A decade ago, leaders of four health systems serving Milwaukee residents recognized that they needed to do something different. Their organizations increasingly were burdened by high rates of uninsured and underinsured patients. Primary care services were underused, and emergency departments were overused for nonurgent care, which drove up costs.
Together, these system leaders formed the Milwaukee Health Care Partnership in 2007 to work collaboratively on three key issues: coverage, access and care coordination.
Today, the partnership’s members include:
- Ascension Wisconsin.
- Aurora Health Care.
- Froedtert Health.
- Children’s Hospital & Health System Inc.
- Four federally qualified health centers.
- The Medical College of Wisconsin, a local, private medical school.
- Three public health agencies: the Milwaukee Health Department, Milwaukee County Department of Health & Human Services and the Wisconsin Department of Health Services.
As the partners began to work together, they recognized that each was engaged in various community health improvement activities.“We had an appreciation of ‘Oh, this health system is doing something in substance abuse, and this health system is doing something about domestic violence,” says Joy Tapper, the partnership’s executive director. “But we didn’t fully understand what each health system was doing.”
As the partnership started to explore where efforts were being duplicated — and where gaps existed — the Affordable Care Act was passed, which includes a requirement that all health systems conduct a community health needs assessment.
The task seemed daunting and expensive, in part because of the way public health is organized in Milwaukee County. Each municipality has its own public health agency rather than being served by a countywide entity. Thus, each health system would need to work with all 12 public health departments to develop its own CHNA, which would put a burden on the public agencies.
Since 2010, the health system members of the Milwaukee Health Care Partnership have funded and designed joint CHNAs to comply with the ACA regulation. The CHNA is also used to guide the partnership’s work and inform the community health plans of each individual health system and health department.
“Rather than [having]each health system undertake that process independently, we recognized it was more efficient and effective to do that together,” Tapper says.
The first shared CHNA revealed that increasing health care access — which was one of the partnership’s original goals — was. indeed. one of the Milwaukee area’s top health care needs. But the assessment also helped the collaborating organizations to pinpoint pressing issues that were more specific, including infant mortality, violence and access to behavioral health services. By working collectively to address these priority issues, partnership members hope to attain major improvements in health outcomes and costs.
“This is an opportunity for us to have a one-plus-one-equals-three impact,” says Travis Andersen, president of Ascension Wisconsin’s South Region. “That’s our job to do — to rise above the fray to ensure that our community is the center of our focus, particularly when it comes to the low-income and vulnerable populations.”
Milwaukee Commissioner of Health Bevan K. Baker appreciates that competing health systems are willing to put competition to the side and assume a neutral focus on public and population health outcomes.
“I don’t think we’re Switzerland, but we are very close,” he says. “When we are in a room, we are there because public health is what matters.”
Ascension’s Andersen serves as the partnership’s chair; the position rotates among the health systems so that no one system dominates. By agreeing on the community’s priority needs and working on them together, the health systems take responsibility for being change agents.
“We have our health care expertise as our framework, but we’re coming to the table with a lens to make a community impact,” Anderson says. “It takes real discipline around action and investment and time to make social impact, and this is the way we do this together.”
How it works
The shared CHNA is designed by a planning team that includes representatives from each of the health systems, the FQHCs and the public health departments.
A smaller group — the partnership’s Health Systems Community Benefit Work Group — is responsible for managing the CHNA process, including the contractual agreements with the consultants who do most of the data collection, analysis and report preparation. The work group, co-chaired by Mark Huber, senior vice president of social responsibility at Aurora Health Care, includes representatives from each of the four health systems.
The health systems underwrite the cost of producing the CHNAs, which are published every three years.
Getting buy-in: The Milwaukee CHNA process benefits from the fact that the partnership was founded by health system CEOs, and that the health systems had been working together on access, coverage and care coordination initiatives for a few years before the shared CHNA was considered.
For that reason, Huber and his community-benefit colleagues from the other Milwaukee health systems had the support they needed from the outset. “If you don’t have that CEO buy-in and agreement that we are going to work together and that we are going to jointly fund this initiative, you’re not going to go anywhere,” he says.
Gathering data: Aurora and Froedtert had conducted community assessments for many years before the federal mandate to do so. The partnership’s work group drew heavily from that experience to get started on the shared assessment.
The CHNA used three data sources:
- Results of a phone survey: People in a random sample of Milwaukee County residents were asked questions about health care access, routine screenings, immunizations, injury prevention, mental health, chronic disease, tobacco and alcohol use, physical activity and other health risk factors. In the most recent CHNA, the community health survey was designed to be completed in about 18 minutes.
