interested in PHAB accreditation, n (%) 12 (54.5%)b Seeking both MICH and PHAB accreditation, n (%) 9 (40.9%) 3 (13.6%) 11 (50.0%)b No interest in accreditation, n (%) 5 (22.7%)b Administrator’s highest degree,c n (%) 7 (31.8%)c Associates 1 (4.5%)c Bachelors 7 (31.8%)c 4 (18.2%)c Masters 7 (31.8%)c 4 (18.2%)c Professional or Doctorate 4 (18.2%)c 0 (0%)c Missing 3 (13.6%) 7 (31.8%) How would you rate your health department’s capacity to utilize performance management principles, methods, and tools throughout the organization? Not doing it, n (%) 3 (13.6%) 2 (9.1%) Getting by, n (%) 3 (13.6%) 11 (50.0%) Okay, n (%) 11 (50.0%) 8 (36.4%) Very good, n (%) 5 (22.7%) 1 (4.5%) Does your agency evaluate programs to determine whether stated goals and outcomes are being achieved? Yes, n (%) 21 (95.5%) 19 (86.4%) How often during the year do you or your staff refer to or use the CHA?c 0 times, n (%) 2 (9.1%)c 5 (22.7%)c c 1-4 times, n (%) 8 (36.4%) 14 (63.6%)c c 5-9 times, n (%) 5 (22.7%) 1 (4.5%)c c ≥10 times, n (%) 7 (31.8%) 2 (9.1%)c Abbreviations: CHA, Community Health Assessment; MICH, Missouri Institute for Community Health; PHAB, Public Health Accreditation Board. a There is a statistical difference between Currently Collaborating and Unsure at the α = .05 level based on Mann-Whitney U tests. b There is a statistical difference between Currently Collaborating and Unsure at the α = .05 level based on the Fishers exact test. c There is a statistical difference between Currently Collaborating and Unsure at the α = .05 level based on Kruskal-Wallis tests.
policies as PHAB accreditation. In developing the collaboration continuum, a quantitative measure is now created to better understand what levels of collaboration seem to be significant. There were differences in characteristics related to accreditation and CHA between LHDs currently collaborating and those unsure about collaborating with
local hospital(s) on a CHA. Local health departments currently collaborating are more interested in accreditation through PHAB and refer to their CHA more often throughout the year. Approximately 65% of all Missouri LHDs have a CHA; the utilization of the CHA shows that currently collaborating LHDs are more likely to treat the CHA as a living document that is
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622 ❘ Journal of Public Health Management and Practice TABLE 2 ● Survey Answers for MO LHDs Who Are Unsure
About Collaboration With Local Hospitals Around the CHA (n = 22) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
TABLE 3 ● Survey Answers for MO LHDs Who Are Currently Collaborating With Local Hospitals Around the CHA (n = 22) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Survey Items
Survey Items
n (%)
Please select the reason(s) you are unsure about future collaboration? I am not aware of any local hospital’s not-for-profit 3 (13.6) status We do not have a good working relationship with local 3 (13.6) hospital We are not sure if local hospital wants to collaborate 5 (22.7) on a CHA We have different goals than our local hospital 3 (13.6) Our health department is in a different jurisdiction 0 (0) than the hospital(s) We currently lack the leadership for a successful 1 (4.5) partnership We currently lack the resources for a successful 3 (13.6) partnership We have not communicated with any local hospitals 0 (0) We have not been contacted by any local hospitals 5 (22.7) We are collaborating with a local hospital on a CHA 5 (22.7) The local hospital is for-profit 1 (4.5) 10 (45.5) Currently working with any local hospitals(s) on another initiativea Type of initiative Community wide health initiative (committee/council) 3 (13.6) Community health assessment 2 (9.1) Emergency preparedness 4 (18.2) Rural health center 1 (4.5) Grant application 1 (4.5) What is your level is satisfaction with the working relationship? (n = 10) Very satisfied 3 (30.0) Satisfied 5 (50.0) Neutral 2 (20.0) Unsatisfied 0 (0) Very unsatisfied 0 (0) a LHDs
were able to choose more than 1 initiative.
revised and referred to often, which is the true intention of the CHA to guide LHD activities based on the needs of their community.9 The ACA requires nonprofit hospitals to complete a CHNA every 2 years and must include individuals with public health expertise.1 Having a CHA is one of 3 prerequisites for PHAB accreditation, and therefore collaborating with local hospital(s) on a CHA helps conserve resources while meeting the needs of both entities.2,14 Of the LHDs that stated they were unsure about collaborating with local hospital(s) on a CHA, 45% stated they either were unsure if the hospital was interested in collaborating or had not been contacted by the hospital to collaborate. These LHDs seem to be waiting for local hospital(s) to start the conversation around collaborating on a CHA, therefore creating a missed opportunity
n (%)
What is your working relationship with local hospital(s) in relation to the community health assessment (CHA)? Exchanging information 6 (27.2) Exchanging info and linking existing activities for mutual 6 (27.2) benefit Sharing resources for mutual benefit and to create 0 (0.0) something new Working jointly to accomplish shared vision and mission 10 (45.5) using joint resources What reasons do you have for working with local hospitals on your CHA? Share the cost, resources 8 (36.4) Maximize resources 12 (54.5) Bring more credibility in the community 11 (50.0) Bring more stakeholders to the table 13 (59.1) Extend population/demographic reach 7 (31.8) Share information 2 (9.1) Part of the MAPP (Mobilizing for Action through Planning 2 (9.1) and Partnership) process Hospital runs local health department 1 (4.5) Accreditation 2 (9.1) Which assessment models or tools are you utilizing MAPP 4 (18.2) Healthy Cities/Communities 3 (13.6) 2 (9.1) Community Indicators Project13 National Public Health Performance Standards Program 5 (22.7) Assessment Protocol for Excellence in Public Health 0 (0) Healthy People 2020 8 (36.4) Protocol for Assessing Community Excellence in 0 (0) Environmental Health Missouri Information for Community Assessment 11 (50.0) National Civic League Community Needs Assessment & 1 (4.5) GP-Red (Indiana University) Developed our own 4 (18.2) None 3 (13.6) Don’t know 1 (4.5) How often are you in contact with your local hospital about the CHA? 3-5 d a week 0 (0) 1-2 d a week 2 (9.1) A few times a month 4 (18.2) Once a month 6 (27.3) Less than once a month 2 (9.1) Quarterly 2 (9.1) Every 6 mo 4 (18.2) Missing 2 (9.1) How satisfied are you with the working relationship? Very satisfied 7 (31.8) Satisfied 7 (31.8) (continues)
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for collaboration. Local health departments have a long history of working in the community and completing CHAs and have valuable assets to share with their local hospital(s) and have reported positive and satisfying relationships in the past with their local hospital(s). It is also noteworthy that those who are unsure about collaborating may use the same CHA tools as those who are currently collaborating but the question was not asked of them. The data and results presented in this study represent that collaboration, as measured by a higher score on the collaboration continuum, is positively correlated with (1) having a CHA, (2) using the CHA, and (3) satisfaction with the hospital relationship. In NACCHO’s December 2011 Issue Brief, they conclude that through collaboration in the CHA process, LHDs and hospitals, along with other community stakeholders, can align resources and efforts in working to improve population-level health and attain public health goals.14 In our study, this collaborative relationship is quantified through the collaboration continuum score. For those LHDs interested in seeking accreditation, there is also a positive correlation with actually using the CHA, not just obtaining a CHA. Conversely, if the LHD has
... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... − 0.39 ... ... ... ... ... ... ... ... ... ... 0.21 0.09 ... ... ... ... ... ... ... ... ... − 0.20 0.38 0.68a ... ... ... ... ... ... ... ... 0.63a 0.35 0.20 0.40 ... ... ... ... ... ... ... − 0.22 − 0.54a − 0.12 0.16 − 0.42 Abbreviation: FTEs, full time equivalents. a Significant at the α = .01 level. b Significant at the α = .05 level.
