Building Community Outreach
Why is it essential to develop strong and effective community relationships?
As a hospital leader in Case Management, you are probably very aware of the pressing Health-Related Social Needs (HRSN) of the patients and families your organization serves. The hospital often acts as the safety net for patients with unmet health care and social needs. To prevent unnecessary hospital readmissions or unnecessary emergency department utilization, community relationships are key to connecting patients to essential resources at discharge.
What contributes to identifying essential community relationships?
As a condition for their tax-exempt status, nonprofit hospitals must offer financial assistance (free or discounted care, also known as charity care) to low-income patients, and engage in other activities to promote community health. They are required by the Accountable Care Act to report spending on these activities on their annual tax form 990. For the entire industry, the nonprofit tax exemption is worth an estimated $30 billion per year. (Garber, 2023; KFF, 2024)
On a triannual basis, nonprofit health systems (hospitals) must perform a community needs assessment of their service area and submit it for review to the Internal Revenue Service, local State Hospital Associations, and the Hospital/Health System Board of Directors.
A community needs assessment provides community leaders with a snapshot of local policy, systems, and environmental change strategies currently in place and helps to identify areas for improvement. To make positive and sustainable changes, communities can use this data to create strategies and map out a course for health improvement (CDC, 2013). This drives the development of community benefit programs or activities that provide treatment and/or promote health and healing as a response to community needs.
According to the World Health Organization, community engagement principles are identified as “trust, accessibility, contextualization, equity, transparency, and autonomy” (WHO, 2020). These principles play a crucial role in engaging communities in the research and interventions of health systems (Durrance-Bagale et al., 2022).
Case management leaders have recognized and developed relationships with post-acute providers and payors to be successful in a value-based care environment. Case management leaders should participate in identifying and developing key community relationships, as they have a direct understanding of the unique patient and family discharge needs.
In 2024, Centers for Medicare and Medicaid Services (CMS) mandated the submission of HRSN data from CMS-participating acute care facilities. Collaboration between Case Management and Clinical Documentation leaders will be key to understanding HRSN data trends and working with their health system leaders to best identify the most beneficial community relationships.
Key Considerations
Ensure case management participation in a Community Benefit Assessment at your organization.
Review the current community benefits assessment and plan for your organization. (Review your organization’s 990 tax form to see where community benefit funds are allocated.)
Assess the status of current community relationships.
Identify opportunities to expand community partnerships/outreach to support modifiable HRSN.
Consider hardwiring community resources/referral processes.
Review the 2.0 Transition of Care (TOC) website. The TOC 2.0 Standards offer a framework to promote essential and effective communication with key stakeholders/community partners (Transitions of Care, 2020).
Review the TOC 2.0 White Paper, which describes how two organizations utilized the TOC standards with HRSN-specific populations requiring care coordination, and community connection (Bober & Ferket, 2024).
If you need support in assessing and developing a strategy to build community relationships, reach out to our team today!
References
Bober, M. & Ferket, K. (2024). Transitions of Care 2.0. [White paper]. American Case Management Association. https://transitionsofcare.org/wp-content/uploads/2024/09/TOC-1169.pdf
Centers for Disease Control and Prevention. (2013). Community needs assessment. https://www.cdc.gov/globalhealth/healthprotection/fetp/training_modules/15/community-needs_pw_final_9252013.pdf
Community-Based Care Coordination: Pathways Community Hub Institute. PCHI. (n.d.). https://www.pchi-hub.org/
Community Health Needs Assessment for Charitable Hospital Organizations - section 501(r)(3). Internal Revenue Service. (n.d.). https://www.irs.gov/charities-non-profits/community-health-needs-assessment-for-charitable-hospital-organizations-section-501r3
Durrance-Bagale, A., Marzouk, M., Tung, L. S., Agarwal, S., Aribou, Z. M., Ibrahim, N. B., Mkhallalati, H., Newaz, S., Omar, M., Ung, M., Zaseela, A., Nagashima-Hayashi, M., & Howard, N. (2022). Community engagement in Health Systems Interventions and research in conflict-affected countries: A scoping review of approaches. Global Health Action, 15(1). https://doi.org/10.1080/16549716.2022.2074131
Garber, J. (2023, April 28). 5 things you need to know about hospital community benefit spending. Lown Institute. https://lowninstitute.org/5-things-you-need-to-know-about-hospital-community-benefit-spending/
Garber, J. (2024, June 27). The most socially responsible hospital systems in America. Lown Institute. https://lowninstitute.org/the-most-socially-responsible-hospital-systems-in-america/
KFF. (2024, May 1). Nonprofit Hospitals’ tax-exempt status worth about $28 billion, new KFF analysis finds. https://www.kff.org/health-costs/press-release/nonprofit-hospitals-tax-exempt-status-worth-nearly-28-billion-new-kff-analysis-finds/
The roadmap to effective transitions. Transitions of Care. (2020, July 20). https://transitionsofcare.org/
World Health Organization. (2020). Community engagement: a health promotion guide for universal health coverage in the hands of the people. https://iris.who.int/bitstream/handle/10665/334379/9789240010529-eng.pdf