- Key informant interviews: For the last CHNA, more than 41 civic and health leaders were interviewed by Huber and other members of the work group, and four focus groups were conducted. Informants were asked to identify community health needs, the social factors that contribute to those problems and the organizations most suited to address the various issues.
- Secondary data analysis: A consulting firm reviewed health indicators reported by local, state and national sources.
Information in action: The shared CHNA is used to inform both multistakeholder community health improvement initiatives and the community improvement plans that each nonprofit health system must develop.
Collective action: For the first time, the most recent shared CHNA identified violence as a top community health need, prompting the partnership to take action.
“The recognition of that helped in our decision-making to become involved in a multisector city of Milwaukee violence-prevention planning process,” Tapper says.
That process was spearheaded by the city’s Office of Violence Prevention, situated in the Milwaukee Commissioner of Health’s department rather than within a law enforcement agency.
“We need to look at violence as a public health concern,” Baker says. “And we are certainly engaging our health systems as a part of this work, because they deal with violence through the gunshot victims that come to their emergency departments and the trauma-informed care that’s needed as a result of continuous violence in some of our … neighborhoods.”
Milwaukee’s Blueprint for Peace, a citywide violence-reduction plan, will be released this fall.
“That will be a catalyst for discussion as to where health care providers fit into implementing that plan,” Tapper says.
Individual analysis: Separately, each health system reviews the shared CHNA to help develop its own community health improvement plan.
For example, when the most recent CHNA was published in 2016, Froedtert Health shared the findings with all of its hospitals through its Community Health Improvement advisory committees. These committees include community members and health system leaders. Members of the committees rated each of the priority areas based on two criteria: Froedtert Hospital’s ability, as the region’s academic medical center, to address that particular need and the likelihood of achieving measurable outcomes.
That process identified four community health needs to be addressed by Froedtert Health’s three-year community health improvement plan:
- Chronic disease management.
- Injury and violence.
- Access to care and navigation.
- Behavioral health.
Action plans were developed for each of the four needs, says Kerry Freiberg, vice president of community engagement at Froedtert Health. For example, Froedtert Hospital, in collaboration with the Medical College of Wisconsin, launched a pilot of the Cardiff Violence Prevention Model in conjunction with a suburban police department. More than half of violent crimes are not reported to law enforcement, according to the U.S. Department of Justice, hindering police officials from knowing where to target their prevention efforts. The Cardiff model seeks to address that problem through partnerships between hospitals and police departments.
“When we see individuals come through our ED who are victims of violence, we collect data on where that violence occurred and share that with law enforcement,” Freiberg says. Victims’ names, however, are not shared with law enforcement.
An obvious benefit of a shared CHNA is the split expense. Huber estimates that Aurora’s CHNA costs dropped by half when Milwaukee-area health systems began conducting the assessment together.
“That allows us to focus limited community resources more on actions addressing those needs rather than on assessing those needs,” he says.
Additionally, because four systems are jointly funding the assessments, they can afford to collect and analyze more data than any health system or public agency could do individually, Baker says.
The most significant benefit, however, may be that the partnership allows all stakeholders to use the same data for deciding how to allocate resources.
“We are all basing our actions on one set of identified needs,” Huber says. “By doing this together, we can see what priority needs are best aligned with our abilities as health care systems to improve community health.”
Sharing the responsibility for a CHNA also presents challenges that require forethought and negotiation up front.
Different fiscal years: The Milwaukee systems operate on three different fiscal calendars and budgeting cycles, which must be taken into consideration when planning the CHNA. Additionally, the different fiscal years mean that some health systems are required to publish their mandated community benefit implementation strategy reports earlier than others.
“It’s manageable, but the timing issues are one of the challenges that we have to work through,” Huber says.
Different geographies: Each of the four health systems has a different service area. The partners chose to conduct a CHNA that covers six southeastern Wisconsin counties with the most overlap among the health systems.
But that six-county CHNA does not cover the entire area served by some of the partners. For example, Aurora Health Care serves 21 counties in Wisconsin and northern Illinois. So, in addition to the partnership-led CHNA, Aurora has collaborative agreements with other health systems and community agencies to produce CHNAs for its entire service territory.
Sharing the cost: Because the four health systems do not all operate in the six counties, it did not make sense to split the cost of the assessment equally. Rather, the health systems that have a hospital location in any one of the six counties equally share the cost for that county.
Thus, the cost of the CHNA for Milwaukee County is shared equally by the four systems, but the cost for the other counties is handled by one, two or three systems that operate hospitals there.