Abbreviation: LHDs, local health departments.
... ... ... ... ... ... − 0.59a 0.16 0.52b 0.14 0.20 0.62a
1 (4.5) 6 (27.2) 3 (13.6) 10 (45.5) 2 (9.1) 10.3 (7.5)
... ... ... ... ... 0.35 − 0.33 0.33 0.56a − 0.23 0.07 0.42
2 (9.1)
... ... ... ... 0.39 0.37 − 0.37 0.53b 0.57b 0.11 0.07 0.54b
2 (9.1) 9 (40.1) 7 (31.8) 1 (4.5) 1 (4.5) 1 (4.5)
... ... ... 0.97a 0.39 0.48b − 0.33 0.04 0.22 − 0.11 − 0.22 0.45b
30 (93.8) 2 (6.2)
... ... 0.05 0.25 0.20 0.26 − 0.1 0.35 0.47b 0.26 0.47 0.57b
6 (27.3) 1 (4.5) 0 (0)
... 0.43 − 0.07 0.23 0.09 0.25 − 0.11 0.46b 0.59a 0.57a 0.30 0.40
Neutral Unsatisfied Very unsatisfied Collaborating hospital(s) are: Non-profit For-profit What challenges are you facing in your current relationships? Lack of hospital staff/time Lack of health department staff/time Lack of resources Different priorities Scheduling conflicts CHA timing for hospitals and LHDs not congruent (3 vs 5 y) None When was your working relationship with the hospital(s) first established? 10 y Missing Collaboration Continuum Scale
Collaboration Continuum Admin. Highest Degree Revenue per person Expenditures per Person MICH accredited Interested in PHAB accreditation No interest in accreditation Has a CHA How often do you use the CHA Satisfaction with hospital relationship Length of relationship with hospital Total no. of FTEs
n (%)
Revenue Interested In Frequency Satisfaction Length of per Expenditures MICH PHAB No Interest in in Use of With Hospital Relationship Total No. Person per Person Accredited Accreditation Accreditation Has a CHA CHA Relationship With Hospital of FTEs
Survey Items
Admin. Collaboration Highest Continuum Degree
Currently Collaborating With Local Hospitals Around the CHA (n = 22) (Continued) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
TABLE 4 ● Spearman Correlations for Selected Variables for MO LHDS Currently Collaborating With Their Local Hospital Around a CHA (n = 22)
TABLE 3 ● Survey Answers for MO LHDs Who Are
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Continuum of Collaboration Among LHDs
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624 ❘ Journal of Public Health Management and Practice no interest in seeking accreditation, there is a negative correlation with actually using a CHA. Seeking accreditation may be a motivating factor in actually using a CHA to make decisions and prioritize for the LHD.9 With the passage of the ACA, the health care sector is now charged with identifying ways to provide higher quality care to patients, while lowering overall health care costs and improving the population’s health.15 To aid in this, the ACA has also emphasized the role of public health in improving the overall population health. Previous documentation in the literature demonstrates the challenges of bringing together the health care sector and public health. For example, previous efforts to integrate primary care and public health have had limited success.3,8,16-18 There have been many challenges to meaningful integration of primary care and public health such as a history of segmentation, lack of financial resources and incentives, lack of commitment at state and national levels, and stringent and inflexible regulatory systems.8,19-21 McGinnis suggested that for integration and collaboration to evolve, certain operational changes need to occur. Specifically, McGinnis emphasized the creation of performance measures to assess the effectiveness of primary care in linking to community and public health resources and providing financial incentives.21 This is information that may be translated beyond primary care to the larger health care sector in linking to community and public health resources. With the passage of the ACA and the establishment of PHAB’s national voluntary accreditation program of health departments, the paradigm is shifting in real, tangible support of the integration of health care and public health.1,19 Future research should include a similar examination from the hospital perspective to compare with the LHD perspective. The collaboration continuum scale developed to quantify the extent of collaboration only represents the LHD perspective. The same scale could be used, with the results examined for the differences in perspectives around collaboration. Our scale was developed using NACCHO’s levels of joint action framework.7 The Institute of Medicine developed a degree of integration continuum from isolation (primary care and public health entities working completely separate) to merger (one combined entity replacing the separate entities).3 The scale developed here can be adapted to quantify levels of integration. The collaboration continuum can be used to define relevant levels of collaboration from both the LHD and hospital perspective, to make better informed and transparent decisions on allocation of resources, and to strengthen the collaborative relationship between LHDs and local hospital(s) by being very explicit with what the level of joint action and frequency of contact are necessary to achieve the stated goals and objectives
from both perspectives. In doing so, potential barriers such as LHD resources and time can be better allocated and shared with LHDs. In other words, now that the inputs into collaboration, as defined by the collaboration continuum scale, are quantified, negotiations between LHDs and hospitals on the collaborative relationship may take place. The CHA becomes a potential starting point for collaboration, and resulting efforts could be quantifiable for allocation of resource purposes. For those LHDs that have been unsure about collaboration, they now have a more specific way to communicate with local hospital(s) around accomplishing CHAs as required for accreditation, and to be specific with local hospital(s) as to the level of resources and time necessary to achieve a more successful collaboration. There were some limitations to this study. We used data from the MO DHSS Infrastructure Survey and only selected a subset of Missouri LHDs that were either currently collaborating or unsure if they would collaborate with local hospital(s) on a CHA, which led to a small sample size. With a small sample size, we did not have the power to conduct complex modeling. Questions about collaboration were only asked to LHDs. It is possible that local hospital(s) could view their level of collaboration differently. Future studies should include local hospital(s). Despite the limitations, this study is the first attempt to quantify the level of collaboration between LHDs and local hospital(s) as it relates to the CHAs. By gaining a better understanding of the levels of joint action, and then quantifying those levels of action, LHDs can begin to use this information to make better informed and evidence-based decisions regarding the strategic deployment of resources on the path to accreditation. By using quantitative measures to evaluate what current collaboration looks like, and what is required to achieve the desired goals of the LHDs, those LHDs that were previously reluctant to participate in the accreditation process or collaborate with local hospital(s) may have greater ability to make necessary resource allocations to engage. Being able to quantify and better understand the varying levels of intensity around collaboration allows LHDs to decide more appropriate levels of collaboration to achieve their goals. This provides added value to the accreditation process and ultimately better informs improved population-level health approaches. REFERENCES 1. Patient Protection and Affordable Care Act, 42, §18001 et seq (2010). 2. Public Health Accreditation Board. National Public Health Department Accreditation Readiness Checklists Version 1.0. Alexandria, VA: Public Health Accreditation Board; 2011.
