AMA Journal of Ethics^®

Abstract

Where people live and work influences how long and how well they live. Clinicians can help keep patients healthy by encouraging health care organizations to support community investments that improve conditions that contribute to health risks, outcomes, and costs. These conditions—the social determinants of health—include housing, transportation, jobs, and educational opportunities. Hospitals and health systems have assets—financial capital, land, and expertise, for example—that can be used to help support community health. Clinicians are uniquely positioned to collect data and ask questions in support of effective partnerships that address the root causes of poor health.

Social Determinants of Health and Community Investment

If you asked a group of clinicians why they pursued careers in health care, many clinicians would probably say they wanted to help people lead healthier lives. Yet research based on health measures from nearly all US counties demonstrates that medical care is just a small part of what determines whether a person is healthy.¹ In fact, 50% of health outcomes—in terms of length and quality of life—can be attributed to nonmedical and nonbehavioral factors related to the places and spaces where people live, work, and study.¹ To be healthy, people need clean air and water, fresh food, safe and affordable housing, good jobs, and educational opportunities. Yet, far too many communities in our country lack these essential elements, especially low-income communities of color, which have endured decades of racial and economic segregation, resulting in deeply entrenched poverty, aging infrastructure, and poor living conditions. In Richmond, Virginia, for instance, people who live just miles apart can face a 20-year difference in life expectancy due to the different conditions in which they grow up and live their whole lives.² These social, economic, and environmental factors—known as the social determinants of health—go beyond what clinicians can address within the walls of their institutions.

Clinicians all too commonly observe the health consequences stemming from neighborhoods with poor housing, unsafe conditions, lack of green space and recreational opportunities, and insufficient healthy food options. For example, Children’s HealthWatch reported in 2017 that “unstable housing among families with children will cost the US $111 billion in avoidable health and education expenditures over the next ten years.”³ Clinicians see firsthand the higher incidence of chronic disease, lower life expectancies, and increased utilization of health care services among patients who live in these neighborhoods.⁴ Even when clinicians provide the highest quality medical care, the conditions their patients return to after leaving the health care setting may limit the success of their interventions. Achieving the triple aim of health care⁵—enhancing quality of care, improving health outcomes, and reducing costs—will require clinicians and their institutions to address the root causes of poor health in the communities they serve. This paper provides examples of how clinicians can help do so by generating the data and demand for greater investment in these communities.

How Community Investment Can Drive Community Health

Building more resilient and thriving communities is the focus of the community investment field, which, since the 1960s, has been working to drive capital to disadvantaged neighborhoods and regions that are underserved by mainstream financial systems.⁶ Community investment finances small businesses, affordable housing, grocery stores, and other community improvements.^6,7 That is, it seeks to reduce many of the negative social determinants that affect health risks and outcomes and to provide the opportunities people need to thrive.

The community investment field includes mission-driven investors, banks, community leaders, foundations, developers, and public officials. Each of these stakeholders plays a critical role in assessing community needs, identifying or creating investments to address them, and changing policies and practices to support better environments for such investment. For instance, neighborhood organizations such as community development corporations—nonprofits that empower residents of low-income communities to take action to solve local problems—can spot opportunities to develop multifamily housing with rents that low-income people can afford. Community development financial institutions (such as the Enterprise Community Loan Fund⁸ and the Local Initiatives Support Corporation [LISC]⁹) operate in regions across the country, bringing together funds from government, philanthropy, and banks to finance community centers, small businesses, and other facilities. By engaging diverse stakeholders and blending public, private, and philanthropic resources, community investment can overcome the difficulties of obtaining purely private financing for much-needed improvements in disadvantaged neighborhoods.

Community investment stakeholders and medical professionals strive to make people’s lives better. However, they have traditionally labored side by side rather than together. While all health institutions have a mission of healing the sick and promoting good health, tax-exempt hospitals have a specific legal obligation to serve their communities,¹⁰ often called community benefit. While tax-exempt hospitals have long provided charity care as part of their community benefit obligation, the Patient Protection and Affordable Care Act of 2010 ushered in new requirements for meeting this obligation, including conducting a community health needs assessment (CHNA) every 3 years and developing a specific plan to address the needs identified in the CHNA.¹¹ Some institutions continue to meet this obligation primarily by providing charity care and doing research. However, several pioneering institutions are meeting this obligation by addressing the root causes of poor health. For example, Bon Secours Baltimore Health System has constructed or rehabilitated more than 800 units of affordable rental housing to address the needs of communities surrounding its campus.¹²

In “Improving Community Health by Strengthening Community Investment: Roles for Hospitals and Health Systems,” the first author and Katie Grace Deane (both staff members of the Center for Community Investment [CCI]) argue that hospitals and health institutions have an array of assets—financial capital, land, and expertise—that can bring new resources to community investment and thereby support better health outcomes for their patients, employees, and communities.¹³ Furthermore, deploying these resources in community investment can support institutional mission, enhance institutional reputation and competitiveness, strengthen community relationships, and—last but certainly not least—generate a financial return as, unlike grants, money that is invested is repaid over time.¹³ This influx of new ideas, expertise, and capital can, in turn, help the community investment field initiate and expand projects that broaden opportunities for good health.