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Continuum of Collaboration Among LHDs
3. Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: National Academies Press; 2012. 4. Beitsch LM, Thielen L, Mays G, et al. The multistate learning collaborative, states as laboratories: informing the national public health accreditation dialogue. J Public Health Manag Pract. 2006;12(3):217-231. 5. Missouri Institute for Community Health. Accredited agencies. http://www.michweb.org/accagencies.htm. Accessed June 13, 2013. 6. Ackerman B, Van Ochten K. The patient protection and affordable care act: newly required community health needs assessments. http://ascendient.com/2011/06/the-patientprotection-and-affordable-care-act-newly-requiredcommunity-health-needs-assessments-2/. Published 2012. Accessed June 13, 2013. 7. National Association of County and City Health Officials. Pulling Together 5, Section 2 Building Collaboration. http:// www.naccho.org/topics/environmental/pullingtogether/ sectiontwo.cfm. Accessed June 13, 2013. 8. Beitsch LM, Brooks RG, Glasser JH, Coble YD, Jr. The medicine and public health initiative: ten years later. Am J Preventive Med. 2005;29(2):149-153. 9. Beatty KE. Organizational and Structural Factors Related to Accreditation in Local Health Departments [dissertation]. Saint Louis, MO: College for Public Health and Social Justice, Saint Louis University; 2013. 10. National Association of County and City Health Officials. 2010 National Profile of Local Health Departments. Washington, DC: National Association of County and City Health Officials; 2011. 11. Missouri Department of Health and Senior Services. LPHA infrastructure capacity assessment report. Data and statistical reports. http://health.mo.gov/living/lpha/report08/ introduction.php. Accessed June 27, 2013.
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12. IBM SPSS Statistics for Windows, Version 21.0 [computer program]. Armonk, NY: IBM Corp; 2012. 13. Community Health Status Indicators Project Working Group. Data sources, definitions, and notes for CHSI 2009. Washington, DC: Department of Health and Human Services; 2009. http://communityhealth.hhs.gov. Accessed June 27, 2013. 14. National Association of County and City Health Officials. Issue Brief: Collaborating Through Community Health Assessment to Improve the Public’s Health. Washington, DC: National Association of County and City Health Officials; 2011. 15. McLellan RK, Sherman B, Loeppke RR, et al. Optimizing health care delivery by integrating workplaces, homes, and communities: how occupational and environmental medicine can serve as a vital connecting link between accountable care organizations and the patientcentered medical home. J Occup Environ Med. 2012;54(4): 504-512. 16. Nutting PA, Connor E. Community Oriented Primary Care: A Practical Assessment. Vol 2. Washington, DC: National Academies Press; 1984. 17. Nutting PA, Connor EM. Community-oriented primary care: an examination of the US experience. Am J Public Health. 1986;76(3):279-281. 18. Deuschle KW. Community-oriented primary care: lessons learned in three decades. J Commun Health. 1982;8(1): 13-22. 19. Scutchfield FD, Michener JL, Thacker SB. Are we there yet? Seizing the moment to integrate medicine and public health. Am J Public Health. 2012;102:S312-S316. 20. Baker EL, Potter MA, Jones DL, et al. The public health infrastructure and our nation’s health. Annu Rev Public Health. 2005;26:303-318. 21. McGinnis JM. Can public health and medicine partner in the public interest? Health Aff. 2006;25(4):1044-1052.
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Background: Hospitals and local health departments (LHDs) are under policy requirements from the Affordable Care Act and accreditation standards through the Public Health Accreditation Board. Tax exempt hospitals must perform a community health needs assessment (CHNA), similar to the community health assessment (CHA) required for LHDs. These efforts have led to a renewed interest in hospitals and LHDs working together to achieve common goals. Purpose: The purpose of this study is to gain a better understanding of levels of joint action leading toward collaboration between LHDs and hospitals and describe collaboration around CHAs. Methods: Local health departments were selected on the basis of reporting collaboration (n = 26) or unsure about collaboration (n = 29) with local hospitals. Local health departments were surveyed regarding their relationship with local hospitals. For LHDs currently collaborating with a hospital, a collaboration continuum scale was calculated. Appropriate nonparametric tests, chi-squares, and Spearman’s rank correlations were conducted to determine differences between groups. Results: A total of 44 LHDs responded to the survey (80.0%). Currently collaborating LHDs were more likely to be interested in accreditation and to refer to their CHA 5 or more times a year compared to the unsure LHDs. In the analysis, a collaboration continuum was created and is positively correlated with aspects of the CHA and CHA process. Conclusions: This study is the first attempt to quantify the level of collaboration between LHDs and hospitals around CHAs. Better understanding of the levels of joint action required may assist LHDs in making informed decisions regarding deployment of resources on the path to accreditation. J Public Health Management Practice, 2014, 20(6), 617–625 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
KEY WORDS: ACA, accreditation, collaboration, community
health assessment, health policy, local health departments, tax-exempt hospitals
The policy environment to improve population-level health is affecting various sectors of health care, both independently, and in conjunction with partners. Specifically, hospitals and local health departments (LHDs) are each under policy requirements from national legislation through the Patient Protection and Affordable Care Act (ACA),1 varying state-level policies, and policy influences such as the new national LHD accreditation standards through the Public Health Accreditation Board (PHAB).2 While there is much contained within these policy requirements that apply specifically to hospitals and LHDs independent of one another, there are also opportunities created within these policies that encourage various levels of joint action between hospitals and LHDs.3 In light of these policies, the literature and practice standards reflect the renewed importance for hospitals and LHDs to work together to achieve common population-level health improvement. In the state of Missouri, a natural experiment exists to explore joint actions between LHDs and local hospitals. Since 2003, the Missouri Institute for Community Health (MICH) has administered the only voluntary state-based accreditation program, the Missouri Voluntary Accreditation Author Affiliations: Health Management and Policy MPH Program (Dr Wilson) and Department of Health Management and Policy (Drs Wilson, Mohr, and Beatty and Ms Ciecior), Saint Louis University College for Public Health and Social Justice, Saint Louis, Missouri. The authors declare no conflicts of interest. Correspondence: Kristin D. Wilson, PhD, MHA, Health Management and Policy, Saint Louis University College for Public Health and Social Justice, 3545 Lafayette Ave, St Louis, MO 63114 ([email protected]). DOI: 10.1097/PHH.0000000000000030
617 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
618 ❘ Journal of Public Health Management and Practice Program (MOVAP) for LHDs in the nation, serving as one of the 5 legacy states for the Multi-State Learning Collaborative.4 In the past 8 years, 24 LHDs, or 21% of Missouri’s LHDs, have begun or successfully completed accreditation activities.5 At the national level, PHAB was established in 2006 by the American Public Health Association, Association of State and Territorial Health Officials, National Association of City and County Health Officials (NACCHO), and National Association of Local Boards of Health. This national voluntary accreditation program was launched in 2011. Similar to MOVAP, PHAB standards were based on findings from the Multi-State Learning Collaborative.4 Before LHDs can begin the process of accreditation through PHAB or MICH, they must meet 3 prerequisites included in the past 5 years: (1) a completed community health assessment (CHA), (2) community health improvement plan (CHIP), and (3) an agency-wide strategic plan. Contained within these prerequisites is the expectation that to achieve these prerequisites for accreditation, LHDs will collaborate with the community, which includes local hospitals.2 While we may be able to describe the types of activities conducted to complete a CHA and CHIP with community partners, what is not as well-known is how to quantify “collaboration” so that the impact of varying levels of joint action can be assessed more thoroughly during the process of accreditation. Most work done thus far around collaboration has been descriptive. By attempting to quantify what collaboration looks like, there is potential to translate it into necessary resources and a reasonable operating budget. Also, once collaboration is quantified, we can begin to correlate it with outputs and quality of collaboration in addition to identifying variables that most correlate with collaboration to aid in future improvements. With the passage of the ACA, tax-exempt hospitals must also perform a community health needs assessment (CHNA) every 3 years. This CHNA is very similar to the CHA required for the LHDs. The CHNA is intended to be a collaborative effort between the hospital and relevant community agencies, including LHDs.6 In addition, hospitals are required to collaborate and include in the process public health expertise when completing both the CHNA and Community Benefit Plan.1 This requirement contained within the ACA creates the main incentive for hospitals to engage with their LHD on CHNAs. This increased pressure on both LHDs and taxexempt hospitals to better identify the needs of their community makes joint action between the 2 organizations a rational choice, as identified in the 2012 Institute of Medicine report, “Primary Care and Public Health: Exploring Integration to Improve Population Health.”3 In the most recent (2012) Missouri De-
partment of Health and Senior Services’ Infrastructure and Needs Survey (MO DHSS Infrastructure Survey), LHDs are asked if they are collaborating with their local hospitals on the CHA.7 Within this survey, “collaboration” is not defined. The results of this survey indicate that many LHDs in Missouri have chosen not to “collaborate,” or are unsure as to whether or not they will “collaborate” in the future. Because MO DHSS uses the term “collaboration” broadly, the levels of joint action are not clear. In addition, being unsure about collaboration is not clearly defined, which through our study we sought further clarify. NACCHO defines collaboration as “ . . . working jointly to accomplish shared vision and mission using joint resources.”7 It further describes levels of joint action to include networking, coordination, cooperation, and collaboration. By evaluating the current levels of joint action between LHDs and nonprofit hospitals in the state, there is an opportunity to identify areas of improvement and make future partnerships more efficient and effective in achieving mutual goals and objectives for improved population level health while continuing to fulfill various policy requirements.7 Current infrastructure and long-standing practices within LHDs and hospitals may create barriers between LHDs and local hospitals in fostering joint action.3,8 The LHDs have reported barriers to joint action, and these barriers may provide challenges in achieving the intent of the policies designed to foster collaboration for improved population-level health.9 To reduce these barriers, a better description and understanding of the current levels of joint action around CHAs is necessary. The purpose of this study was to gain better understanding of levels of joint action leading to collaboration, and describe, qualitatively and quantitatively, the collaboration between hospitals and LHDs from the LHD perspective. Specifically, we (1) examined the differences between LHDs that were currently collaborating with their local hospitals on the CHA and those who were unsure about collaborating, (2) described the collaboration among those LHDs currently collaborating, and (3) among those unsure about collaborating.
● Methods Participant selection In 2012, the MO DHSS Infrastructure Survey was administered to all LHDs (n = 115) in the state of Missouri. Local health departments were asked if they collaborated with local hospitals on a CHA. Our study chose to examine more closely those LHDs that reported being in collaboration (n = 26) or unsure about collaboration (n = 29) with local hospitals. In our study, those LHDs
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Continuum of Collaboration Among LHDs
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that reported a future desire to collaborate as indicated on the Infrastructure Survey, no desire to collaborate, or do not have a hospital in their jurisdiction were excluded as this study looks at only those who are collaborating or have a greater likelihood of collaborating.
selves with peer agencies. In addition, it reflects capacity of the administration, facility, workforce, services and programs offered, and information related to their governing bodies.11 Data from these 2 surveys were matched by LHD and merged with the data collected from the collaboration survey.
Key informant surveys
Analysis
The Saint Louis University institutional review board deemed this study exempt from oversight, as it did not qualify as human subjects’ research. Surveys were sent to LHD administrators in the form of a Qualtrics survey attached to a short e-mail and statement about the research being conducted. Time to fill out the online survey was estimated at less than 10 minutes and all questions were regarding the organization itself with no personal identifying factors included. Nearly all administrators who responded are full-time employees at their LHD, with the majority being older than 40 years. More than 90% of the administrators were Caucasian, and 95% held a bachelor’s degree or higher. Two distinct e-mails were sent to those LHDs that were either currently collaborating (n = 26) or unsure about collaboration (n = 29). Those who did not fill out the survey within 1 week’s time received the same email a second time. Administrators who still did not fill out the survey received a phone call after another week of no response. During the phone call, key informants were introduced to this project and given the option of taking the survey online by resending the Web link a third time or completing the survey over the phone. This was the last attempt at contact with the key informants.