So, what would it take to build stronger relationships between medical professionals and the community investment sector to achieve their individual and shared goals?

How Clinicians Can Help Catalyze Community Investment

Clinicians are uniquely positioned to support partnerships between health institutions and the community investment field. Their daily experience of interacting with patients and their credibility as health experts make them valuable voices to and for their patients, institutions, and communities. Their positions enable them to marshal both the data that provides the rationale for community investment and the demand for that investment. By asking questions about patients’ lives, clinicians can treat not only symptoms but also the underlying causes of poor health. By asking questions of hospital leadership, they can guide their own institutions to higher levels of impact. And by encouraging their institutions to add their weight to advocacy efforts, they can help make the case for neighborhood revitalization projects that strengthen health outcomes. The CCI has witnessed the power of all of these actions, described in more detail below, through its Accelerating Investments for Healthy Communities initiative,¹⁴ which is supporting 8 nonprofit health care organizations that are investing in health-promoting social determinants such as affordable housing with coaching and technical assistance.

Collecting data. Asking questions about patients’ home and work environments is recognized as helpful for improving their care experiences, compliance with medical treatment, and health outcomes,¹⁵ while at the same time providing important social determinants data to guide institutional investments. Clinicians at ProMedica, an integrated health system in Toledo, Ohio, use a social determinants screening tool to assess patient employment, food, housing, and transportation needs.¹⁶ Answers from the screen are entered into the patient’s electronic medical record and used to connect the patient to support services, while the aggregated data about the patient population as a whole is used to inform institutional investments, including a $45 million partnership between ProMedica and LISC to finance affordable housing and economic development projects in surrounding neighborhoods.¹⁶

Clinicians can also advance policy and system changes by leveraging data to raise broader awareness of health needs. As mentioned previously, under the Affordable Care Act, nonprofit health care organizations are required every 3 years to conduct a CHNA that solicits input from residents and experts and to develop a community health improvement plan to meet the health needs of the communities they serve.¹⁰ Clinicians can push their institutions to use their CHNAs to engage their communities more effectively by asking meaningful questions about social determinants rather than just focusing on diseases, sharing aggregated and deidentified data with decision makers to improve the quality of planning and programs, and cooperating with other health systems to produce joint CHNAs that delve more deeply into the needs of historically underserved communities and nurture the relationships that can undergird joint action.

Creating demand. By asking administrators in finance and in community and government relations departments what their hospitals are doing to meet their community benefit obligations, as well as by asking patients what their communities need, clinicians can help create demand for interventions that address underlying causes of health problems, not just for research and charity care. Similarly, clinicians can ask human relations, finance, and administration departments whether their institutions are hiring, buying, and investing locally, all of which can play a big role in improving surrounding neighborhoods. Clinicians can—and should—be active in asking questions about community benefit and involvement throughout their careers, from the start of the recruiting process through every stage of their employment.

Clinicians can push their employers to harness not only their operations but also their assets to promote health. Hospitals and health institutions have an array of assets—financial capital, land, expertise—that can be put to work to address the social determinants of health. As health care institutions consider engaging in community investment, they have many options as to how to deploy these assets. Through its Healthy Neighborhoods Healthy Families initiative, for instance, Nationwide Children’s Hospital leverages its staff, financial capital, data analysis capabilities, and government relations expertise to support affordable housing, education, and workforce development for children and families on the South Side of Columbus, Ohio.¹⁷ Kaiser Permanente recently dedicated $200 million of its investment portfolio to create its Thriving Communities Fund to address housing stability and homelessness.¹⁸ Among other activities, Dignity Health developed partnerships with local banks that directly support small business lending and affordable housing loans in the communities they serve throughout the country; one such partnership jumpstarted a housing and community revitalization project in San Bernardino, California.¹⁹ Clinicians can make it clear to senior institutional leaders that being part of institutions like these that invest in their communities is key to their sense of mission and job satisfaction and their ability to keep their patients healthy.

Conclusion

Every day, clinicians witness the effects of social and environmental factors on the health of their patients. At the same time, they are under tremendous pressure to see more patients, reduce health care costs, deal with changing regulations and electronic medical records, and more. These burdens can make addressing the social determinants of health seem overwhelming, even when they know it is one of the most important things they can do for their patients. Fortunately, clinicians and hospitals are not alone. The community investment sector exists to do this work and would welcome partnering with the health sector to support better outcomes for communities. Clinicians can promote community investment by helping to create the data and demand that will catalyze efforts to address the root causes of ill health. Ultimately, hospitals investing in communities will result in healthier environments and healthier patients.