Because of the small sample size (n = 55), the data are not normally distributed and do not meet the underlying assumptions of parametric techniques. Because of this, Mann-Whitney U tests were used to determine differences between groups for continuous variables. Kruskal-Wallis tests were used for categorical variables with more than 2 categories, Fisher exact tests were used for dichotomous variables, and Spearman rank correlations were used to determine bivariate relationships between variables. An alpha level of .05 was chosen a priori. All statistical analysis was completed using SPSS version 20.12 Five of those LHDs who reported being unsure about collaboration on the MO DHSS Infrastructure Survey reported on our survey that they were now collaborating with 1 or more local hospitals on a CHA. All analyses were run with these 5 LHDs included in the unsure category and with them removed from the analysis. There was no statistical difference between their inclusion and exclusion, so for the purposes of this study, they were included in the unsure category, per the original study design. For those LHDs currently collaborating with 1 or more local hospitals, a collaboration continuum scale was calculated using information from the questions regarding levels of joint action7 with the local hospitals and frequency of contact with the hospital(s) regarding the CHA. Frequency of contact was scaled from a “1” for contact every 6 months to a “7” for intense contact 3 to 5 days a week. Levels in between the “1” and the “7” reflect varying degrees of frequency of contact. The level of joint action was scaled as a “1” for exchanging information, “2” for exchanging information and linking existing activities, “3” for sharing resources for mutual benefit and to create something new, and “4” for working jointly to accomplish a shared vision and mission using joint resources. These 2 scaled variables were then multiplied together to create a scale of collaboration, which was defined as level of joint action × frequency of contact. Possible values for the collaboration continuum range from “0” to “28.”
Secondary data sets used in analysis Data from the NACCHO 2010 National Profile of Local Health Departments Study (2010 Profile Study) and the MO DHSS Infrastructure Survey were included to create a data set of characteristics of Missouri LHDs. Of the 115 LHDs receiving the NACHHO survey, 97 responded (84.3%). The purpose of the 2010 Profile Study is to provide a closer look at the funding, staffing, governance, and activities of LHDs with an emphasis on understanding how these patterns vary across the country and by the size of the population served by the LHD.10 The MO DHSS Infrastructure Survey is an online survey of the 115 LHDs in Missouri. Data were collected in 2012 and includes questions related to accreditation through the MOVAP and CHA, all 115 LHDs responded to this survey. The MO DHSS Infrastructure Survey collects information about public health system capabilities, identifies variation among agencies, and provides agencies a means to compare them-
● Results Of the total 26 surveys sent out to LHDs that were identified from the MO DHSS Infrastructure Survey
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620 ❘ Journal of Public Health Management and Practice as currently collaborating with local hospital(s), 22 responded (response rate = 84.6%). Of the 29 surveys sent out to LHDs identified by the MO DHSS Infrastructure Survey as unsure about collaboration, 22 responded (response rate = 75.9%), for a total response sample size of 44 LHDs (overall response rate = 80.0%). Those LHDs currently collaborating with 1 or more local hospitals served a population with a smaller percentage of individuals older than 65 years (p = .03) and a higher median household income (p = .01) than those LHDs who reported being unsure about collaboration with local hospitals. Currently collaborating LHDs were also more likely to have higher total expenditures (p = .02), be interested in PHAB accreditation (p = .01), and have an administrator with a bachelor’s degree or higher (p = .01) when compared with the unsure LHDs. Unsure LHDs were more likely to report having no interest in accreditation (p = .04) and to have an administrator with an associate’s degree (p = .01). Currently collaborating LHDs were also more likely to refer to or use their community health assessment 5 or more times in a year compared with unsure LHDs (p = .01) (Table 1). Among those LHDs who were unsure about collaborating with local hospital(s) on a CHA, 22.7% stated they were unsure if the local hospital wanted to collaborate; 22.7% stated they had not been contacted by a local hospital; and 22.7% stated that they are now collaborating with a local hospital on a CHA. Almost half of the unsure LHDs reported working with 1 or more local hospitals on another initiative (45.5%). These initiatives included emergency preparedness, community-wide health initiative committees, community health assessments, rural health centers, and grant applications. Of those who were working with a local hospital, 80.0% indicated they were satisfied or very satisfied with the relationship (Table 2). Among those LHDs currently collaborating with local hospital(s) on a CHA, 27.2% reported they are exchanging information; 27.2% reported they are exchanging information and linking existing activities for mutual benefit; and 50.0% reported they are working jointly to accomplish a shared vision and mission using joint resources. Common reasons for working with local hospitals on the CHA include bringing more stakeholders to the table (59.1%), maximizing resources (54.4%), bringing more credibility in the community (50.0%), sharing the cost and resources (36.4%), and extending population reach (31.8%) (Table 3). Models, standards, and tools commonly used by currently collaborating LHDs in developing their CHA include the following: Missouri Information for Community Assessment (50.0%), Health People 2020 (36.4%), National Public Health Performance Standards Program (22.7%), and Mobilizing for Action through Plan-
ning and Partnership (18.2%). Seven LHDs (31.8%) reported either not using any model, standard, or tool or developing their own (Table 3). Only those currently collaborating were surveyed about the tools used to complete the CHA. Currently collaborating LHDs reported varying frequency of contact with the local hospital(s) regarding the CHA. Nine percent stated they contacted the hospital 1 to 2 days a week; 18.2% contacted the hospital a few times a month; 27.3% contacted the hospital once a month; 9.1% contacted the hospital less than once a month; 9.1% contacted the hospital quarterly; and 18.2% contacted the hospital every 6 months. The majority (63.6%) of currently collaborating LHDs were satisfied or very satisfied with their working relationship with the local hospital(s), and 27.3% were neutral about the relationship (Table 3). Almost all local hospital(s) working with the collaborating LHDs were tax-exempt hospitals (93.8%). Common challenges in the current relationship identified by the LHDs included a lack of health department staff and time (40.1%) and a lack of resources (31.8%). Almost half of the relationships with hospitals were first established more than 10 years ago (45.5%); 13.6% were established 6 to 10 years ago; 27.2% were established 1 to 5 years ago; and 4.5% were established less than 1 year ago. The results for the collaboration continuum scale ranged from “1” to “24” with a mean of 10.3 (SD = 7.5) (Table 3). Spearman rank order correlations found the collaboration continuum was positively correlated with (1) having a CHA (r = 0.46, p = .04), (2) how often the CHA is used during the year (r = 0.59, p = .006), and (3) satisfaction with the hospital relationship (r = 0.57, p = .009). How often the LHDs uses the CHA was positively correlated with having current MICH accreditation (r = 0.56, p = .007) and interest in PHAB accreditation (r = 0.52, p = .01). Frequency of LHD CHA use was negatively correlated with having no interest in accreditation (r = −0.54, p = .01) (Table 4).
● Discussion This cross-sectional study sought to provide a more qualitative and quantitative description of the actual practices of LHDs around levels of joint action leading toward collaboration with their respective hospitals in their geographical area. In doing so, LHDs may be able to make more informed decisions on resource allocation based on their goals. Quantifying the collaboration between LHDs and local hospital(s) provides a means to begin evaluating and making informed decisions about the extent of collaboration necessary for each LHD to achieve goals and objectives around such
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Continuum of Collaboration Among LHDs
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TABLE 1 ● Characteristics of MO LHDs Who Are Currently Collaborating and Unsure About Collaborating (N = 55)
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq Currently Collaborating (n = 26)
Unsure (n = 29)
Total population, mean (SD) 127 331 (250 170) 29 775 (25 258) Percentage minority population, mean (SD) 10.1 (6.3) 5.4 (2.9) Percentage female, mean (SD) 50.8 (1.3) 50.7 (1.1) 17.3 (4.0)a Percentage 65 y of age and older, mean (SD) 15.2 (3.3)a Percentage rural, mean (SD) 48.5 (26.4) 67.0 (23.7) 37 926 (7604)a Median household income, mean (SD) 42 500 (8300)a Percentage children eligible for free lunch, mean (SD) 35.9 (7.6) 38.2 (8.5) Total revenue, most recent year, mean (SD) 5 029 147 (11 825 769) 1 060 481 (1 069 908) 1 078 888 (1 124 353)a Total expenditures, most recent year, mean (SD) 6 539 957 (13 427 987)a Average per person revenue, mean (SD) 42.79 (24.47) 46.01 (42.97) Average per person expenditure, mean (SD) 42.62 (23.72) 45.91 (42.86) Has local Board of Health, n (%) 16 (72.7%) 15 (68.2%) Has completed CHA in the last 5 y, n (%) 20 (76.9%) 20 (70.0%) Has completed in the last 5 y or is currently working on Community Health 18 (81.8%) 14 (63.6%) Improvement Plan, n (%) Has a strategic plan, n (%) 13 (59.1%) 7 (31.8%) Currently MICH accredited, n (%) 5 (22.7%) 3 (13.6%) Seeking MICH accreditation in 1-2 y, n (%) 4 (18.4%) 3 (13.6%) Seeking MICH accreditation 5 y, n (%) 5 (22.7%) 4 (18.2%) 3 (13.6%)b Interested in PHAB accreditation, n (%) 12 (54.5%)b Seeking both MICH and PHAB accreditation, n (%) 9 (40.9%) 3 (13.6%) 11 (50.0%)b No interest in accreditation, n (%) 5 (22.7%)b Administrator’s highest degree,c n (%) 7 (31.8%)c Associates 1 (4.5%)c Bachelors 7 (31.8%)c 4 (18.2%)c Masters 7 (31.8%)c 4 (18.2%)c Professional or Doctorate 4 (18.2%)c 0 (0%)c Missing 3 (13.6%) 7 (31.8%) How would you rate your health department’s capacity to utilize performance management principles, methods, and tools throughout the organization? Not doing it, n (%) 3 (13.6%) 2 (9.1%) Getting by, n (%) 3 (13.6%) 11 (50.0%) Okay, n (%) 11 (50.0%) 8 (36.4%) Very good, n (%) 5 (22.7%) 1 (4.5%) Does your agency evaluate programs to determine whether stated goals and outcomes are being achieved? Yes, n (%) 21 (95.5%) 19 (86.4%) How often during the year do you or your staff refer to or use the CHA?c 0 times, n (%) 2 (9.1%)c 5 (22.7%)c c 1-4 times, n (%) 8 (36.4%) 14 (63.6%)c c 5-9 times, n (%) 5 (22.7%) 1 (4.5%)c c ≥10 times, n (%) 7 (31.8%) 2 (9.1%)c Abbreviations: CHA, Community Health Assessment; MICH, Missouri Institute for Community Health; PHAB, Public Health Accreditation Board. a There is a statistical difference between Currently Collaborating and Unsure at the α = .05 level based on Mann-Whitney U tests. b There is a statistical difference between Currently Collaborating and Unsure at the α = .05 level based on the Fishers exact test. c There is a statistical difference between Currently Collaborating and Unsure at the α = .05 level based on Kruskal-Wallis tests.
policies as PHAB accreditation. In developing the collaboration continuum, a quantitative measure is now created to better understand what levels of collaboration seem to be significant. There were differences in characteristics related to accreditation and CHA between LHDs currently collaborating and those unsure about collaborating with
local hospital(s) on a CHA. Local health departments currently collaborating are more interested in accreditation through PHAB and refer to their CHA more often throughout the year. Approximately 65% of all Missouri LHDs have a CHA; the utilization of the CHA shows that currently collaborating LHDs are more likely to treat the CHA as a living document that is
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622 ❘ Journal of Public Health Management and Practice TABLE 2 ● Survey Answers for MO LHDs Who Are Unsure
About Collaboration With Local Hospitals Around the CHA (n = 22) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
TABLE 3 ● Survey Answers for MO LHDs Who Are Currently Collaborating With Local Hospitals Around the CHA (n = 22) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Survey Items
Survey Items
n (%)
Please select the reason(s) you are unsure about future collaboration? I am not aware of any local hospital’s not-for-profit 3 (13.6) status We do not have a good working relationship with local 3 (13.6) hospital We are not sure if local hospital wants to collaborate 5 (22.7) on a CHA We have different goals than our local hospital 3 (13.6) Our health department is in a different jurisdiction 0 (0) than the hospital(s) We currently lack the leadership for a successful 1 (4.5) partnership We currently lack the resources for a successful 3 (13.6) partnership We have not communicated with any local hospitals 0 (0) We have not been contacted by any local hospitals 5 (22.7) We are collaborating with a local hospital on a CHA 5 (22.7) The local hospital is for-profit 1 (4.5) 10 (45.5) Currently working with any local hospitals(s) on another initiativea Type of initiative Community wide health initiative (committee/council) 3 (13.6) Community health assessment 2 (9.1) Emergency preparedness 4 (18.2) Rural health center 1 (4.5) Grant application 1 (4.5) What is your level is satisfaction with the working relationship? (n = 10) Very satisfied 3 (30.0) Satisfied 5 (50.0) Neutral 2 (20.0) Unsatisfied 0 (0) Very unsatisfied 0 (0) a LHDs
were able to choose more than 1 initiative.
revised and referred to often, which is the true intention of the CHA to guide LHD activities based on the needs of their community.9 The ACA requires nonprofit hospitals to complete a CHNA every 2 years and must include individuals with public health expertise.1 Having a CHA is one of 3 prerequisites for PHAB accreditation, and therefore collaborating with local hospital(s) on a CHA helps conserve resources while meeting the needs of both entities.2,14 Of the LHDs that stated they were unsure about collaborating with local hospital(s) on a CHA, 45% stated they either were unsure if the hospital was interested in collaborating or had not been contacted by the hospital to collaborate. These LHDs seem to be waiting for local hospital(s) to start the conversation around collaborating on a CHA, therefore creating a missed opportunity
n (%)
What is your working relationship with local hospital(s) in relation to the community health assessment (CHA)? Exchanging information 6 (27.2) Exchanging info and linking existing activities for mutual 6 (27.2) benefit Sharing resources for mutual benefit and to create 0 (0.0) something new Working jointly to accomplish shared vision and mission 10 (45.5) using joint resources What reasons do you have for working with local hospitals on your CHA? Share the cost, resources 8 (36.4) Maximize resources 12 (54.5) Bring more credibility in the community 11 (50.0) Bring more stakeholders to the table 13 (59.1) Extend population/demographic reach 7 (31.8) Share information 2 (9.1) Part of the MAPP (Mobilizing for Action through Planning 2 (9.1) and Partnership) process Hospital runs local health department 1 (4.5) Accreditation 2 (9.1) Which assessment models or tools are you utilizing MAPP 4 (18.2) Healthy Cities/Communities 3 (13.6) 2 (9.1) Community Indicators Project13 National Public Health Performance Standards Program 5 (22.7) Assessment Protocol for Excellence in Public Health 0 (0) Healthy People 2020 8 (36.4) Protocol for Assessing Community Excellence in 0 (0) Environmental Health Missouri Information for Community Assessment 11 (50.0) National Civic League Community Needs Assessment & 1 (4.5) GP-Red (Indiana University) Developed our own 4 (18.2) None 3 (13.6) Don’t know 1 (4.5) How often are you in contact with your local hospital about the CHA? 3-5 d a week 0 (0) 1-2 d a week 2 (9.1) A few times a month 4 (18.2) Once a month 6 (27.3) Less than once a month 2 (9.1) Quarterly 2 (9.1) Every 6 mo 4 (18.2) Missing 2 (9.1) How satisfied are you with the working relationship? Very satisfied 7 (31.8) Satisfied 7 (31.8) (continues)
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for collaboration. Local health departments have a long history of working in the community and completing CHAs and have valuable assets to share with their local hospital(s) and have reported positive and satisfying relationships in the past with their local hospital(s). It is also noteworthy that those who are unsure about collaborating may use the same CHA tools as those who are currently collaborating but the question was not asked of them. The data and results presented in this study represent that collaboration, as measured by a higher score on the collaboration continuum, is positively correlated with (1) having a CHA, (2) using the CHA, and (3) satisfaction with the hospital relationship. In NACCHO’s December 2011 Issue Brief, they conclude that through collaboration in the CHA process, LHDs and hospitals, along with other community stakeholders, can align resources and efforts in working to improve population-level health and attain public health goals.14 In our study, this collaborative relationship is quantified through the collaboration continuum score. For those LHDs interested in seeking accreditation, there is also a positive correlation with actually using the CHA, not just obtaining a CHA. Conversely, if the LHD has
... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... − 0.39 ... ... ... ... ... ... ... ... ... ... 0.21 0.09 ... ... ... ... ... ... ... ... ... − 0.20 0.38 0.68a ... ... ... ... ... ... ... ... 0.63a 0.35 0.20 0.40 ... ... ... ... ... ... ... − 0.22 − 0.54a − 0.12 0.16 − 0.42 Abbreviation: FTEs, full time equivalents. a Significant at the α = .01 level. b Significant at the α = .05 level.
Abbreviation: LHDs, local health departments.
... ... ... ... ... ... − 0.59a 0.16 0.52b 0.14 0.20 0.62a
1 (4.5) 6 (27.2) 3 (13.6) 10 (45.5) 2 (9.1) 10.3 (7.5)
... ... ... ... ... 0.35 − 0.33 0.33 0.56a − 0.23 0.07 0.42
2 (9.1)
... ... ... ... 0.39 0.37 − 0.37 0.53b 0.57b 0.11 0.07 0.54b
2 (9.1) 9 (40.1) 7 (31.8) 1 (4.5) 1 (4.5) 1 (4.5)
... ... ... 0.97a 0.39 0.48b − 0.33 0.04 0.22 − 0.11 − 0.22 0.45b
30 (93.8) 2 (6.2)
... ... 0.05 0.25 0.20 0.26 − 0.1 0.35 0.47b 0.26 0.47 0.57b
6 (27.3) 1 (4.5) 0 (0)
... 0.43 − 0.07 0.23 0.09 0.25 − 0.11 0.46b 0.59a 0.57a 0.30 0.40
Neutral Unsatisfied Very unsatisfied Collaborating hospital(s) are: Non-profit For-profit What challenges are you facing in your current relationships? Lack of hospital staff/time Lack of health department staff/time Lack of resources Different priorities Scheduling conflicts CHA timing for hospitals and LHDs not congruent (3 vs 5 y) None When was your working relationship with the hospital(s) first established? 10 y Missing Collaboration Continuum Scale
Collaboration Continuum Admin. Highest Degree Revenue per person Expenditures per Person MICH accredited Interested in PHAB accreditation No interest in accreditation Has a CHA How often do you use the CHA Satisfaction with hospital relationship Length of relationship with hospital Total no. of FTEs
n (%)
Revenue Interested In Frequency Satisfaction Length of per Expenditures MICH PHAB No Interest in in Use of With Hospital Relationship Total No. Person per Person Accredited Accreditation Accreditation Has a CHA CHA Relationship With Hospital of FTEs
Survey Items
Admin. Collaboration Highest Continuum Degree
Currently Collaborating With Local Hospitals Around the CHA (n = 22) (Continued) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
TABLE 4 ● Spearman Correlations for Selected Variables for MO LHDS Currently Collaborating With Their Local Hospital Around a CHA (n = 22)
TABLE 3 ● Survey Answers for MO LHDs Who Are
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Continuum of Collaboration Among LHDs
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624 ❘ Journal of Public Health Management and Practice no interest in seeking accreditation, there is a negative correlation with actually using a CHA. Seeking accreditation may be a motivating factor in actually using a CHA to make decisions and prioritize for the LHD.9 With the passage of the ACA, the health care sector is now charged with identifying ways to provide higher quality care to patients, while lowering overall health care costs and improving the population’s health.15 To aid in this, the ACA has also emphasized the role of public health in improving the overall population health. Previous documentation in the literature demonstrates the challenges of bringing together the health care sector and public health. For example, previous efforts to integrate primary care and public health have had limited success.3,8,16-18 There have been many challenges to meaningful integration of primary care and public health such as a history of segmentation, lack of financial resources and incentives, lack of commitment at state and national levels, and stringent and inflexible regulatory systems.8,19-21 McGinnis suggested that for integration and collaboration to evolve, certain operational changes need to occur. Specifically, McGinnis emphasized the creation of performance measures to assess the effectiveness of primary care in linking to community and public health resources and providing financial incentives.21 This is information that may be translated beyond primary care to the larger health care sector in linking to community and public health resources. With the passage of the ACA and the establishment of PHAB’s national voluntary accreditation program of health departments, the paradigm is shifting in real, tangible support of the integration of health care and public health.1,19 Future research should include a similar examination from the hospital perspective to compare with the LHD perspective. The collaboration continuum scale developed to quantify the extent of collaboration only represents the LHD perspective. The same scale could be used, with the results examined for the differences in perspectives around collaboration. Our scale was developed using NACCHO’s levels of joint action framework.7 The Institute of Medicine developed a degree of integration continuum from isolation (primary care and public health entities working completely separate) to merger (one combined entity replacing the separate entities).3 The scale developed here can be adapted to quantify levels of integration. The collaboration continuum can be used to define relevant levels of collaboration from both the LHD and hospital perspective, to make better informed and transparent decisions on allocation of resources, and to strengthen the collaborative relationship between LHDs and local hospital(s) by being very explicit with what the level of joint action and frequency of contact are necessary to achieve the stated goals and objectives
from both perspectives. In doing so, potential barriers such as LHD resources and time can be better allocated and shared with LHDs. In other words, now that the inputs into collaboration, as defined by the collaboration continuum scale, are quantified, negotiations between LHDs and hospitals on the collaborative relationship may take place. The CHA becomes a potential starting point for collaboration, and resulting efforts could be quantifiable for allocation of resource purposes. For those LHDs that have been unsure about collaboration, they now have a more specific way to communicate with local hospital(s) around accomplishing CHAs as required for accreditation, and to be specific with local hospital(s) as to the level of resources and time necessary to achieve a more successful collaboration. There were some limitations to this study. We used data from the MO DHSS Infrastructure Survey and only selected a subset of Missouri LHDs that were either currently collaborating or unsure if they would collaborate with local hospital(s) on a CHA, which led to a small sample size. With a small sample size, we did not have the power to conduct complex modeling. Questions about collaboration were only asked to LHDs. It is possible that local hospital(s) could view their level of collaboration differently. Future studies should include local hospital(s). Despite the limitations, this study is the first attempt to quantify the level of collaboration between LHDs and local hospital(s) as it relates to the CHAs. By gaining a better understanding of the levels of joint action, and then quantifying those levels of action, LHDs can begin to use this information to make better informed and evidence-based decisions regarding the strategic deployment of resources on the path to accreditation. By using quantitative measures to evaluate what current collaboration looks like, and what is required to achieve the desired goals of the LHDs, those LHDs that were previously reluctant to participate in the accreditation process or collaborate with local hospital(s) may have greater ability to make necessary resource allocations to engage. Being able to quantify and better understand the varying levels of intensity around collaboration allows LHDs to decide more appropriate levels of collaboration to achieve their goals. This provides added value to the accreditation process and ultimately better informs improved population-level health approaches. REFERENCES 1. Patient Protection and Affordable Care Act, 42, §18001 et seq (2010). 2. Public Health Accreditation Board. National Public Health Department Accreditation Readiness Checklists Version 1.0. Alexandria, VA: Public Health Accreditation Board; 2011.
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Continuum of Collaboration Among LHDs
3. Institute of Medicine. Primary Care and Public Health: Exploring Integration to Improve Population Health. Washington, DC: National Academies Press; 2012. 4. Beitsch LM, Thielen L, Mays G, et al. The multistate learning collaborative, states as laboratories: informing the national public health accreditation dialogue. J Public Health Manag Pract. 2006;12(3):217-231. 5. Missouri Institute for Community Health. Accredited agencies. http://www.michweb.org/accagencies.htm. Accessed June 13, 2013. 6. Ackerman B, Van Ochten K. The patient protection and affordable care act: newly required community health needs assessments. http://ascendient.com/2011/06/the-patientprotection-and-affordable-care-act-newly-requiredcommunity-health-needs-assessments-2/. Published 2012. Accessed June 13, 2013. 7. National Association of County and City Health Officials. Pulling Together 5, Section 2 Building Collaboration. http:// www.naccho.org/topics/environmental/pullingtogether/ sectiontwo.cfm. Accessed June 13, 2013. 8. Beitsch LM, Brooks RG, Glasser JH, Coble YD, Jr. The medicine and public health initiative: ten years later. Am J Preventive Med. 2005;29(2):149-153. 9. Beatty KE. Organizational and Structural Factors Related to Accreditation in Local Health Departments [dissertation]. Saint Louis, MO: College for Public Health and Social Justice, Saint Louis University; 2013. 10. National Association of County and City Health Officials. 2010 National Profile of Local Health Departments. Washington, DC: National Association of County and City Health Officials; 2011. 11. Missouri Department of Health and Senior Services. LPHA infrastructure capacity assessment report. Data and statistical reports. http://health.mo.gov/living/lpha/report08/ introduction.php. Accessed June 27, 2013.
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12. IBM SPSS Statistics for Windows, Version 21.0 [computer program]. Armonk, NY: IBM Corp; 2012. 13. Community Health Status Indicators Project Working Group. Data sources, definitions, and notes for CHSI 2009. Washington, DC: Department of Health and Human Services; 2009. http://communityhealth.hhs.gov. Accessed June 27, 2013. 14. National Association of County and City Health Officials. Issue Brief: Collaborating Through Community Health Assessment to Improve the Public’s Health. Washington, DC: National Association of County and City Health Officials; 2011. 15. McLellan RK, Sherman B, Loeppke RR, et al. Optimizing health care delivery by integrating workplaces, homes, and communities: how occupational and environmental medicine can serve as a vital connecting link between accountable care organizations and the patientcentered medical home. J Occup Environ Med. 2012;54(4): 504-512. 16. Nutting PA, Connor E. Community Oriented Primary Care: A Practical Assessment. Vol 2. Washington, DC: National Academies Press; 1984. 17. Nutting PA, Connor EM. Community-oriented primary care: an examination of the US experience. Am J Public Health. 1986;76(3):279-281. 18. Deuschle KW. Community-oriented primary care: lessons learned in three decades. J Commun Health. 1982;8(1): 13-22. 19. Scutchfield FD, Michener JL, Thacker SB. Are we there yet? Seizing the moment to integrate medicine and public health. Am J Public Health. 2012;102:S312-S316. 20. Baker EL, Potter MA, Jones DL, et al. The public health infrastructure and our nation’s health. Annu Rev Public Health. 2005;26:303-318. 21. McGinnis JM. Can public health and medicine partner in the public interest? Health Aff. 2006;25(4):1044-1052.
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